3 1924 104 226 125 CORNELL UNIVERSITY MEDICAL LIBRARY ITHAOA DIVISION. OrPT E-BOM THE LIBRARY OF CHARLES EDWARD VAN CLEEF. M.D. B. S. CORNBLIi UNIVERSITY, "7\. Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104226125 SYSTEM OF MEDICINE. EDITED BY J. RUSSELL REYNOLDS, M.D., F.R.S., FELLOW OF THE ROYAL COLLEGE OP PHYSICIANS OF LONDON ; FELLOW OF THE IMPERIAL LEOPOLD-CAKOLISA ACADEMY OP GERMANY ; FELLOW OP UNIVERSITY c'oLLEflB, LOND. : PROFESSOR OF THE PRINCIPLES AND PRACTICE OP MEDICINE IN UNIVERSITY COLLEGE ; f PHYSICIAN TO UNIVERSITY COLLECE HOSPITAL ; EXAMINEE IN MEDICINE TO THE UNIVERSITY OP LONDON. WITH NUMEROUS ADDITIONS AND ILLUSTRATIONS, BY HE"N"RT HARTSHOR:Ne, A.M.,M.D., FBLLOW OF THE COILEQE OF PHTBICIANa OF PHILADELPHIA; FORMERLY PROFESSOR OF PRACTICE OP" MEDICiyB IN MEDICAL DEPARTMENT OF PENNSYLVANIA COLLEGE, AND PHYSICIAN TO THE EPISCOPAL HOSPITAL OF PHILADELPHIA ; LATELY PROFESSOR OF HTQIENE IN THE UNIVERSITY OF PENNSYLVANIA, AND PROFESSOR OF HYGIENE AND DISEASES OF CHILDREN IN THE woman's MEDICAL COLLEGE OF PENNSYLVANIA; ETC. IN THREE VOLUMES. VOL. I. GENERAL DISEASES AND DISEASES OF THE NERVOUS SYSTEM. PHILADELPHIA: HEI^ET 0. LEA'S SON & OO. 1880. Entered according to Act of Congress, in the year 1S79, by HENRY C. LEA, I the Office of the Librarian of Congress. All rights reserved. COLLINS, PRINTER. PREFACE TO THE AMERICAN EDITIOK Oe the eminent authority of the contrihutors to this System of Medicine, and the excellence of their work, there can be but one opinion on either side of the Atlantic. If the present republication were made only in the interest of medical literature, in the historical sense, it would be an unwarrantable presumption to attempt any additions to it. But the purpose of such a work, cyclopsedic in character, is, obviously, to render the greatest possible advantage to students and practitioners ; for which end, it is desirable that the most important recent advances in clinical observation, pathology, diagnosis, and therapeutics should be supplied in connection with essays, some of which were written several years ago. This remark applies especially to the articles contained in the first Volume of the present edition, upon General Diseases and the Affections of the Nervous System. Moreover, the practical aspect of some subjects is different in this country from that which they present abroad, and the American physician may reasonably expect that the results of American experience should be concisely laid before him. So far as comments are made, and opinions occasionally expressed in this edition, more or less divergent from those of the authors of the work, it is, of course, at the option of every reader to estimate them at their proper value. If such comments appear at times obtrusive, the excuse of tbe American Editor is, his conscientious desire, sustained by the request of the Publisher, that he should omit nothing which seemed likely to prove serviceable to those concerned in, or preparing for, the responsible and arduous labors of medical practice. The text of the articles in the English edition has nowhere been altered, except in correction of typographical or other oversights ; and in the omission or abridgment of several extremely elaborate and com- plex Tables, which, it is believed, very few readers would follow in detail, as the inferences deduced from them are fully developed in the text. In two or three instances, the order of succession of articles has (iii ) PREFACE. been changed ; not, however, without conformitj- to the general plan of arrangement. The most considerable additions are upon the following subjects : the question of Blood-letting (Introduction) ; Ecitheln, or G-erman Measles ; Apyretic measures in Typhoid Fever; Prophylaxis of Yellow Fever; recent history of Plague ; Typho-malarial Fever ; Pemicious Fever ; ' Pathology and Treatment of Cholera; Chlorosis; Scrofula; Salicylic Acid in Eheumatism ; Hysterical Ilcmianfesthesia ; Hystero-epilepsy ; Methomania ; Athetosis ; Puerperal Convulsions ; Pseudo-hypertrophic jNIuscular Paralysis ; Tubercular Meningitis ; Ophthalmoscopic Appear- ances in Brain Disease ; Cerebral Localization ; Spinal and Cerebro-spinal Sclerosis ; Symptomatology of Locomotor Ataxy ; Eeflex Paralysis ; Croup ; Communicability of Phthisis ; Treatment of Pneumonia ; Para- centesis Pericardii ; Cardiac Exhaustion ; Hemophilia ; Cholera Infantum ; Trichina; Progressive Pernicious Ansemia. All additions are marked by brackets, and signed [H.]. IIEXEY HAETSHOEXE. Philadelphia, November, 1879. ENGLISH PREFACES. PREFACE TO THE FIRST EDITION OF VOL. I. The object proposed to himself by the Editor of this System of lledicine is to present, within as small a compass as is consistent with its practical utility, such an account of all that constitutes both the natural history of disease and the science of pathology as shall be of service in either preventing the occurrence, or detecting the presence, and guiding the treatment of special forms of illness. As the science and art of Medicine have within the last few years increased very greatly, in regard to both facts and principles, it is held to be desirable — and indeed almost imperative — in order to secure the ends that have been mentioned, to divide the large field of growing knowledge into such comparatively small sections as should be enriched by the results of individual and special culture. The Editor feels con- fident that these results have been obtained ; and, in order to secure the like confidence of others, has simply to refer to the names of the many distinguished men who have kindly contributed to this volume. The general scope of the System of lledicine, and the mode in which it has been carried out, render unnecessary any discussion of the so-called " Principles" of Medicine ; and the Editor has preferred, by the omission of articles on " general" subjects, to incur the risk of occasional repeti- tion, rather than that of such apparent contradiction as might arise from the treatment of some matters " in the general" by one contributor, and " in detail" by many others. He has, further, only to express his most grateful thanks to those who have rendered him their invaluable aid ; and to submit these results of their toil to the Profession of which they are the distinguished orna- ments. Marcli 21st, 1866. (V) VI ENGLISH PREFACES. PREFACE TO THE SECOND EDITION OP VOL. I. In this Second Edition, the articles have been submitted for revision to their respective authors. That on Purpura, by the late Dr. Thomas HiLLiER, has been revised by Dr. Tilbury Fox. The Editor has introduced into this volume the article on Epidemic Cerebro-Spinal Meningitis, ^vhich in the First Edition -was placed among the diseases of the Nervous System. 38 Grosvenok Street, Grosvenok Square, January ISth, 1870. PREFACE TO YOLUME III. In dealing with so large a series of subjects as those which make up the section on " Diseases of the Respiratory System," some repetition of statement and occasional divergence of opinion have been found inevita- ble. The Editor has, however, thought it desirable to allow the occur- rence of the former, in order to give completeness to separate articles, and has taken pleasure in the representation of the latter, inasmuch as, in his opinion, such divergence expresses, with the greatest faithfulness, the present state of scientific knowledge on many unsettled problems of pathology, and by so doing will prove more useful than would any attempt at enforced uniformity of teaching. The general doctrine of Tubercle ; the relation which that material bears to local and general diseases ; the precise meaning of certain morbid conditions, the characters of which are matters of familiar recognition ; and the inter-relations of many well-known words, are each and all of them susceptible of various interpretations : and the Editor is grateful and glad to be able to bring together in a connected form, under the notice of his professional brethren, the views that are severally enter- tained by those distinguished authors who have already shed much lio-ht upon these obscure regions, and have furnished many of the results of their finest labors in the present work. J. RUSSELL REYNOLDS. 38 Grosvenor Street, August Sth, 1871. ENGLISH PREFACES. PREFACE TO YOLUME lY. The Articles on Position and Malposition of the Heart, on Angina Pectoris, on Pericarditis, and Endocarditis, were begun by their respective authors some years ago, and several distinct portions of each of those articles wore at once committed to the press. But both Dr. Gairdner and the late Dr. Sibson held that much new matter must be introduced into them ; and by far the largest contributor to this volume, the late Dr. Sibson, found a mass of facts at his disposal, the analysis and repre- sentation of which occupied an amount of time and space that far exceeded his anticipation. The entire originality of his work, the sub- tlety of thought which it displayed, the carefulness of the observations upon which it was based, the catholicity of the views which it expressed, the honest, kind, although keen criticism that it contained of the opin- ions of other workers, and the intimate and important relations of all its parts, decided me not to reduce its magnitude beyond that which it now presents, and to wait for its completion. Those who know what it is to give a concise account of facts derived from their personal observation, and represented by the statistical method, will appreciate the years of labor that have been bestowed upon the articles. Position and Malposi- tion of the Heart, upon Pericarditis and Endocarditis. Their Author, when he left England during this past autumn, had left one table uncor- rected, and three pages on Carditis unwritten ; I have endeavored to correct the table, and Dr. Gowers has written the article on Carditis. "We have, in this volume, the results of many years of Dr. Sibson's ai'dent toil, and the last, and, as I think, the best production of that earnest, industrious, enthusiastic worker, and most kind and genial friend. Another of the contributors to this volume has also passed away since his papers were printed, and happily in the main corrected by himself; I refer to the late Dr. Warburton Begbie, whose work was as good as his heart was large, and who never spared any pains to carry to the highest point of his ability even the smallest fragment of labor that he undertook to perform. J. RUSSELL EEYN0LD8. 38 GEOsvEifOK Steeet, December, 1876. VIU ENGLISH PREFACES. PREFACE TO VOLUME Y. The fifth and concluding volume of this System of Medicine will, I believe, be as instructive and interesting as any of those which have preceded it. It contains information upon a very wide range of diseases, and the manner in which the authors of the respective articles which fill its pages have dealt Avith them throughout, has been such as to justify my belief. To those who have contributed to this volume, and to whom I can now address myself, I off"er my heartiest thanks, both for the readi- ness with which they have done their work, and for the industry, learn- ing, and critical faculty which they have displayed. One of the contributors, Dr. Basham, was removed by death before he had completed his work, but I was most kindly and ably assisted by Dr. Frederick Roberts, in the anxious work of editing MSS., which in some cases proved to be but half completed. To Dr. Gowers, I am deeply grateful, not only for the very able papers which he has written, but also for his kindness in rendering me very great assistance in the preparation of this volume for the press. It is not a matter for much surprise that a work, which has taken so long a time to produce, by men who had already become eminent in our profession — the longevity of which is less than that of most — should not be completed until many of its contributors had passed bej'ond the reach of either our praise or our blame, and that they should not have seen the work, which they had done so carefully, placed in its proper niche in the edifice that they had helped to raise. To two of these, Drs. Warburton Begbie and Sibson, I have made some allusion in my note of introduction to the fourth volume; of the others, from whom I had expected further help, I must say something here. Dr. Anstie — whose loss the profession has never ceased to feel, and about whom, every one who had the privilege of his friendship can scarcely speak in terms that shall do justice to the memory of his earnest, loving soul, and of that devotion to duty and science which led to his early death — was one of my most helpful and considerate coadjutors in the production of the second volume, not only by contributing his papers to the System of Medicine, but by the great assistance which he rendered me in the preparation of the second volume for the press. From him, I had hoped for much more help, but, for him " there was nobler work to do." ENGLISH PREFAOES. Dr. Basham entered most heartily into the scheme of this book, hut the publication of his pa^iers was long delayed in conserjuenee of circum- stances which I explained in my note to the fourth volume. Those which he has left behind him, nearly completed, and which have been finished by Dr. Frederick Roberts, will show, as his other works have done, the simple and scientific character of his writing, and the thorough practicality of all his teaching. The death of Dr. Warburton Begbie, to whom I have already alluded, occasioned another of the great losses which this System has sustained. There are few, if any, who have surpassed him in the scientific ability, scholarship, and high moral tone of his work. Dr. Hughes Bennett, whose strong personal views on pathological questions gave an interest to the subjects with which he dealt, con- tributed the article on I'hthisis, containing much original matter and tliought, which will be useful to all interested in the history of tuber- culosis. The death of Dr. Thomas ITillier, the whole of whose published works afforded such rich promise of still more useful labors, occasioned another loss which the profession could ill sustain, a loss also to myself as a friend, colleague, and, as I hoped, future fellow-worker. To Dr. Parkes, it is absolutely impossible for me to express my obliga- tion. From the first day that I planned the construction of these volumes, until the last day but one before his death, he was my faithful counsellor and friend. His direct contribution to the System of Medicine was comparatively small, but the help that he gave me, indirectly, was immeasurably large. He was punctual to an hour, and precise to a tliree- place decimal. High above all his scientific work, great as it was, rose his grand moral character, for which all who have known him well must be profoundly grateful, in feeling that they arc " better men, and are conscious that they may be better still." Dr. Hyde Salter contributed a valuable paper on Asthma, condensing for this System the result of a great many years of good, scientific work. His well-known and recorded personal sufferings from the malady, upon Avhich he wrote so ably, supply an interest and instruction that could perhaps have not been otherwise obtained. To Dr. Sibson, the profession is much indebted for some most carefully elaborated papers, which appeared in the fourth volume, and to which in its introductory preface I have already alluded, so that I can here do no EXCtLTSII PTtEFACES. more than reiterate my regret for the loss Avhich medical science and literature have sustained in his unexpected death. Dr. Edward Smith, a highly distinguished member of our profess^ion, who had contributed much to the advance of medical science, and espe- cially in some of its more practical bearings upon daily life, took a warm interest in the volumes which I have edited, and, until his Avork was prematurely arrested by death, he had hoped to render still further assistance in their production. Dr. Squarey, a worker of great earnestness and promise, contributed several articles on Diseases of the Mouth and Throat to the third volume, but his life was cut short in the midst of his devoted labor. The value of this work is greatly enhanced by the Indices to each separate volume, and also to the five volumes collectively. For the production of these, I have to thank, and I do so most heartily, Mr. Marcus Beck, the late Dr. Loy, and Dr. J. "W". Langmore, the last of whom has furnished the Indices to the fourth and to the fifth volume. To the dead and to the living, I again express my thanks, and feel most grateful that I have been able to put into the hands of the medical profession a series of admirable original contributions to the medical literature of our country, of which I think any country might be proud. J. RUSSELL REYNOLDS. 38 Gkosvenor Street, November, 1878. CONTENTS OF VOL. I. INTRODUCTION, by the Editor. Definition of Disease ; and Names of Diseases .... Structural and Functional Disease Natural History of Disease Causes of Disease Predisposing Causes . Exciting Causes Symptoms of Disease . Symptoms and Signs Objective and Subjective Symp toms . . 17 19 21 21 21 23 23 23 24 Natural History of Disease — Course of Disease Duration of Disease Termination of Disease Diagnosis of Disease Pathology Pathological Anatomy Prognosis Therapeutics and Hygienics Classification of Diseases 26 26 27 28 29 30 32 PART I. GENERAL DISEASES, OB AFFECTIONS OF THE WHOLE SYSTEM. I I. Tlwse determined by Agents operating from without. INFLUENZA, by Edmund A. Parkes, M.D., F.R.S. Definition .... 33 Varieties .... . 43 Synonyms .... 33 Mortality .... . 43 History of Influenza 34 Diagnosis . 43 Spread of the Disease 34 Pathology . 43 Etiology 34 Morbid Anatomy . . 44 Symptoms .... 41 Prognosis . 44 Consideration of the Special Symp Treatment . 45 toms . 41 HOOPING-COUGH, by Edward Smith, M.D., F.R.S. Definition of Hooping-Oougli History .... Causes .... Symptoms Diagnosis 4S 48 48 49 52 Pathology Morbid Anatomy Prognosis Treatment 52 52 53 53 DIPHTHERIA, by William Squire, L.R.C.P., Lond. Definition . 57 Diagnosis . 70 Synonyms . 57 Pathology . 72 Name . 58 Morbid Anatomy . 74 History . . 58 Prognosis . 77 Etiology . . 61 Therapeutics . 78 Symptoms . 65 (xi) xu CONTENTS OF VOL. I. SCARLET FEVER, by Samuel Jones Gee, M.D., Lond. PAGE s:! Definition . , ^ . Causes 84 Symptoms Si Symptoms of Ordinary Scarlet Fever 85 Symptoms of Malignant Scarlet Fe- ver 88 Symptoms of Latent Scarlet Fever 89 Si'queliB . Diagnosis Morbid Anatomy Prognosis Prophylaxis Treatment 89 93 94 94 95 95 DENGUE, or DANDY FEVER, by William Aitken, M.D. Definition Synonyms History Symptoms 98 98 98 99 Etiology and Propagation Diagnosis Treatment 103 103 103 Definition Cause Course ROSEOLA, by Hermann Beigel, M.D. 104 j Diagnosis 1115 Prognosis 105 i Treatment 106 106 106 Definition Sjnonyms Symptoms Varieties . MEASLES, by Sydney Ringer, M.D. 106 ] Complications and Sequels 106 , Diagnosis 106 I Prognosis 107 i Treatment 111 113 114 114 [ROTHELN (German Measles), by Henry Hartsiiorne, M.D. Sj'mptoms Diagnosis 117 117 Treatment 117] Definition Syni-inyms Symptoms PAROTITIS, by Sydney Ringer, M.D. 118 118 118 Pathology Diagnosis Treatment 119 120 120 SUDAMINA and JIILIARIA, by Sydney Ringer, M.D. Sudamina Miliaria . 122 I Treatment 123 124 VARICELLA, by Samuel Jones Gee, M.D. Definition Causes .... Description of the Disease Diagnosis 121 125 125 126 Prognosis Treatment Varieties and Synonyms , 127 127 127 SMALLPOX, by J. F. Marson. Definition . . . . . 127 Varieties . Synonyms . . . . . 127 Primary Fever History . 127 Secondary Fever Descrijjtion of Smallpox . . 128 Diagnosis 129 132 132 135 CONTEXTS OP VOL. I. XIU Prognosis Susceptibility to Smallpox Infectious Nature of Smallpox Treatment Mortality from Smallpox Morbid Appearances PAGE l:iG 138 138 140 145 14G Anatomical Cliaracters of tlie Yari- olous Pcjck 147 Smallpox after Vaccination. — Vari- celloid, and modilicd Smallpox . 14'J Epidemic DUliisidu of Smallpox . l"i(j Inoculation from Smallpox . . l-ji> VACCINATION, by Edward Cator Seaton, M.D. Phenomena of Cow-pox in the Hu- man Subject .... 159 Phenomena of Eevaccination . . lOl Method of Vaccinatins; . . . 161 Protection aftbrded by Vaccination against Smallpox . . . .106 Revaccination ..... 174 Kelatious of Variola and Vaccinia 170 Alleged Dangers of Vaccination . 177 GLANDERS — EQUINIA, by Arthur Gamgee, M.D., and Joim Gamgee. Definition 182 Nomenclature and History . . 182 Glanders and its Varieties in the Horse, Ass, and Mule . . . 183 Chronic Glanders .... 183 Acute Glanders .... 183 Chronic Parcy ..... 184 Acute Parcy 184 History of the Disease in Man Etiology of the Disease in Man Semeiology Diagnosis . ■" . ilorbid Anatomy Prognosis Therapeutics . 185 ISS 189 191 191 192 192 HYDROPHOBIA, by John Gamgee and Arthur Gamgee, M.D. Definition . 192 Synonyms . 192 History .... . 192 Causes .... . 195 Hydrophobia in Man . 197 Symptoms of Hydrophobia in man 197 Diagnosis ..... 199 jNIorliid Anatomy .... 199 Prognosis ..... 200 Therapeutics ..... 200 ENTERIC or TYPHOID FEVER, by John Harvey, M.D., F.L.S. Definitive Description 201 Varieties O'^O Synonyms 201 Distribution '. hi Preliminary Observations 202 Causes . 235 Clinical History of the Disease 202 Diagnosis . 244 Morbid Anatomy .... 209 Prognosis . 246 Pathology 218 Treatment . 247 Associated Pathology of Enteric Fever 221 TYPHUS EEVER, by George Buchanan, M.D. Definition Etiology .... Symptomatology Duration .... Termination and Sequela; Diagnosis 251 ' Pathology 252 Morbid Anatomy Prognosis and Mortality Therapeutics . Varieties . 254 261 261 202 203 264 2(;5 266 269 RELAPSING FEVER, by J. Warburton Begbie, M.D. 269 Definition .... History, Nomenclature, and Bibli ography .... Geographical Distribution 269 273 Etiology . Symptomatology Therapeutics . 274 277 280 X17 CONTENTS OF VOL. I. YELLOW FEVER, by J. Denis Macdonald, M.D., F.R.S. Definition i^i^ Synon5-ms -i^t liistory iiSl Altitudinal and Horizontal Kauo-es 284 S3"mptoms ..... 2S4 Diagnosis -SO Pathology .... Morbid Anatomy Prognosis .... Therapeutics .... Varieties and their Classification EPIDEMIC CEREBRO-SPINAL MENINGITIS, by John Netten Radcliffe. Definition Synonyms Description of the Disease Special Symptoms . Complications . Duration . Termination Mode of Death Diagnosis 296 2'JO 297 299 303 303 304 304 304 Prognosis Morbid Anatomy .... History and Geographical Distribu- tion Etiology . S'ature Treatment Bibliography 280 290 292 293 294 305 305 306 308 311 312 314 THE PLAGUE, by Gavin Milroy, M.D. Definition Synonjmis Symptoms lUagnosis Morbid Anatomy 314 314 314 313 316 Curative Treatment Natural History Causation Prop)hylaxis, &c. [Becent History ERYSIPELAS, by J. Russell Reynolds, M.D., F.R.S. Definition Synonyms Xatural History C'auses Sj-mptoms Diaonosis 321 321 321 321 322 325 Pathology Morbid Anatomy Prognosis Treatment Varieties . PYEMIA, by John Syer Eristowe, M.D. Etymology Definition Pathology iSlorbid Anatomy General Pathology Symptoms Considered collectively Considered in relation to the vari ous Organs 330 330 330 331 338 344 344 343 317 317 317 317 320] 325 325 326 327 329 Symptoms — Considered further in regard to Pyajmia 347 Diagnosis ..... 347 Treatment 348 Prophylactic .... 348 Medical 350 MALARIAL FEVERS, by W. C. Maclean, M.D. In"teemittent Eevee . . 352 Definition 334 Synonyms 354 History and modes of Commence- ment 354 Causes 356 Symptoms 356 Diagnosis 358 Morbid Anatomy .... 358 Prognosis 359 Treatment 360 Kemittbnt Fever Definition Synonyms History Symptoms Diagnosis Pathology Prognosis Treatment 365 365 365 365 366 368 368 368 369 CONTENTS OF VOL. I. XV DYSENTEEY, by W. C. Maclean, M.D. Definition Terminology . History . Modes of Commencemeut Causes Symptoms Acute . Chronic Malarious PAGE ■.iT2 37-2 373 373 375 37(5 37(j 377 Symptoms — Malignant Scorbutic Diagnosis Pathology Morbid Anatomy Prognosis . Treatment 377 377 378 378 378 380 380 EPIDEMIC CHOLERA, by Edward Goodeve, M.B. Definition 384 Diagnosis . 409 Synonyms 384 Pathology . 410 liistory . 385 Morbid Anatomy . . 410 Etiology . 386 Considered during life . . 412 Symptoms 308 Prognosis . 415 Varieties 406 Treatment . 415 Duration . 408 Treatment of Choleraic Diarrhcea . 4l.'() Mortality 408 Prophylaxis . 421 CONSTITUTIONAL SYPHILIS, by Jonathan Hutchinson, F.R.C.S. Stages of Syphilis .... 424 Conditions interfering with their Evolution 426 Modes of Communication . . 429 Tertiary Symptoms .... 431 Treatment ..... 435 Diagnosis 438 Diagnosis when consequent upon in- herited Taint . . . .440 Contrast between acquired and in- herited Syphilis .... 443 ? II. General Diseases determined hy Conditions existing within the Human Body. SCORBUTUS, or SCURVY, by Thomas Buzzard, M.D. Definition . 445 Pathology Synonyms . 445 Morbid Anatomy Etiology .... . 445 Prognosis Symptoms . 451 Therapeutics . Diagnosis . 454 455 456 457 458 PURPURA, by Thomas Hillier, M.D., revised by Tilbury Fox, M.D. Description of different Eorms . 460 Pathological Anatomy . 463 Anatomical Characters . . 460 ISTature .... . 4(;5 Symptoms .... . 460 Prognosis . 466 Varieties .... . 461 Diagnosis . 466 Causes . 463 Treatment . 467 History . Symptoms Causation [CHLOROSIS, by Henry Hartshorne, M.D. 408 468 469 Pathology Prognosis Treatment . 469 . 470 . 470] xn CONTENTS OF VOL. I. Definition Synonj'ms Causes Symptoms Diagnosis . RICKETS, by W. Aitken, M.D. PAilE 47-2 472 473 475 484 Pathology Morbid Auatomy Prognosis . Tlierapeutics . PARE 4S-J 487 4! 14 4iJo [SCROFULA, by Henet Hartsiiornb, 'M .D. History . Symptomatology Anatomy . 497 498 5U3 Pathology Causation Treatment 503 507 509] GOUT, by Alfred BARraa Gareob, M.D., F.R.S. Definition 512 Synonyms 512 History 512 Description of an attack of Acute Gout, and progress of the Dis- ease 512 Gout in a Chronic form 510 Ii'regular Gout ; effects on differ- eiit forms of Gout 518 State of the Urine in different forms of Gout .... 522 Morbid Anatomy . . . . Causes dependent on the Individual Causes independent of the Indi- vidual . Patholog'y Diagnosis Prognosis . Treatment Diet and Regimen in diflerent forms of Gout ...... 520 527 531 530 537 533 RHEUMATOID ARTHRITIS, by A Definition 550 Synonyms ..... 550 Piistory 550 Description of Rheumatoid Arthritis 551 Morbid Anatomy .... 55:! Causes ...... 554 )y A. B. Gareod, M.D. F.R.S. Pathology 554 Diagnosis . 555 Prognosis . 550 Treatment 556 Diet and Regimen 558 RHEUMATISM, by A. B. Gareod, M.D., F.R.S. ^..rticular Rheumatism Definition ..... Synonyms ..... Piistory ..... Description of Acute and Sub- acute Rheumatism Consideration of the different Phenomena .... Condition of the Blood in Acute Articular Rheumatism . Urine in Acute Articular Rheu- matism ..... Cardiac and other Inflammatory jVffections .... Morbid Anatomv .... Causes 559 Articular Rheumatism — 559 Eflects of Climate, Seasons, anc 559 Weather 565 559 Pathology .... 505 Diagnosis .... 506 559 Prognosis and Treatment 507 Muscular Rheumatism 573 561 Definition .... 573 Synonyms 573 502 History . 573 Description 573 502 Causes . 574 Pathology 575 503 Diagnosis 575 503 Prognosis 575 564 Treatment 575 GONORRHCEAL RHEUMATISM, by B. E. BEOcnuRsx, F.R.C.S. History 570 I Treatment Symptoms ..... 570 j CONTENTS OF VOL. I. XVll PAKT II. LOCAL DISEASES. INTRODUCTION, by The Editor. GENEKAL DISEASES OF THE NEEVOXJS SYSTEM, List of PAGE 581 584 INSANITY, by Henry Maudsley, M.D., F.R.C.P. PAGE Synonyms 584 Definition 584 Classification 585 Causes ...... 587 Forms of Insanity and their Symp- tomatology .... 591 Melancholia 592 Mania 595 Monomania 599 Dementia ..... 600 Forms of Insanity and their Symp tomatology — Moral Insanity .... 601 Idiocy . oo;5 General Paralysis 605 Diagnosis . 607 Pathology 610 Morbid Anatomy 614 Prognosis . 616 Therapeutics . 618 HYPOCHONDEIASIS, by Sir William Withby Gull, Bart., M.D., D.C.L., F.R.S., and Francis Edmund Anstib, M.D., F.R.C.P. Definition 623 Nomenclature 623 History 624 Symptoms 624 Diagnosis ...... 626 Prognosis. ..... 628 Etiology 628 Treatment 029 HYSTERIA, by J. Russell Reynolds, M.D., F.R.S. Natural History .... 631 Causes 631 Symptoms 634 Pathology 640 Diagnosis ...... 642 Prognosis 643 Treatment ECSTASY, by Thomas King Chambers, M.D., F.R.C.P. [HYSTERO-EPILEPSY, by Henry Hartshorne, M.D. CATALEPSY, by Thomas King Chambers, M.D., F.R.C.P. Name ...... 652 I Causes Definition ..... 652 Treatment .... Description 652 | 644 646 649] 654 658 SOMNAMBULISM AND ALLIED STATES, by Thomas King Chambers, M.D., F.R.C.P. Description 658 | Treatment 660 SUN-STROKE, by W. C. Maclean, M.D. Definition Synonyms History . EtioIog3" • Symptoms Diagnosis . Pathology B 661 661 661 664 666 667 667 Morbid Anatomy Mortality . Prognosis . Prophylaxis Treatment Treatment of the Sequelae 668 668 668 668 669 670 XVIU CONTENTS OF VOL. I. ALCOHOLISM, by Francis Edmund Anstib, M.D., F.R.C.P. Definition Synonyms History . Etiology . Symptoms Chronic Alcoliolism Acute Alcoholism PAOE 670 670 670 671 675 675 678 Diagnosis . Prognosis . Complications Pathology Treatment PAGE 681 6S2 683 684 684 Definition Description Prognosis Etiology . Varieties . VERTIGO, by J. Spence Ramskill, M.D. 690 690 691 691 691 Stomachal Vertigo . Vertigo of the Aged Essential Vertigo . Vertigo from Overwork Treatment 691 693 693 694 695 CHOREA, by C. B. Radclifee, M.D., F.R.C.?. Symptoms 696 Exceptional Eorms of Chorea . 700 Pathology 704 Causes 709 Diagnosis Prognosis Treatment 710 711 711 PARALYSIS AGITANS, by W. Rutherford Sanders, M.D., F.R.C.P. Synonyms Defmition Historical Notice Description Causes 718 718 719 720 725 Diagnosis 720 Complications 727 Pathology and Morbid Anatomy . 727 Treatment 720 Bibiography . ." . . . 730 [ATHETOSIS, by Henry Hartshorne, M.D. 731] WRITER'S CRAMP, by J. Russell Reynolds, M.D., F.R.S. Definition Synonyms Symptoms 732 733 733 Etiology 734 Diagnosis . Prognosis Pathology Treatment 734 735 735 737 CONVULSIONS, by J. Hughlings Jackson, M.D., F.R.C.P. Convulsions in Children , The Paroxysm Premonitory Symptoms Sequelae The Causes of Convulsions Prognosis 738 740 740 744 745 749 Convulsions in Children — Treatment 749 Convulsions in Adults . . . 752 The Convulsion begins unilaterally 752 Causation 754 Death 761 Treatment 761 EPILEPSY, by J. Russell Reynolds, M.D., F.R.S. Definition 762 Synonyms 763 Natural History . . . .763 General Prevalence of the Disease 763 Causes 703 Symptoms 767 Eelations between the Symptoms 775 Natural History — Complications . 776 Pathology . 777 Diagnosis . 778 Prognosis . 779 Treatment . 780 CONTENTS OF A^OL. I. XIX MUSCULAR ANESTHESIA, by J. Russell Reynolds, M.D., F.R.S. Definition Nomenclature . Symptoms Causes PAGE 783 783 783 781 Diagnosis Pathology Prognosis Treatment PAGE 781 7S5 785 780 WASTING PALSY, by William Roberts, M.D., F.R.C.P. Definition . 786 Synonyms . 780 History . . . . . 786 Etiology . . . . . 786 Symptoms . 788 Course and Duration . 789 Diagnosis .... . 790 Morbid Anatomy . 790 Pathology . 793 Prognosis .... . 796 Therapeutics . . 798 METALLIC TREMOR, TREMBLEMENT M:6TALLIQUE, by W. RuTHERFOED Sandbrs, M.D., F.R.C.P. Synonyms Definition • 801 801 Mercurial Tremor or Slaaking Palsy 801 Causes .... . 801 Description . Symptoms . Course and Prognosis . • 802 802 801 Diagnosis 805 Pathology and Morbid Anatomy . 805 Lead Tremors 806 Symptoms 807 Causes 807 Course 807 Prognosis ..... 807 Pathology and Morbid Anatomy 807 Diagnosis 807 Treatment 807 PARTIAL DISEASES OF THE KERYOUS SYSTEM, List of 808 SIMPLE MENINGITIS, by J. Spence Ramskill, M.D. Definition 808 Acute Meningitis .... 808 Symptoms ..... 808 Inflammation of the Dura Mater 813 Progress, Duration, and Termina- tion 813 Pathological Anatomy . . 814 Acute Menin£titis — Etiology . 814 Diagnosis . 815 Treatment . . 815 Chronic Meninaitis . , 816 History and Description . 816 Treatment . . 817 TUBERCULAR MENINGITIS, by Samuel Jones Gee, M.D., F.R.C.P. Primary Tubercular Meningitis in the Child— {h) jMeningitis of the Convexity . 827 Secondary Tubercular Meningitis in the Child 828 Tubercular Meningitis in the Adult 829 Diagnosis 829 Morbid Anatomy .... 832 Prognosis and Treatment . . 835 Causes 817 Symptoms 818 Primary Tubercular Meningitis in the Child 818 Symptoms 818 Invasion 819 The Established Disease 820 (a) Meningitis of the Base . 820 CHRONIC HYDROCEPHALUS, by J. Spence Ramskill, M.D. Anatomical Characters Symptoms 836 I Diagnosis 837 Treatment 839 839 XX CONTENTS OF VOL. I. MENINGEAL HEMORRHAGE, by J. Spence Ramskill, M.D. Symptoms Treatment PAGE 841 842 Adventitious Pkodtjcts in the Meninges . ■ . . . . 843 Congenital Malfoemations of THE Meninges .... 844 CONGESTION OF THE BRAIN, by J. Russell Reynolds, M.D., F.R.S., and H. Charlton Bastian, M.D., F.R.S. Symptoms 845 Causes 848 Diagnosis 848 Pathology 849 Morbid Anatomy Prognosis . Treatment 851 853 853 CEREBRITIS, by J. Russell Reynolds, M.D., F.R.S., and H. Charlton Bastian, M.D., F.R.S. Causes 855 Symptoms ..... 855 Diagnosis 855 Pathology Prognosis Treatment 855 856 856 SOFTENING OF THE BRAIN, by J. Russell Reynolds, M.D., F.R.S. , and H. Charlton Bastian, M.D., F.R.S. Definition 856 Causes 857 Symptoms ..... 857 Acute Softening of the Brain . . 857 Chronic Softening of the Brain . 864 Pathology iMorbid Anatomy Diagnosis Prognosis Treatment 865 873 880 882 882 ADVENTITIOUS PRODUCTS OF THE BRAIN, by J. Russell Reynolds, M.D., F.R.S., and H. Charlton Bastian, M.D., F.R.S. Symptoms Diagnosis Morbid Anatomy 883 Prognosis . Treatment 901 901 CEREBRAL HEMORRHAGE AND APOPLEXY, by J. Hughlings Jackson, M.D., F.R.C.P. Morbid Anatomy . , , 902 Localization of Lesions — Etiology and Pathology . 905 Pons Variolii .... 914 Constitutional State prior to Cere- Medulla Oblongata 915 bral Hemorrhage , , 906 Cerebellum 915 Hemorrhage from Aneurism of the The Apoplectic Condition 920 larger Cerebral Vessels 910 Diagnosis 922 Localization of Lesions . 910 Premonitory Symptoms 923 Cerebral Hemisphere . 910 Mode of Onset of Cerebral Hemor- Lateral Yentricles 911 rhage 925 Corpus Striatum . 911 Special Diagnosis .... 927 Thalamus Opticus 91b Prognosis ..... 931 Crus Cerebri 913 Treatment 932 CONTENTS OF VOL. I. XXl ABSCESS OF THE BRAIN, by Sir William W. Gull, Bart., M.D. F.R.S., and Henry G. Sutton, M.B., F.R.C.P. ' History 934 Morbid Anatomy .... 936 Symptoms 937 Pathology 938 Diagnosis 940 Treatment 941 DISEASES OF THE SPINAL COLUMN, List of 942 DISEASES OF THE SPINAL CORD, by C. B. Radclipfe, M.D., F.R.C.P. App: Preliminary Remarks Meningitis Symptoms Post-mortem Causes . Diagnosis Prognosis Treatment Myelitis Symptoms Post-mortem Causes . Diagnosis Prognosis Treatment Congestion Symptoms Post-mortem Causes . Diagnosis Prognosis Treatment Tetajstus Symptoms Post-mortem Causes . Diagnosis Prognosis Treatment Locomotor Ataxy Symptoms Causes . Appearances App. App. earances 942 951 951 955 955 955 955 956 956 956 962 968 963 964 964 965 965 968 968 968 968 968 968 969 976 977 978 979 979 980 981 989 Locomotor Ataxy — Prognosis 989 Diagnosis 989 Treatment 990 Spinal Irritation . . . 991 Symptoms 991 Post-mortem Appearances . . 997 Causes 997 Diagnosis 997 Prognosis 998 Treatment 998 General Spinal Paralysis . 999 Hysterical Paraplegia . . 1000 Reflex Paraplegia . . . 1001 Infantile Paralysis . . . 1004 Spinal Hemorrhage . . . 1007 NoN-iNFL ammatory' Spinal Soft- ening 1008 Induration of the Spinal Cord 1008 Atrophy and Hypertrophy of THE Spinal Cord . . . 1015 Tumor of the Spinal Cord . 1016 Concussion of the Spine . . 1016 Compression of the Spinal Cord 1017 Caries of the Vertebral Col- umn 1017 Spina Bifida 1018 DISEASES OP THE NERVES, List of 1020 NEURITIS AND NEUROMA, by J. Warburton Begbie, M.D., F.R.C.P.E. Neuroma 1022 I Traumatic Neuroma 1025 NEURALGIA, by Francis E. Anstib, M.D., F.R.C.P. Definition 1026 Synonyms 1026 Clinical History and Symptoms . 1027 Varieties 1027 Complications 1037 Diagnosis . . Prognosis Pathology and Etiology Treatment 1040 1040 1041 1042 XXU CONTENTS OF VOL. I. LOCAL PARALYSIS FROM NERVE DISEASE, by J. AVakburton Begeie, M.D., F.R.C.P.E. ■J PASE PAGB General History .... 1048 Varieties • 1050 Prognosis ltlo3 LOCAL SPASMS, by J. Warburton Begbie, M.D., F.R.C.P.E. 1055 TORTICOLLIS, by J. Russell Reynolds, M.D., F.R.S. Definition 1060 Sj'nonj'ms 1060 Causes 1061 Symptoms 1061 Diagnosis 1062 Patlaology 1062 Prognosis 1063 Treatment 1063 LOCAL AN^STHESI^, by J. Warburton Begbie, M.D., F.R.C.P.E. 1064 li^^DEX 1067 List of Chief Authors keferred to dj Each Aeticlb .... 1109 LIST OF CONTRIBUTORS TO VOL. I. William Aitkek, M.D., L.E.C.S. Edinburgh ; Professor of Pathology in the Army Medical School, Netley. Francis Edmukd Anstie, M.D., F.K.C.P. ; Senior Assistant Physician to the Westminster Hospital, and Lecturer on Medicine in the Westminster Hospital Medical School. Heney Charlton Bastian, M.A., M.D., P.E.S., P.L.S.; Professor of Pathological Anatomy in University College ; Physician to University College Hospital. J. Wabbtjrton Begbie, M.D., P. B.C. P. Edinburgh; Physician to the Eoyal In- firmary of Edinburgh. Hermann Beigel, M.D. Berlin; M.R.C.P. Lond.; Fellow of the Imperial Leopold- Carolina Academy of Germany ; Physician to the Metropolitan Free Hospital. John Syer Bristowb, M.D., F.R.C.P. Lond.; Physician to St. Thomas's Hospital. Bernard Edward Brodhtjrst, F.E.O.S., F.L.S., Surgeon to, and Lecturer on Orthopsedic Surgery at, St. G-eorge's Hospital. George Buchanan, M.D., F.E.C.P. Lond.; Fellowof University College; formerly Phj'sician to the Lond. Fever Hospital, and to the Hospital for Sick Children ; Inspector of Public Health in Medical Department of H.M. Privy Council. Thomas Buzzard, M.D., M.E.C.P. Lond., University Medical Scholar ; Physician to the National Hospital for the Paralyzed and Epileptic ; formerly on the Staff of H.H. Omar Pacha. Thomas King Chambers, M.D. Oxon., F.E.C.P. Lond.; Hon. Physician to H.E.H. the Prince of Wales; Consulting Physician and Lecturer on Medicine in St. Mary's Hospital. Tilbury Fox, M.D. Lond., M.E.C.P.; University Medical Scholar; Physician to the Department for Skin Diseases in University College Hospital. Arthur Gamgee, M.D. Edinburgh, late Eesident Physician to the Eoyal Infirmary of Edinburgh. John Gamgee, Principal of the Albert Yeterinary College. Alfred Baring Gaeeod, M.D., F.E.S., F.E.C.P. Lond.; Physician to King's College Hospital, and Professor of Materia Medica and Therapeutics in King's College. Samuel Jones Gee, M.D., F.E.C.P. Lond., University Medical Scholar, Assistant Physician to St. Bartholomew's Hospital and to the Hospital for Sick Children. Edward Goodeve, M.B., Deputy Inspector-General of Hospitals H.M. Bengal Army ; Hon. Physician to the Queen ; late Professor of Medicine in the Medical College, and First Physician to the Medical College Hospital, Calcutta ; Member of the Senate of the University of Calcutta. Sir William Withby Gull, Bart., M.D., F.E.S., F.E.C.P. Lond., D.C.L. Oxon.; late Physician to Guy's Hospital. ( xxiii ) XXIV LIST OF CONTRIBTJTOKS TO VOL. I. John Harley, M.D., F.E.C.R Lond., F.L.S.; Hon. Fellow of King's College, Lon- don ; Assistant Physician to the London Fever Hospital. Henry Hartshorne, M.D., lately Professor of Hygiene in the University of Penn- sylvania, &c. Thomas Hillier, M.D., F.E.C.P. Lond.; Fellow of University College ; late Phy- sician to the Hospital for Sick Children, and to the Department for Skin Diseases in University College Hospital. Jonathan Hutchinson, F.K.C.S. Lond.; Surgeon to the London Hospital, and to the jNIetropolitau Free Hospital. J. HuGHLiNGS Jackson, M.D., F.E.C.P., Physician to the National Hospital for the Paralyzed and Epileptic ; Physician to the London Hospital. John Denis Macdonald, E.2f., M.D., F.E.S., Staflf-Surgeon to H.M.S. Victory. "William Campbell Maclean, M.D. Edin. ; Member of the Senate of the University of Madras ; Deputy Inspector-General of Hospitals ; Professor of Clinical and Military Medicine in the Army Medical School, Netley. James Furness Marson, F.E.C.S. Lond.; Corresponding Fellow of the Eoyal Academy of Surgeons of Madrid ; Eesident Surgeon to the Smallpox and Vac- cination Hospital. Henry Matjdsley, M.D. Lond., F.E.C.P., Physician to the West of London Hos- pital ; Professor of Medical Jurisprudence in University College, London. Gavin Milroy, M.D. Edinburgh, F.E.C.P. Lond.; Superintendent Medical In- spector to the General Board of Health. Edmund A. Parkes, M.D., F.E.S., F.E.C.P. Lond.; Emeritus Professor of Clinical Medicine in University College ; Member of the General Council of Medical Edu- cation ; Professor of Hygiene in the Army Medical School, Xetley. Charles Bland Eadcliffb, M.D., F.E.C.P. Lond.; Physician to the Westminster Hospital, and to the National Hospital for the Paralyzed and Epileptic. John Netten Eadcliffb, Hon. Secretary of the Epidemiological Society; Inspector of Public Health in Medical Department of H.M. Privy Council. J. Spence Eamskill, M.D. Lond. ; Physician to the London Hospital, and to the National Hospital for the Paralyzed and Epileptic. J. EussELL Eeynolds, M.D., F.E.S., F.E.C.P. Lond., Examiner in Medicine to the University of London ; Professor of the Principles and Practice of Medicine in University College ; Physician to University College Hospital. Sydney Eikger, M.D., M.E.C.P. Lond.; Professor of Materia Medica and Thera- peutics in University College ; Physician to University College Hospital, and to the Hospital for Sick Children. William Egberts, M.D., F.E.C.P. Lond.; Physician to the Manchester Eoyal Infirmary ; Lecturer on Medicine in the Manchester School of Medicine. William Eutherford Sanders, M.D., F.E.C.P. Edinburgh; Physician to the Boyal Infirmary, and Lecturer on the Institutes of Medicine, Edinbur"-h. Edw^ard Cator Seaton, M.D. Edin., M.E.C.P. Lond., Medical Department of Il.Zil. Privy Council. Edward Ssiith, M.D., F.E.S., F.E.C.P. Lond.; Inspector to the Poor Law Board; late Assistant-Physician to the Hospital for Consumption, Brompton. William Squire, I.E.C.P., M.E.C.S. Lond.; late Senior Surgeon to the St. Maryle- bone Infirmary. Henry G. Sutton, M.B. Lend., F.E.C.P., Assistant Physician to the London Hos- pital and to the City of London Hospital for Diseases of the C'liest. A SYSTEM OP MEDICINE. INTEODUCTION. BY THE EDITOR. Definition of Disease ; and 2Tames OF Disease. — The attempt to define " dis- ease" must be a failure until we are possessed of a satisfactory definition of "health;" and we are not likely to arrive at this possession until we are able to define the idea that we entertain of the still more fundamental fact of " life. " Yet some at- tempt at definition is not only important, but even essential, for the work set before us in these volumes ; inasmuch as the gen- eral ideas entertained about disease vary as the years pass on, and the position oi ''medicine" in the "system of the sci- ences" is not only expressed by the ap- proximative definition that we frame of disease, but is actually determined by tlio principle or idea which such definition is constructed to convey. If we regard disease in the "abstract," we have to deal with that which changes, fetters, renders painful, shortens, or puts an end to life ; and, from this point of view, disease may be defined to be any condition of the organism which limits life in either its powers, enjoyments, or duration. We need not stop to discuss the many futile essays that have been made to define that which transcends definition, but which we all, more or less accurately, understand by " life." We accept it as a fact, of which we all know much, but of which we are all assured, by what we do know, that there is much more that we do not know ; for it goes beyond our observation, not only at its beginning, and at its end, but in its middle term, when it is the most — but even then only partially — exposed to both our senses and our consciousness. Disease is a condition of the individual man ; it is always something more than the changes that we yet can recognize and describe in any particular organ or its func- tion. It is the man who is ill ; and, under all circumstances of illness, he has a di- minished life. Some organs may be over- VOL. I.— 2 active ; but their excess of work is needed either because work elsewhere has been left undone, or because it has been done so roughly that parts of organs have been killed before their time, and their wasted materials have to be changed and got rid of with all haste ; or because that which held their activity in check has been dam- aged or destroyed. At all times such over- work is fatiguing and hazardous ; often it is directly dangerous, and sometimes it is destructive. Disease is that which limits life — in its usefulness, enjoyments, or du- ration ; and although the body is so con- structed that it can often regain its bal- ance when the disturbance has been slight, yet disease, under all circumstances and to all degrees, is the lowering of life, and, even in its most trivial forms, is the "shadow of death." This mode of regarding disease furnishes us with the measures of its importance. A man is ill, or diseased, in degree exactly corresponding with this limitation of his life. A morbid idea may make life miser- able and useless ; a fatty tumor may be an unfelt excrescence. Many lives are spoiled by diseases that the anatomist cannot name ; many lives are but little altered by growths or lesions which may be weighed and demonstrated before a crowd. If we consider disease from another point, and deal with it as a "fact" of daily experience, we come to regard it as .any departure from the structure or functions of the body as these are shown to us in health ; and thus we may define it to be an abnormal condition of function, or structure, or both. But if we contemplate disease in its re- lation to the many "names" by which its various forms are recognized, we have a complicated problem with which to deal, and can only solve it by endeavoring to separate that which is common to all phases of ill-health, from that wliich is pe- (17 ) 18 INTRODUCTION. culiar to the various names by which those phases may be known, but by which tliey are only imperfectly expressed. And in order to do this we must recall some typi- cal examples of these names. A patient may be described as suffering from, or he may be said to be an example of, the dis- ease called inflammation of the lung, hoop- ing-cough, tuberculosis, anaemia, typhoid fever, hysteria, or of some other malady, which would or would not readily fall into one or the other of these categories. And be it observed that by this term " inflam- mation of the lung," is expressed a par- ticular kind of change in one organ of the body; by "hooping-cough" is meant a special and characteristic variety of a symptom common to many very different affections ; by "tuberculosis" is intended some general change in the whole body, distinguished from other general changes by its association with the appearance in one, two, or many organs of a particular material known as tubercle ; by " anae- mia" is understood literally only an ab- sence or deflciency of blood, but generally an alteration of quality rather than of quantity ; by " typhoid fever" is conveyed the idea of a change, of a particular type, in the whole organism, and one which is produced by the introduction into the body of a poison from without ; while by "hys- teria," and similar phrases, is conveyed some meaning or none at all, and, when the former, a meaning as various in cha- racter as are the individuals who use the word. There are other principles upon which disease has been named, and by which it is now described, but these ex- amples are suflicient to show by their very existence the varying prevalence, at dif- ferent periods, of diverse theories about disease ; about the relation of the one or- gan to the whole system of organs ; the nature of the changes which different or- gans may undergo ; the value of particular functional alterations, and of special symp- toms ; the relation of the blood to life, and to the tissues of the body ; the lien be- tween certain materials we can see, and some general conditions we can appre- ciate by their effijct on life ; the position in which life-functions stand to the vari- ous poisonous agencies around them, and the concealment, by patent facts of little moment, of important conditions which may be inferred to be their cause. Thus the history of a science might be shown to be written in the names by which the objects about which it is concerned have been described and recognized : but such is not the end now in view ; it is to show that the principles upon which diseases have been named have varied widely, not only at different periods, but at the same ; and that so great is the diversity among them, and so strangely aberrant are the forms which disease sometimes assumes, that, hitherto, no self-consistent and at the same time practical nosology has been devised. English physicians have there- fore thought it better to retain old names that were well understood, although based upon doubtful, if not erroneous pathology, rather than to invent new terms which could not possess the advantages of their predecessors, although they might very probably share their faults. We have therefore gradually accepted a nosology of most complex composition with the tacit or expressed admission on all hands, that by "pneumonia" is intended much be- yond the particular condition of the lung ; that it implies changes antecedent to itse'lf in the general nutrition of the body, and alterations in all the tissues and in their processes when the disease itself appears ; that the words "hooping-cough" convey more than is included in a particular va- riety of cough which is characterized by a hooping sound, viz., the well-known his- tory and social relationships of a disease altogether distinct from the paroxysmal cough and hooping sounds not rarely met with in cases of chronic bronchitis and emphysema; that by "tuberculosis" is intended a condition as well marked by general as by local changes, and probably dependent upon some constitutional vice which determines, and is not determined by, the special form of local change ; that by "anaemia" is meant much more than the mere etymology of the word can con- vey ; that by "typhoid fever" is intended the description of a disease having rela- tionships only very inadequately expressed by the words in common usage to denote it; and that by "hysteria" and similar expressions are understood more than the present state of medical science will ex- plain, and much more than the words themselves accurately define. In this state of medical nomenclature, and of medical science as represented by the names it sanctions, it is difficult to ar- rive at any other definition of " disease," than that it is the sum total of morbid changes in both function and structure ; and we must further admit that the names by which diseases are recognized are some- what arbitrary terms used for the purpose of recognition without any constant value as to the meaning of those words in a sys- tem of pathology. Sometimes the name expresses what is believed to be the essen- tial or most important fact ; sometimes the first link in a long chain of causes and effects ; sometimes a characteristic symp- tom or group of symptoms ; sometimes an idea as to the mode of origin of the dis- ease; and sometimes such a negation of all theory as contents itself with words which shall be understood to mean certain things to which they bear no more pathological relation, although they may have more seeming scientific value, than the common STRUCTURAL AND FUNCTIONAL DISKASE. 19 algebraical expressions for "unknown qualities," — x, y, z. But there is, underlying all our nosol- ogy, an idea of something special or indi- vidual in the diseases that we name. This notion is distinctly expressed with regard to some, hinted at in relation to others, and unsuccessfully concealed in respect of the rest. In spite of opinions to the con- trary, the physician knows that there is, in his mind, an ideal type of disease, which he cannot define, and cannot find realized in actual practice, but yet to which type he refers the examples that come before him. Disease to him is something more than a group of symptoms, it is that which makes the group ; and he is — as indeed he ought to be — like the naturalist in his pro- cess of nomenclature, striving to express, by the names he uses, that which occa- sions the inner relation between essential facts, and not merely that which will de- note the outer and often quite superficial assemblage of phenomena. As, however, the idea above alluded to is very different in different minds, and pathology is, as yet, in such a condition that it cannot furnish a complete scheme of nosology, based upon the attempt to express, by name, the fundamental fact of all the many maladies with which we are acquainted, disease is defined to be the sum total of changes from a condition of health which may be recognized in either function or structure, or both ; and the names of diseases are held to be merely convenient expressions for their recog- nition. StEUCTUBAL AND rtTKCTIOlSrAL DIS- EASE. — In describing the elements of what we call disease, two terms have been fre- quently used, "structure" and "func- tion ;" and we know that the two phrases "structural disease" and "functional disease" have passed into common usage. Eecently it has become somewhat the fashion to object to the latter, and to deny the existence of any such condition. It is necessary therefore to state the grounds upon which the phrase "functional dis- ease" has been retained in this " System of Medicine," and tlie precise sense in which it is employed. For this purpose three classes of facts have to be remembered. 1st. That there are some structural alterations, such for example as atheroma in the vessels, which may, if an individual has been killed by an accident, be found extensively distrib- uted throughout the body, the existence of which had been neither known nor sus- pected by the presentation of any func- tional change, or symptom, during life. On the other hand, a man may have suf- fered for many years from discomfort, or marked derangement of the functions of the brain, heart, or lungs, and yet the most practised anatomist, with all means and appliances to help him, may fail to dis- cover, post-mortem, any organic change which is sufficient to have accounted for them. 2d. Another class of facts, con- stantly lost sight of by those who deny the existence of functional disease, is to be found in the relations between structure and function in health. At the end of a day's work, and after a night's repose, we might find the two extreme conditions of the organism as regards function. For twelve hours every muscle, nerve, and organ has been doing its utmost, and, as we know, has been wearing out : during the hours of sleep, many organs have been doing little, and some nothing, whereas others have, as it seems, to work on with- out repose ; but in all repair has been going on. By an examination of the body, killed suddenly at the end of one or the other of these periods, it might be possible to infer which had been the condition immediately preceding death. But this inference would be based upon the relation exhibited between the products of func- tional activity, such as the nature, quan- tity, and quality of the secretions in their several receptacles ; and the raw materials upon which the organs have to work, such as the nature, quantity, and quality of the chyle, lymph, and blood. It would not be formed upon regard directed only to the condition of organs which had been either in activity or repose. It could not be so based, because the process of repair in the living, healthy body is one that is simulta- neous and commensurate with waste. The muscles are not mended up as we mend a damaged wall, by patching up a hole here, and binding on an iron brace or girder j'onder ; but the process is interstitial ; new material is brought in, and brought everywhere ; the existing organ is worn down, and the waste matter is carried away ; but, with all this change, there is a persistent ttxtural result. Looking at this question still more closely, we see that function is related to structure, not only in the sense that it is what the organ does, but in the much more important meaning that it is at once the expression of the wear and also of the repair of tissues ; or in other words the outcome of their life. In the present state of physiology, it is impossible to conceive of a living organ without believing in the nutritive, mole- cular changes it is undergoing ; and these are the essential conditions of its func- tional activity : it is equally impossible to imagine the function of any living tissue being called into exercise without recog- nizing the dependence of this functional operation upon interstitial movements of repair and waste. But we should be wrong on the other side were we to con- found function with the nutritive changes which constitute, not the function itself, 20 IXTRODUCTIOX. but the conditions of its exercise. It is, for example, the peculiar function of a muscle to shorten itself, of a nerve to con- vey an impulse either of motion or sensa- tion, and of a nerve-centre to convert one of these impulses into the other ; the or- gans referred to, in exercising these func- tions, undergo certain nutrition-changes ; hut these molecular changes are not the functions of the organs, but the conditions essential for their performance. This prin- ciple, vi^hich it seems almost unnecessary to state, in regard of the particular organs or tissues now referred to, is, however, not unfrequently lost sight of in respect of secreting organs. It is the function of the salivary gland to secrete a fluid having special characters ; of the liver to do this, and to effect changes in the blood which comes to it ; and so of other secreting or- gans : they receive blood into them, and from all of them it passes away, changed ; and the organ, as part-product of this change, gives up its secreted matter. These functions, be its observed, depend for their performance upon nutrition- changes in the cells and tissues of the or- gans ; but those fine processes of change are the conditions of functional activity, and are not to be confounded with the thing itself. The secreting cell has to live, to waste, and be repaired; and it lives at a degree of pressure, and is wasted and repaired at a rate, directly proportioned to the amount of work that it accomplishes; and thus it is conditioned precisely as are the ultimate elements of the muscle or the nerve. But minute as is our knowledge of much that goes on in the secreting or- gans, and of the chemical nature of the results or products of their work, we know no more of the physical conditions which determine that one set of cells shall sepa- rate urea, another set saliva, and a third bile acids from the blood, than we do of those which enable one nerve-fibre to con- vey impressions of hght, another of sound, and another those of motion. These are, at present, ultimate facts of physiological science ; the function is the expression of the life of the structure ; it is what the latter was constructed for the purpose of doing ; in doing it, the structure under- goes change ; it is wasted and repaired, but these processes are carried on without any breach in the integrity of tissue. Function is to nutrition, as electricity is to the chemic changes in the galvanic battery, a "correlated force." We do not say that the one is the other, but that it is converted into it ; and, as in the in- organic world, the arrangement and na- ture of the particular materials witli which difierent forces come into contact, determine whether chemic action shall appear as heat or magnetism, w^hether heat shall be sliown in motion, light, or electricity, so do the different materials of the living organs, and their arrangement, determine the nature of the functions they perform : how they do this, we do not know, but the facts of physiological science are well known, viz., that the nerve cell exhibits one class of powers, the muscular cell another class, and the secreting organs a third. 3d. A third class of facts'to be remembered is, that in many diseases, the only symptoms to be recognized are changes in the degree of activity with which "certain organs per- form their functions. JSTo new element is introduced by some diseases into the cate- gory of vital actions ; such affections as chorea, hysteria, epilepsy, might be shown to consist of mere modifications in the de- gree, time of occurrence, and combina- tions of functions, each of which, taken per se, is consistent with health. The sudden loss of consciousness in epilepsy, for example, is not more mysterious than is the sudden hut every-day recurring passage from wakefulness to sleep ; the arrested respiration is similar in kind to that seen when the chest is fixed in the performance of any great muscular exer- tion involving the upper hmbs ; and still more similar to that which can scarcely be called morbid, the prolonged apnoea of a screaming child, whether tlie scream be the expression of terror, temper, or pain : the convulsive movements are neither more nor less than nerve and muscular functions, any of which might separately, and many of whicli might in combination, be the expression of healthy vital activity. Prom these three classes of facts, there- fore, we are compelled to admit that, in the present state of science, the onus prohandi lies with those who assert the constant presence of structural in association with functional change ; and we affirm that those who make the assertion have never proved their point. Further, that as a matter of inference from what we know of the relation subsisting between struc- ture and function in health, we should not even expect to find solutions of continuity or coarse changes of texture in those dis- eases, the essential elements of which are functions altered, not in kind, but only in degree and mode of association ; and that, on the other hand, when we do find mate- rial changes in association with functional disturbances, we should refer many of the latter only indirectly to what we see of the former, the more numerous and more important of them being dependent upon what we do not see, viz. the finer chanizes in the interstitial processes of nutrition. A scirrhous tumor of the stomach, for ex- ample, may produce certain symptoms easy explicable by its mechanical effects ; it may be so situated as to prevent the in- gress or egress of food ; but vomiting may occur when the orifices are free or when the tumor is situated in some orr^an in the NATURAL HISTORY OF DISEASE. 21 pelvis : the supposed tumor may cut off the supply of food, and so explain some of the changes we see in color and general nutrition ; but, on the other hand, the ex- treme of wasting and of cancerous tinting ma}' be seen when there is no such enforced abstinence from food, but when indeed a large quantity is not only taken, but is di- gested and enjoyed. So again a clot of blood in the corpus striatum may sever the nerve-fibres, and so explain the severance between the will and certain muscles of the extremities ; but it will not so explain the presence of convulsions, or of spasms in those palsied limbs. For these reasons we retain the words "functional disease;" understanding by them such changes as have no recognized morbid anatomy, but such as depend upon corresponding changes in the finer pro- cesses of nutrition. We do not believe that there is any altered function without a correlated change in the nutrition of the organ ; but what we assert is that such a change, as a matter of fact, is of such kind as to be undiscoverable by our senses, and as a matter of inference, from what we know of the relation between nutrition and function, is of such nature that it may always be beyond the reach of observa- tion. No healthy function is performed with(3ut nutrition-change; no morbid func- tion can exist without altered nutrition- change ; but the relation between the two elements, "structure" and "function," is the same in the two conditions. Nothing is more erroneous than the common notion that " functional " means trivial, and that "structural" means se- vere. Many diseases, designated by the former word, are long-continued, obsti- nate, or destructive ; many known by the latter are of short duration, are amenable to treatment, or are harmless. Diseases which spoil or shorten life are not trivial because they depend upon such fine changes as may escape our observation ; but they are the more serious when they thus elude our notice, just because they have their place in the very centre — the most ultimate process and fact — of life, the eonduct of nutrition. Natural History of Disease.— Un- der this phrase are recorded the symptoms or phenomena of disease, their causes, the manner of their development, their dura- tion, and the different mode of their termi- nation, whether the termination be in death, or in a return to health. In the natural history of disease no theory is in- volved'; we have to deal only with facts. Caiuses. — Commencing with that which precedes the appearance of symptoms, viz. the "causes" of disease, there are some principles which it is important to lay down ; inasmuch as our ideas of the caus- ation of disease are determined, in great measure, by our conceptions of what dis- ease itself is. Nothing is more easy some- times than the discovery of a cause, and its distinct separation trom a particular and well-known malady. Por example, a healthy child is brought into a room where some one is suffering from scarlet-fever, and after a certain period it exhibits symp- toms of the same malady, and passes through all its stages. Here we say there was direct communication of the malady; but we must not forget two facts, first that some children so exposed do not take the fever, although they have not previously had the disease ; and secondly, that those who have suffered from it once rarely take it again, although they may be exposed to infection. We suppose a constitutional disposition in one case, an indisposition in a second, and assert the existence of the latter in a third. Still, when the cause has operated we feel that we tread on safe ground when asserting broadly that the cause is "infection." Nothing, however, is more difficult in some cases than to say what the cause of a disease has been. For example, six people take an indigestible meal, and one of them suffers nothing, a second is trou- bled with dyspepsia, a third with asthma, a fourth has an epileptic fit, a fifth an at- tack of gout, and a sixth is disturbed with diarrhcea. One element in the causation of all these maladies is the same, viz. an indigestible meal, but the results vary widely; and we say that this is owing to constitutional conditions which "predis- pose" to these particular affections. These have been called "predisposing causes ;" but we must inquire what they are, and how they are related to these diseases, if we would understand the latter. Among the predisposing causes are reckoned he- reditary taint, sex, age, and constitutional peculiarities, either congenital or acquired; and with regard to two of these, heredi- tary taint and constitutional peculiarity, we must admit that they are, in reality, disease. When we allow the existence of either, we but throw back a few steps fur- ther the line and widen the circle which includes all that we mean by the disease itself: we include in the malady more than its name expresses ; we partially ac- count for its occurrence, but do not ex- plain its "cause." It is quite true that we may sometimes draw a line between certain so-called causes and effects ; we may say, for example, this man, of tuber- culous family and with latent tubercle, was yesterday apparently well, but he was exposed to cold, and to-day he has tuber- cular pneumonia ; his constitutional state "predisposed" him to the evil, which the exposure "excited" into activity ; but re- garding him from a pathological point of view in his present position, that of a suf- ferer from tubercular pneumonia, we can- 22 INTRODUCTIOX. not separate the elements of his disease so easily, for it was not a cause of his malady which was there before, but an integral part of the affection under which he is now laboring. A similar difficulty is to be encountered on almost every hand ; the worry of the Stock Exchange is borne by some men bravely, others succumb, but va- riously, one goes mad, another is " broken down," a third becomes epileptic, and so on; and we fly to the resource of "pre- disposition," some weakness somewhere, ■which this wear and tear has pointed out, and urged into morbid activity ; but in that very weakness, if there was not the whole of the disease called A, B, or C, there was some important element of it, and not its remote or predisposing "cause." If disease be, and we believe it must be, defined to be the sum total of changes in either structure or function, or both, then almost all of these so-called "predisposing causes" are part of the disease itself. But those other conditions, sex and age, it may be asked, are they integral ele- ments of disease, or are they its cause ? Sex cannot be said, accurately, to be a cause of disease any more than the same can be affirmed of hfe, but yet, in all modern treatises on medicine, it figures in the chapter on etiology. Be it observed, however, that the word " sex" when thus used, has reference to many conditions of difference beyond those which exist in the reproductive organs. The male sex, as a rule, exhibits the masculine frame of body and of mind, while the female sex dis- plays the opposite, and their respective " predispositions" to disease have relation to these characters as well as to the phys- ical structure of the apparatus of repro- duction. Tlie existence of an organ is the necessary condition of its becoming diseased — a man cannot suffer from ova- rian tumor, nor a woman from orchitis — but there are some organs common to the two sexes, and equally developed in each until the sexual distinctions of puberty are seen ; then in the one they become rudimentary and inactive, whereas in the other they take on new and important functions. In these instances sex may be said to be a predisposing condition of dis- ease, but it is so only in this sense, that it exposes certain organs to some of the causes of disease by the simple fact of their functional activity. It must not be supposed that the healthy action of any organ predisposes it to morbid change ; on the contrary, it exerts rather a strength- ening and protective influence ; but such activity simply lays it open to the opera- tion of influences which cannot be brought to bear upon its coiinterpart which re- mains in a rudimentary condition in the other sex. But besides these essential dif- ferences there are others whicli are acci- dental, and which depend upon education, practice, and habits of life, as these are determined by the customs, fashions, or peculiarities of the people and their times. And, further, there are many facts with regard to the relative proclivity of the sexes to special diseases which have not yet been explained by any known relation of these maladies to the reproductive or- gans. Simple ulcer of the stomach and carcinoma of the same organ afford exam- ples of this difference of proclivity, and we at present have to regard them as ulti- mate facts of pathology. Among the conditions which deter- mine, therefore, the differences of sexual predisposition to disease we reckon (1) the actual presence or absence of the organs ; (2) the action or almost absolute inaction of the organs ; (3) the relation between the amount of activity of some functions of cer- tain systems of organs, and other functions of the same systems, where differences ex- ist ab initio; and (4) the effects of habit, education, and fashion, in either produc- ing or lessening functional activity, with ali its correlated structural conditions. In a similar manner must we regard the influence of age in the production of disease. It is not per se a predisposing cause, but it carries with it certain things which may be. If we can conceive of a perfectly healthy organism, placed in ab- solutely healthy conditions, then we may believe that it would pass through the stages of growth, dentition, puberty, adult life, and decline ; and that it would per- form all the functions of self-preservation and reproduction without either hurt or hindrance ; sometimes, nay, very often, we do actually see some of these stages passed through with as entire a freedom from discomfort as any ideal being placed in the most Utopian circumstances could wish for ; but at some point or another in the long course of life, the chain of good succession is broken by a faulty link or an unexpectedly heavy blow, and then follow one or another of the many ills that make up the miseries of common life, and ave- rage health. On the other hand, we see cases in which nothing seems to be capa- ble of going well ; every epoch, every change, every organ, seems, as it were, pounced upon at every turn by all the evil agencies that surround it ; action or inaction, gi-owth or decay— it matters not which — seems exaggerated into a condi- tion of disease, and life is a lifelong mis- ery. It is clear that no one period of life is in itself a cause of disease, or of exemp- tion from its occurrence, since all periods may be passed through without any dis- turbance of the health, and no period pos- sesses absolute immunity from its attack. But it is also evident that the changes which take place at certain periods, render some individuals liable to the operation SYMPTOMS OF DISEASE. 23 of other causes, and that this operation may be very ettectual in tlie production of disease. Such periods are those of rapid structural development, and the com- mencement of new functional activities, or the decline of structure and the arrest of action. That which would seem to be the condition tending to morbid develop- ment is the disturbance of the balance of activity and growth between different or- gans, or systems of organs, so that for a time at least an undue preponderance is given to a certain set. Thus during the tirst dentition, although there is general growth, there is particular activity of cer- tain organs ; and, in like manner, at the commencement of puberty, there is, as it were, undue prominence given to the or- gans effecting reproduction ; and although the particular structures involved in these developmental changes may not be se- lected as the localities for morbid action, the very fact of their disproportionate ac- tivity — by a disturbing balance of general nutritive progression — may become a cause of derangement in other systems of organs, such as the vascular or nervous. In like manner, at the climacteric period, the repression of certain functions, to the operation of which the whole body has become habituated through a long series of years, may prove itself the starting- point of morbid changes in the functions of other organs which are, by this repres- sion, placed in new and trying circum- stances. By these considerations we may, for the most part, explain the influence, where it is marked to the highest degree-, of age as a so-called '' predisposing cause" of disease. But tliere are some maladies which ap- pear to have a definite relation to age, and which are not explicable upon these principles ; and with regard to these we must admit tliat certain periods of life are associated with proclivity to disturbances of particular kinds, the nature of tlie rela- tion between the two classes of conditions being at present unrecognized by medical science. At the same time the history of all science is such that it teaches us to believe that these relations will be here- after discovered and found to be analogous to those which we already understand and appreciate. The term "exciting cause" of disease has been applied to another class of con- dition altogether, and one with regard to which there is much less difficulty. That which is involved in the term is the ope- ration of some influence from without, be that such as to act upon mind, emotion, sensation, nutrition, vascular conditions, temperature, or any other function or property of the living body. A great sur- prise, or an overwork, may affect the mind ; a domestic calamity, or the worry of business, maj^ disturb the emotional centres ; a physical injury may set up changes in sensation ; a forced rest may weaken muscular nutrition ; a tight band- age, or an altered position, may influence the vascular supply ; cold or heat may di- minish or increase the temperature of parts ; and in like manner other agencies may affect the organism, and become the exciting causes of disease. The form the latter take is determined partly by the nature of the exciting cause, and its rela- tion to this or that system of organs ; and partly by the condition of the organism, in regard of hereditarily received or cou- genitally acquired morbid state, the pecu- liarities of sex, and the period of life. Two things therefore concur to make up what we term the causes of disease, but they are essentially distinct, and it would be better to denote them by differ- ent names, than by one name differently qualified. The one, the so-called "pre- disposing cause," is a "diseased condi- tion," and is therefore a part of the disease itself ; the other has no necessary relation to the individual or his constitution, and is in reality a "cause" of the disease from which he is suffering. Symptmns of Disease. — The meaning which now we must assign to the word "symptom" or "sign" of disease, is very different from that which some time ago would be conveyed by those terms, ^o long as disease was regarded as some- thing put into, added to, or engrafted upon the body ; a material, or other en- tity, — having even a more or less substan- tive existence, — these words described the means by which we might recognize the presence of such an entity : but so soon as disease is recognized to be, as we have defined it, the sum of changes in function and structure presented by the living be- ing, the words "symptom" and "sign" have another meaning, and describe onlj-- those parts of the disease which are ap- preciable by others. Disease is a complex state of a complicated organism, and al- though the iiatne which we may give it may be intended to express its primary or most important fact, we cannot separate this one fact from others with which it is associated, but must regard them as inte- gral parts of the malady we have eitlier to study or to treat. They may differ, from an outside point of view, in proximity of relationship ; but the heat of skin, the altered pulse-respiration ratio, the natui-e. of the expectoration, the changes in the secretions, in the nervous system, and in the prospects of life, together with the al- tered resonance, breath and voice-souiads, are as much parts of the disease called "pneumonia" as are the structural condi- tion of the lung. Some of them may be signs by which we recognize its presence ; but they are also essential elements: of the malady itself. In like manner it might 24 INTRODUCTION. be shown with regard to those other dis- eases, the noiiieuclature of which dift'eis as we have ah-eauy described, that a pre- cisely similar relation exists between what we have denominated "sj-mptoms" and what we understand by "disease." AVe cannot know of the existence, during life, of any disease except by its symptoms ; we cannot conceive of disease apart from some recognizable changes in either func- tion or structure ; and these changes con- stitute the disease ; nor can we, on the other hand, imagine the existence of what we call " symptoms" apart from the cor- relative idea of what we conceive to be "disease." The two classes of notion have been, of necessity, distinct in their development ; but the maintenance of the distinction between them has been a hin- drance to true progress in pathology ; and it will be well for us to try and remove that hindrance. So long as "disease" is thought of as a something — it matters not what — distinct from the "phenomena," or " symptoms," by which it makes itself known, so long are we in danger of mis- taking its real meaning, and of overlook- ing those true guides towards the removal or alleviation of its evil, an end to which all medical science ultimately points. "Disease," we have said, is a change of structure, or of function, or of both ; "symptoms" are those changes in struc- ture or function, or both, which we can recognize. The latter, the symptoms, are not separate from, but are parts of the disease, and their only characteristic is that they are such parts as are apprecia- ble during life. But they differ in kind and in value among themselves, and have heen known by different names, so that we meet with such distinctions as tliose between "signs" and "symptoms, " be- tween "objective" and "subjective" symptoms; and between "general" and " local" symptoms. These terms almost explain themselves, and are retained be- cause they possess a certain amount of utility ; but it is more easy to make use of them in practice than to define their exact meaning in the abstract. The idea underlying the word "sign" is that it is some physical change which can be ob- served directly ; and thus we speak of dul- ness on percussion, tubular breathing, augmented vocal fremitus, and broncho- phony, as "physical signs" of condensa- tion of the luns ; whereas we speak of dj'spnoea, expectoration, and fever as "symptoms" of pneumonia, or tubercu- losis. But heat of skin, an eruption on its surface, the wasting of a muscle, or the fact and quality of a secretion, are as much " physical signs" of a disease as are the particular phenomena we have men- tioned. Yet it is almost unknown, it is certainly very unusual, to hear the term "physical sign" applied to any of them. It is easy to trace the origin of t'.iis dis- tinction between symptoms and signs to the period when the physical examination of the chest arrived at its due position. It was felt that an amount of precision in diagnosis was arrived at by percussion and auscultation, such as was never dreamed of in the times before such modes of exploration were employed ; and therefore the conditions revealed by their aid were expressed in terms differing from those which had been previously em- ployed, to describe such changes as short- breathing, pain, expectoration, and the like. But it is impossible to maintain the distinction ; the number of respirations per minute is as much a " sign" as is the dulness on percussion, and both of them may be " symptoms" of disease. Every- thing that may be observed is both the one and the other, and the reason why the distinction has been maintained is, be- cause with regard to the former — the " sign"— there may be but one means for its recognition, namely, observation from without ; whereas with regard to the latter — the "symptom" — there is a pos- sibilitj' of confounding two things essen- tially distinct, namely, the sensations of the patient, and the phenomena he pre- sents. Deficiency of resonance is dis- covered only by percussion ; hut short- breathing is a sensation of which the patient complains, as well as a pheno- menon which may be appreciated and measured by the ishysician ; and in like manner wasting of a limb may make itself at once evident to the observer, whereas paralysis is a condition which the patient may assume. The really valuable element of distinc- tion between these two classes of pheno- mena is therefore that which exists be- tween "objective" and "subjective" symptoms ; meaning, by the former word, ah those elements of disease which can be appreciated by the senses of the observer, and by the latter, those which can only he known through the statements of the pa- tient. Whatever of disease comes to us only through the mind or feelings of the patient, as expressed by language, either of gesture or words, is a "subjective" symptom. Its form and its degree of in- tensity are subjected to the conditions of the machinery — mental, emotional, and sensational — through which it passes, and it is liable therefore to be changed, either in character or degree. Whatever of dis- ease comes to us through our own senses alone escapes this danger of addition, alteration, or subtraction, and is pro tcwlo of higher value. In one class the patient gives his version of his case ; the symp- toms are such as we can only get at through his mind, and they are termed "subjective ;" in the other, we make our own observations— the feelings or ideas of COURSE AND DURATION OF DISEASE. 25 the sufferer have nothing to do with them — simply, physical facts are the objects we recofiuize, and such symptoms are called '"objective." As a general rule the objective are much more valuable than the subjective symp- toms ; but let it be remembered that the importance of the latter is very widely variable, and that sometimes it may far exceed anything that can be derived from direct observation. In the early stages of some serious diseases of the heart or brain, nothing may be presented to the practised ear or eye ; and yet the patient tells us of a deep unrest, or sudden horror, which, although it has no objective sign, may be the herald of a sudden or lingering disease ; as true and as important — although to others the mind seeuis clear, and the heart's beat healthy — as any murmur we might hear with the stethoscope, or any palsy we might measure by the hand. We have to deal with man as a whole ; and to ignore or undervalue what he tells us of his ideas, emotions, or sensations, because they may be termed "subjective symp- toms," and be held to be therefore unre- liable, would be to shut out from ourselves that which — egotistic and fearful, preju- diced and ignorant as man may be — yet forms an integral part of his life, and therefore of his disease. We must be careful to give to both groups of symp- toms their true value, and our danger in the present day is to underrate the im- portance of those which, a few years ago, constituted almost the total symptoma- tology of disease. The distinction between "general" and "local" symptoms need not detain us, since the terms are obvious in their mean- ing, and the difference between them is gradually dying out by the recognition of the fact, that no one organ can have its functions or its structure changed without the existence of some relative change in all the rest. Course. — In describing some few dis- eases we have little more to do than to detail the phenomena present at any one given time ; whereas in furnishing the natural history of others we are compelled to speak of premonitory symptoms, or prodromata, of the modes of commence- ment of the illnesses, their forms of attack or their debut, and of the different stages ^two, three, or more — through which they pass. Between these two extremes we have every amount of variation : the natural history of one disease may be compressed into a sentence ; that of an- other may expand into a book ; but more commonly we have to deal with histories intermediate in duration, and perhaps less emphatic in their interest. It often happens, however, that the mode in which one event follows another is of great importance in the diagnosis of disease. For example, the decumboncy in pleurisy has different meanings at the commencement of the malady, and at its later stages ; and in like manner rigid muscles teach one thing at the onset of a paralytic seizure, anotlier when the im- mediate effects are passing off and the pa- tient is regaining power ; and still a third when without such restoration it makes its appearance at a yet later period, and in a well-known order. Not merely the mode of sequence, but the actual time of sequence, is of diagnos- tic and therapeutic value ; and this we know full well in the study and recogni- tion of the acute specific diseases, of mala- rial fevers, and the like ; and with equal significance, though with less accuracy of measurement, can we use the element of time in the diagnosis of many chronic diseases ; and such element may some- times be sufficient to determine a question left wholly in the dark by other elements which we liave had before us. In this manner time enters occasionally into the diagnosis of tubercle, of cancer, of hemor- rhage, and of other maladies ; and it would be difficult to overrate its value in those special cases which are left in obscu- ,, rity by the absence of special or pathogno- monic symptoms. Again, the relative intensity of symp- toms is a point to which attention must be frequently directed, for by this alone a diagnosis may be possible. If we regarded the relative intensity of pain, dyspnaa, fever, cough, and general nutrition- change, each of which might be present in bronchitis, pneumonia, pleurisy, phthi- sis, or asthma, it might be possible to say which disease existed, and this without the aid of auscultation or percussion. And in like manner by regarding the relative amount of coma, paralysis, spasm, and rigidity, it would be possible to dis- tinguish, in some cases, between cerebral hemorrhage, acute softening of the brain, congestion of the brain, or urinsemia. All these particulars have to be de- scribed under the head " course" of symp- toms ; and they form an essential part of the natural history of disease. Duration. — The importance of a consid- eration of time in the diagnosis of some classes of disease has already been referred to ; it is of no less importance when, diag- nosis being determined, a knowledge of the natural history of disease gives us power to foretell, with some approxima- tion to accuracy, its probable results. We know approximately the duration of herpes zoster, of vaccine, or variolous pustules, of typhus, or scarlet fever ; and we know also, approximately, the dura- tion of phthisis pulmonalis, of carcinoma ventriculi, and of other maladies. With regard to the latter— the chronic class^ our knowledge is much less definite, or 26 INTRODUCTION. rather it lies within a larjier range, and is of less practical utility. It may, regarded from a pathological point of view, be even more accurate than that which we boast of in respect of the acute diseases; for the relative range of variation is not greater, although in the one case we deal with days or even hours, and in the other with months or years. But life is on one side of the balance, and death is on the other, and the balance is struck between these two, whether the beam be long or short ; and so we congratulate ourselves upon a readily used and readily appreciated fore- casting of the immediate, present evil, and perhaps underrate our sounder knowl- edge, with regard to that which may not happen for ten, twenty, or a hundred months. The duration of sj'mptoms, therefore, though of variable social value, is of vast interest in the natural history of disease Termination. — A disease may end in various ways : (1) The patient may gradually get rid of it altogether. (2) Ho may lose all the urgent symptoms — all that at one time seemed to constitute the malady — and yet retain some less urgent symptoms ; or some which are not recog- nized at all ; or some which — so far as the patient's own feelings are concerned — are not, even after recover}', recognizable, but wliich may be discovered by a physical examination of the organs instituted by the physician. (3) He may continue to present all the local disturbances, while the general or constitutional changes pass away, and thus the disease persists, but in an altered and what is called a '' chro- nic" form ; or (4) the disease may become worse, pass from one stage of weakness to another, and end by the destruction of the patient, which may be brought about in various ways. Now, all these points in the natural history of disease, are of much interest in regard of prognosis and of treatment. The recognition of early signs of recovery is a great help towards the choice between therapeutic means, and is a good ground for employing one of the strongest of these means of cure, viz., hope. The search for and discovery of the eifects of an acute illness — although in that acute form it has passed away — are of great importance to the life, pros- pects, work and career of the unconscious sufferer. We must know these probable consequences if we would perform our du- ties as the advisers of those who place themselves under our care. It is not enough to guide a disease to an apparently successful issue ; we must know what weak point it may have left behind, and we must guard this with the utmost cau- tion. Again, the tendency to pass into a chronic form often reveals the existence of some constitutional vice we had not before suspected, and thus renders itself available for a more effective direction of our therapeutic agencies. And, lastly, the perception of the early indications of a fatal issue may be of great social or in- dividual value ; whereas the recognition of the mode in which death threatens to approach, may be the means of teaching us to select such measures as shall tem- porarily, or even indefinitely, postpone the evil. Thus the "terminations" of disease, whether they be in health, in im- paired health, or in death, are not only of interest to the natural historian and the pathologist, but are full of teaching to him whose aim is to render natural history and pathology subservient to the great work of healing diseases, of relieving them, or of measuring their duration, and lessen- ing the pain with which they do their work. Diagnosis of Disease.— In the earlier days of medical science, the problem of diagnosis might have been stated thus : "given the symptoms, to find the dis- ease;" but, in these days, such problem must be translated into the following terms: "given some of the elements of disease, to discover the others." We do not now regard erujjtions on the skin, pe- culiar changes in the mucous membrane of the throat, an elevated temperature, and a disturbed innervation as the signs by which some morbid "entity" in the body reveals its presence ; but as parts of the morbid condition of the organism, from which we may infer the existence of simultaneous changes in stomach, in- testines, hver, spleen, or kidneys. The rose rahh of tj'phoid is as much a part of the disease as is the ulceration of Peyer's glands ; the dulness on percussion, the altered condition of the urine, the changed nervous power, are as truly elements of the disease called pneumonia as are the minute alterations which constitute in- flammation of the lung. Some of the ele- ments of disease escape our observation during life ; some are directly perceived by us ; and others are appreciated in- directly by such processes as percus- sion, chemical examination, laryngoscopy, spirometry, and the like: but the only difference between these is their relation to the observer ; they occupy precisely the same position in regard to the disease itself. The process of diagnosis therefore is the passage, not from effects to causes, not from phenomena to noumena, for, strictly speaking, we do not at all know what are either the causes or the noumena of disease ; but diagnosis is the process by which, perceiving some particulars, we infer the existence of others, which we know to be commonly associated with them. This is however the pathologic or scientific side of diagnosis ; and the ques- tion may still be asked. What is it practi- PATHOLOGY. 27 cally ? Practically, diagnosis is the pro- cess by wliich to a certain set of symptoms we affix a more or less familiar name ; and become able to say that such a one is suffering from typhoid fever, meningitis, hooping-cough, epilepsy, or gout. And when we have given some names to dis- eases, we have, more or less intentionally and with differing degrees of accuracy, conveyed some theory into the process of diagnosis. Eemembering what was said with regard to "names of disease," we shall find that, in this practical sense, diagnosis is sometimes the discovery of and the calling of a disease by what we conceive to be the most important struc- tural change by which it is accompanied, such as pneumonia ; at other times diag- nosis stops short at the recognition of a pathognomonic symptom, such as hooping- cough ; again, it may mean to express the starting-point or principal fact in a grouii of symptoms ; or some general condition but imperfectly understood, or some con- dition which is not understood at all. In all of these instances we notice two things : first, that diagnosis — looked at from its scientific side — is the step from particulars to particulars, from those which are ob- served to those which during life can only be inferred ; the step from the one or the one hundred to the whole ; second, that diagnosis — regarded practically — is the giving of a name to the disease from which an individual suffers ; the ticketing, and as it were placing of that malady in some niche with others that resemble it, so that it may be known and brought out when required. But let it be remembered that the principles upon which names are con- structed are so various that no expression can be framed to convey their meaning, in so far forth as that it should carry further what is meant by diagnosis. Pathology. — When a patient presents himself for examination or for treatment, he tells us of certain things that he feels or sees, which are wrong, and which we call "symptoms ;" we ask him questions, and learn additional facts of a similar class ; we observe him, and notice other facts which he can neither feel nor know by independent means, and these we call " signs," or " objective symptoms. " From what we are informed, and from what we observe, we pass on to the inference of otlier facts : we believe, when some three, four, or more changes from the healthy state are present, that other alterations exist ; and this belief is more or less strong, and its character more or less defi- nite, according to the state of medical sci- ence, and our knowledge of it, at the time that the patient presents himself. We infer certain things, certain conditions which we cannot see, but which we may, in some measure, classify, and therefore call by distinctive names. Thus heat of skin is a symptom from which we infer a number of ulterior conditions. The reason for this heat of skin may — other symptoms being regarded— be conjectured by us to be an altered blood-state, such as typhoid fever, tuberculosis, or the like : it may, on other symptomatic evidence, be referred to a change in some particular organ, such as inflammation of the lung, or destruction of a portion of the spinal cord : and we may give names to the general conditions, part of which we have observed, part of which we have inferred. This is what we call "diagnosis" in its practical sense ; but that which makes diagnosis possible is the existence of a certain amount of informa- tion about the relations subsisting between different organs, and about the modes in which particular organs may become al- tered in function or in structure. We ob- serve a change in the quantity, color, or other qualities of a certain secretion, and we infer from this that there is diminished, increased, or perverted action of a certain organ. We examine further, we discover other changes, and we infer the nature of the disease which that organ has under- gone, or through which it is now passing. What in this sense is true of one organ is, more or less, true of all, and of the organ- ism as a whole, so that we are able to give some general expression to its general state ; and thus we speak of paralysis, fever, anaemia, suppression of urine, weak- ness, etc. etc., and so advance from symp- toms — by diagnosis — to pathology. This is what we do in particular cases ; finding certain symptoms, and knowing certain principles, we place the individual who presents those symptoms in a particular category, and call his disease by a name that is understood : and in this way the process of thought which we call "diag- nosis" is a bridge across from "symp- toms" to "pathology." Diagnosis is, then, the practical application of what we know about pathology ; and its accuracy will be in proportion to the amount of our information, and to the keenness and readiness of our observing power. Path- ology, therefore, is the foundation, the essential condition of diagnosis ; for it would be simply impossible to advance, from the observation of symptoms, one step towards the recognition of the nature of disease, unless thkt step were based upon pathology ; i. e., upon a knowledge of the conditions under which morbid changes occur in structure and in func- tion, and also of the modes in which such changes may so aflect organs as to render themselves appreciable during life. Prac- tically, as cases come before us, we ob- serve symptoms and we diagnosticate pathological conditions ; but we could form no diagnosis without pathologic knowledge, and diagnosis is in reality but 28 INTRODUCTION. a portion of, or the practical application of pathology. Theoretically, however, pathology is the ground worli of diagnosis ; and not only so, but of all valuable and correct observation : and thus the one is seen to be but the necessarj' complement of the other in the practice of physic. The one is a science, the other is an art : the latter could not exist without the former ; the former grows daily by the application of the latter. By Pathology, then, we mean the gene- ral doctrine of disease, the knowledge of the conditions under which it occurs, and of the kind of change which it expresses in the functions of the body. We mean also the inter-relations of different organs, or systems of organs, whether these may be compensative, or sympathetic, or an- tagonistic of one another. By the pathol- ogy of a disease we mean tlie scientific classification and nomenclature of its phenomena, and the interpretation of the conditions under which they have arisen. Pathology is to the body, under diseased conditions, what physiology is to the healthy organism, viz. the law of its being, or rather the best expression that we can give to what we believe that law to be. In its detail it must embrace all changes in either structure or in function ; but in its common and general accepta- tion it is used to express the idea that is entertained of the primary or essential or most important change in both ; and the bearing that this has directly upon life as a whole is, in its statement, the unravelling of the problem of ^\'hat we ordinarily mean by "Pathology." Pathological Anatomt. — Structu- ral changes in some organs are so con- stantly and definitely related to functional alterations observed during life that " Pa- thological Anatomy" in some maladies constitutes the most important, if not the major, part of their pathology. There are other eases in which structure-changes cannot be shown so to account for all the detail of symptoms ; and in these, patho- logical anatomy has its interest, but is of less immediate value. And further, there are diseases with regard to which patho- logical anatomy has hitherto taught no- thing that is worth our knowing ; while, on the other hand, it has not seldom ex- hibited the existence of disease, never suspected during life, and yet dire enough to be the cause of death, and thus to show that our diagnostic powers are not such, that we may boast of them. Unquestioned as is the value of Patho- logical Anatomy, it is no less unquestion- able that this value may be overrated and misapplied ; and it is possible that such mistake may exist at the present day. Lot us, therefore, remember what Patho- logical Anatomy is, and what it teaches. It is the condition of an organ after death, when tissues are cold, ordinary ch(Mnic changes have begun, secretion and living motion have ceased, circulation has stop- ped, and all that we know to be unex- plained by ordinary physical conditions, and that we call "vital," has gone, and gone we know not whither, and know not how. Pathology, on the other hand, re- fers to the conditions and modes of action of tlie organs when they are warm ; when chemic changes seem to be directed by a power that cannot yet be explained by chemic force ; when sensation and motion are constantly placing the organ in new positions, in "regard to other organs, and in new conditions, in so far as relate s to their own integral parts ; when the blood is constantly flowing, and aftecting. as it does so, both the tissues and itself, not leaving them as it found them, not leaving them as it came ; when all that we under- stand, and all that we dimly guess at about that complex force or principle, combina- tion of forces, condition or what-not, that we call "life," is the director or harmo- nizer of all we see, or is engaged in what seems a fierce struggle with powers it has long directed, but which, having now risen in defiance of its authority, seem likely to accomplish its dethronement. Everything that we can see is altered by that change from life to death ; and Pathological Anatomy has to do directly with physical conditions, which may he partially causes, partially effects, partially conditions of, and partially unrelated to the disease of which they are but a part, although an important one. If everytliing that we can see is thus altered in the step that all bodies make before they come under the scalpel or the microscope of the pathologist, still more altered is almost everything that we cannot see, but which we have inferred to exist from our laborious physiological investigations. It would seem therefore that Pathological Anatomy is about as capable of furnishing, per se, a notion of disease as dissection would be of teaching physiology ; and if we are to exalt into such undue prominence — as it has been the fashion of late years to do — this branch of science, which is yet only a branch and not the science itself it would be nothing more than consistent to attempt to write biographies from post-mortem ex- amination and to construct the history of a nation by exhuming the bodies from its graveyards. Pathological Anatomy has reference to one element of disease — structural or tis- sue change — and that only under condi- tions very different from those which exist during life, and when only disease can be said to exist. Further, we get the mate- rials for examination when disease has passed throusih all its stages, and througii that final one which cannot be said to PKOGNOSIS. 29 form a part of either life or of disease. It is only when, by accident or intercurrent malady, a patient is struck down in the earlier stages of morbid change, that we have the opportunity for observing the kind of alteration which exists at such most important periods ; and even to them is added all that we have already described, and probably much more than we can even guess at, by the great fact of death. Disease, being a complex of change in function and in structure, is represented anatomically only by the latter : disease, having a history, and passing through stages, is shown to us only in one stage, and with infinite predominance of fre- quency in the last stage : disease, being a change in the conditions of life, is shown to us anatomically only in the condition of death : while General Pathology, there- fore, may embrace all tliat we know or can know of the mechanism of human suf- fering. Pathological Anatomy but touches the human body when the period of sutfer- ing has passed. But the facts revealed by a study of Pathological Anatomy have a peculiar kind and a high degree of value, which we would most unwillingly underrate. There is an intimate and constant relation be- tween function and structure (see p. 19) ; and we beUeve that, although certain structural conditions liave yet escaped our i observation, they may hereafter be ren- j djred patent to the senses of the observer ; and on the other hand, we hold that there are some structural changes which may always transcend our powers for their im- mediate recognition ; but, notwithstand- ing these facts and principles, we must remember that wliere anatomical changes have been discovered and verified, they have thrown unexpected light upon pre- viously dark and complicated problems ; and that they have possessed — in them- selves and by their very nature — a deflnite- ness, or precision, and have been suscepti- ble of description and measurement to a degree that is quite unattainable by our present modes of research in regard of functional change. In Pathological Ana- tomy, what we have, however little it may be, is definite, describable, demonstrable, and measurable. These characters con- stitute its great value ; and it is against its undue exaltation — and not its proper use — that we raise our protest. Let us be as exact in our inferences from its facts as we may be in our observation and de- scription of them, and then Pathological Anatomy will take its proper place, and we sliall learn from it its most useful lessons. Prognosis.— The practical test of a true science is the power which it confers of " prevision," or of knowing now what will follow hereafter. Some sciences have attained to this point, as we see daily illustrated by physics and chemistry ; but as yet medical science has arrived at only very partial security of forecast. And yet the fore-knowledge of the consequences of a present disease is that for wliich patients and their friends often seek from the phy- sician with the greatest eagerness. Wlien we can prognosticate with certainty, medicine will have become a "science." At present we only, with different degrees of nearness, approach this end. We may describe the "• probabilities" of a given disease ; we may even measure them ; we may accept or reject lives at insurance offices ; or we may affix a numerical value to their duration ;' but we deal with doubts, and not with certainties. Life is too subtle for us to know or measure all its possible contingencies ; and our informa- tion is too scanty to render us thoi'oughly satisfactory interpreters of the outcome of any malady. But, with all this doubt, much may be accomplislied for the safety of society, and the relief of individual anxiety or care. In prognosis we have almost always two ends to be considered : the immediate effects of the present illness, and its re- mote consequences upon life. We have also two main elements by which we are guided in judging of these ends, viz. : the local changes which we may directly ap- preciate, and the general conditions which we may infer to underlie tliem, or to be, in some way, their consequence. Prognosis with regard to the immediate effects of a present malady is guided mainly by the degree to wdiich it intei'- feres with any or all of the great vital functions, the circulation, respiration, in- nervation, or nutrition of the body. Prog- nosis in regard of the ultimate issue of a malady is based upon all these, but still more frequently upon the recognition of changes, often minute, in either function or structure, which our knowledge of pathology leads us to interpret for either good or evil. For example, a man is suf- fering from pneumonia, and we ma}' — finding his general functions performed with an amount of ease consistent with life— infer that he will recover from the attack which to other eyes may appear most threatening ; but we may discover physical signs of tubercular disease — slight, even unnoticed previously — and these teach us that the ultimate prognosis is unfavorable. In like manner, a child may be taken with convulsions which ap- pear as (rightful as only convulsions can do, and yet we may give a favorable opinion as to the present illness ; while, on the other hand, some much slighter convulsive movement accompanied by heat of skin, a variable pulse, an obstinale ' See pp. 2.'), 21, on the duration and tur- mination of diseases. 30 INTRODUCTION. vomiting and constipation, and a history of failing health, or of hereditary tuber- cular taint, may lead us, in the midst of what seems a trifling malady, to augur the worst results from what we believe to be the onset of tubercular meningitis. In prognosis, therefore, we must bear in mind the two objects we have set be- fore us, and the two classes of means by which we may advance towards them. The immediate prognosis turns upon the degree to which great vital functions are interfered with ; the remote depends upon the nature of slighter changes, of which pathology teaches us the meaning. Therapeutics and Hygienics.— In the prevention or treatment of a disease our science culminates and becomes an art. Unless it can accomplish one or the other of these ends, the world would do as well without as with our aid. It is of some value to know the probabilities of our state, but it is of comparatively small value to have this knowledge if we can do nothing either to ward off, alleviate, or cure disease. We may prepare some peo- ple for the worst, we may dispel some groundless fears ; but our mission is to do more than this : we have to try to "cure the curable, and comfort the incurable." In the prevention of disease regard is had to the condition in which the indi- vidual is placed, to his hereditary or ac- quired constitutional peculiarities, and to the minute physical or functional depart- ures from health which we may discover. In the treatment of disease no one of these can be lost sight of with impunity, but we are guided principally by the ac- tual symptoms present at the time. These symptoms, however, it must be remem- bered, are of two orders : from the one set we learn the actual physical condition of an organ, or group of organs, such as inflammation of a lung, congestion of the hver, or paralysis of one side of the body; while from the other series we become ac- quainted with the state of the system generally, whether this be antecedent to the local change, its cause, its effect, or a mere coincidence of its existence ; and from such a group of symptoms we infer the existence of dyscrasise ; such as tuber- culosis, carcinoma, or the like, and appre- ciate the presence of vigor, or of asthenia, of sound constitution, or of impaired health and wasted strength. To the most superflcial observer it must be obvious that therapeutics has under- gone great and important changes, that the rnode of treatment now adopted for many diseases is just the opposite of that which was in vogue a generation ago, and which lingers even in recent editions of standard books, although their authors have long since ceased to follow the direc- tions which they still give to others. A few years ago the treatment of inflamma- tion of an important organ was laid down deflnitely ; such and such things were to be done, and no questions were to be asked as to whether the case was of this, that, or the other type. Inflammation was there, and blood was to be taken ; low diet was to be enjoined, and lowering medicines were to be exhibited ; and sup- posing the inflammation did not yield, the forces of attack were to be again placed in action : but here evidently there crept in some distrust of the theory at the bottom of the practice ; for, instead of general bleeding, leeches or cupping were to be employed, and then only to a mild degree. Somehow or another the inflam- mation was to be put down, and it not rarely happened that the process urged against the bugbear "inflammation" proved fatal or highly injurious to the patient. If we can, by bleedinw, and by it alone, save the eyesight which may be threatened by iritis, or if we can by de- pletion save a life which is endangered by laryngitis, we are quite justified in adopt- ing that measure, although it may entail some injurious consequences. It would, however, be as unkind as it would be un- philosophical to relieve the pain of a sim- ple pleurisy by abstracting blood, in such amount as sliould damage the individual in after years, when equal relief might be obtained by poultices and patience. We still find it written, if these conditions are found — a hard, full, strong, frequent pulse, with great heat of skin, no prostra- tion, impending evil from this condition being patent as the phenomena them- selves — then bleeding, antiphlogistics, and the like must be employed. i?ut, as a matter of fact, we do not find these cases, and the more common on dit of medical practice is to the effect that as the inflammation seemed extending, the quantity of wine has been doubled, the supplies of beef-tea increased, and bark and ammonia given more frequently. Partly to account for, and partly to jus- tify, so material a change in our modes of dealing with disease, it has been assumed that the vis vitce of the British constitution has been lessened, or that the so-called "type" of its maladies has altered; an assumption which has little to be said in its defence, and still less that can be re- garded as its establishment. A more simple, and we believe accurate, explana- tion of the change is to be found in this, that previously theory was the ground- work of therapeutics, and that now fact is the basis of treatment : that, years ago, diseases were treated by their names, and that now they are treated by their known conditions : that local changes were the main guides in times gone by, but that the general state of the patient is that which in these days the physician esteems THERAPEUTICS AND nYGIEXICS. 31 as his therapeutical informant. When pathology scarcely existed, medical prac- tice was an empirical art ; aud had, with tlie few advantages of that position, all its evils : whereas, with the growth of pathology, therapeutics, still an art, has become, or is becoming, a science ; and, knowing more accuratelj' tlie limits of its powers, is content to attempt less heroic measures, being convinced that it does less harm. Much Is done by medical treatment now, more real good than ever was done before, but it is done in a dif- ferent way, and with another aim. Dis- ease is detected in its earlier stages, and often arrested there ; and when developed the patient is guided through it, if he can bo, and is not sacriliced to some wild at- tempt at its destruction. What we now believe and act upon is no set theory regarding the nature of par- ticular diseases, or disease in general — modern times have not been devoid of theories upon which the fathers of medi- cine would justly have turned their backs in derision ; but such notions, although they may have misguided a few individ- uals, have soon found their proper place, or no place at all, in the science of the day — what we do believe and act upon is a better knowledge of the laws and rela- tions of morbid change : when we see that the man is greater than his maladies ; that his general condition is of more im- portance than his local ailments ; that disease is a change in him rather than in some part of him ; and that no treatment can be of any real service which sacrifices the greater to the less. In all treatment, therefore, what is general is to be dealt with upon the basis of a true appreciation of the general pathological condition, and this in spite of all theories in regard of local changes, however they may be termed, whether they come to us with names hoary with age, or scarcely intelli- gible, and even sometimes ludicrous from their novelty. If the general condition be one of weakness, it matters not that the brain, the heart, or the lungs may be in a state of so-called " inflammation ;" the weakness is the one thing that demands immediate treatment, and to neglect its treatment is to run the risk of sacrificing the patient to a theory of a compound state even now but imperfectly under- stood. This is the starting-point, the es- sential element in therapeutics ; but the mode in which the treatment should be applied will often be determined by the nature and position and origin of the spe- cial lesion ; and these conditions of the latter will direct the management of those means and appliances which, employed locally, will prove of service to the injured organ. [While the view above given of the therapeutics of inflammation may be re- garded as corresponding with the actual practice of a large number of physicians at the present time, in Great Britain aud Ireland, on the European continent, aud in America, there is reason to believe that more practitioners will partially dissent from it now (1879) than would have been the case ten or twelve years ago. Cer- tainly it is a sound principle, not only to disregard, but to annul, in practical books and teaching, all merely traditional or "theoretical" precepts, which either im- proved pathology or extended experience has shown to have been erroneous. But, was it only, or chiefly, local changes, that were the guides of Sydenham, Cullen, Rush, and others in the old days of the lancet and otlier "antiphlogistic" meas- ures ? The pulse, the skin, the period of the attack, and the absence of evidence of exhaustion of the recuperative energy of the system ; these, rather than merely organic conditions, determined, with them, whether or not depletion should be resorted to. It would seem to be a change in the interpretatiiin of general indications, and a different theory of therapeutics, that have introduced, instead of the somewhat overdone antiphlogistic measures of our predecessors, the expectancy with some, and the stimulism with others, that have chiefly characterized the middle portion of the present century, in general practice. That some important qualification of the view set forth in the above paragraphs would now be approved by a considerable number of the most eminent practitioners, might be shown by many citations. It is illustrated by some examples in the work to which this essay furnishes so able and fitting an Introduction. Thus, W. Squire, L.B.C.P., advises, in croup, under cer- tain circumstances, "a free abstraction of blood." J. Hughhngs-Jackson, M.D,, in the instance of repeated convulsions, thinks that "we neglect to bleed as often as we ought to do, on the principle Mark- ham has laid down." J. Spence Rams- kill, M.D., in regard to the treatment of simple meningitis, refers to three great remedial measures, of which the first is bloodletting. Dr. J. S. Bristowe speaks well of the same remedy in certain cases of enteritis ; and Dr. J. S. Wardell desig- nates it as our best ally in sthenic acute peritonitis. The intention of these remarks is not to antagonize, but to qualify, the summary conclusion which the language of Dr. Reynolds appears to convey, that vene- section and kindred measures of treatment may be with advantage dismissed as ob- solete procedures. 'Of names not yet antiquated, in favor of the occasional and moderate use of the lancet, in the early stage of acute inflammatory disorders, it may suffice to add here as examples those of Aitken and B. W. Richardson in Eng- INTRODUCTION'. land ; Niemeyer and "Wunderlich in Ger- many ; Jaccoud, llerard, and Cornil in France ; S. D. Gross and Fordyce Barker in America. Tlie most important qualification of the expressions upon whicli these comments are made is, in regard to "weakness" being tlie "one thing that demands im- mediate treatment;" this being "the starting-point, tlie essential element in therapeutics." Few, if any, pathologists ■will hesitate to admit that a ditterence, often momentous, exists, between the ex- haustion of a system weakened by the continuance for some time of severe dis- ease, and that opinessive debility with which the most robust person may be tem- porarily affected, under the influence of an acute malady, such as pneumonia, meningitis, or croup. Those physicians who (like the present writer) were trained under the "anti- phlogistic " regime, and had the opportu- nity of seeing something of its clinical re- sults, which they may compare with those of the last two decades under a different prevailing practice, will hardly be able to insist, from their own observation, that the general effect of the abandonment of the lancet and of local depletion in private practice has proved advantageous. The mortality of pneumonia in Philadelphia has, for some reason, certainly increased ; not in the hospitals, where the average character of the patients has always made them unfavorable subjects for depletion ; but in private practice. It is not too bold an assertion, indeed, for one who, without partisanship, maintains his conviction of the occasional importance of venesection and local depletion as remedies, — that, while acute, uncomplicated pneumonia under moderate depletory treatment was, thirty years ago, rarely fatal outside of hospitals, and not at all frequently so within them, the indiscriminately stimu- lating method, now often applied to all classes of cases, has increased very con- siderably the fatality of this and other inflammatory diseases in private prac- tice.— II.] Classification of Diseases. — A cor- rect classification is a condition of the existence of a science, and an essential for its teaching ; but we do not think that " medicine" has yet arrived at this high position. That it will advance to it, that it is making progress towards it, we have no doubt ; but, at the present time, we must admit that imperfections abound in every system that has been propounded. The problem is too vast and too compli- cated for solution now, and we have there- ; fore to adopt that which appears to pos- '■ sess the greitcst amount of practical ad- vantage. It would be useless here to spend time upon criticism of the various schemes which have been proposed ; we prefer rather to state briefly the very simple plan upon which this book will be constructed. It is proposed to make the first division of diseases into their two great groups ; 1st. Those in which the whole organism appears primarily and prominently de- ranged, and 2d, those in which special or- gans or systems of organs are, in like manner, affected. Subdividing the first group we have two classes ; A, those in w^iich the disease appears to be developed by causes operating from outside the body ; and B, those in which the malady seems to depend upon some internal change. Thus in the first subdivision we find the acute specific diseases, and their analogous affec- tions ; in the second, gout, rheumatism, s(torbutus, and the like. Subdividing the second group we have many classes, con- sisting of diseases of systems of organs, such as : A, diseases of the nervous sys- tem ; B, diseases of the digestive system and its appendages ; C, diseases of the circulatory system ; D, diseases of the respiratory system ; E, diseases of the uri- nary system ; F, diseases of the repro- ductive sj'stem ; G, diseases of the loco- motive system ; and H, diseases of the cutaneous sj'Stem. Each of these is, in its turn, again sub- divided, upon the primary principle of general or partial change, so that, in re- gard of the nervous system, for example, we have 1st, those of general or undeter- mined seat, and 2d, those depending upon distinct local change in its parts, anatomi- cally considered : and this leads to further reduction into affection of parts, such as, a, brain ; 6, spine ; c, nerves : whereas the final division is based upon the nature of the changes which these portions of sys- tems undergo. If this mode of arranging diseases has no other merit, it has that of simplicity ; and it will, we believe, bring, as a general rule, into closer proximity than some more ambitious systems would allow, those diseases which have the most intimate clinical association. It involves little theory in any case, none in many, and may therefore commend itself to those who realize, amid the great progressive science of medicine, the difficulties and dangers which attend upon all nosologies which, based on theories, partly right and partly wrong, carry with them, and only with great effort disentangle themselves from, what is erroneous in their ground- work, and d fortiori luxuriant in their after-growth. .J. KUSSELL REYKOLDS. PAET I. In the First Part of this Systmi of Medicine are included those diseases in which the whole organism is primarily and prominently deranged. We have therefore to deal idth ;— General Diseases, or Affections of the Whole Systesi ; and dividing these into two sections, we have to consider first : — I I.— Those determiiied by agents operating from ivithout, such as malaricd diseases, the exanthenwta, and tlieir allies. Influenza. hooping-cough. Diphtheria. Scarlet Fever. Dengue. Roseola. Measles. Mumps. SUDAMINA and MILIARIA. Varicella. Variola. Vaccination. Glanders. Hydrophobia. Enteric Pever. Typhus Fever. Relapsing Pever. Yellow Pever. Epidemic Cerebro-Spinal Meningitis. Plague. Erysipelas. Pyemia. Malarial Pbvbrs Dysentery. Cholera. Syphilis. INFLUENZA. By Edmund A. Parkes, M.D.,F.R.S. Definition. — An epidemic specific fever, witli special and early implication of the naso-laryngo-bronchial mucous mem- brane ; duration definite of from four to eight days ; one attack not preservative in future epidemics. Synonyms. — Scientific Names. — Peri- pneumonia Notha (Sydenham, Boerhaare). Peripneumonia Catarrhalis (Huxham). Pleuritis Huniida (Stoll). Pebris Catar- rhalis {F. Hofman, Sauvages). Catarrhe Pulmonaire (Pinel). Catarrhus a Contagio (Gullen). Defluxio Catarrhalis. Cepha- lalgia Contagiosa. Rlieuma Epidemicum. Prjpular Names. — Pose (in old English writings, from the Anglo-Saxon gepjose, heaviness). Tac or Horion (in France in 1411). Coqueluche (in France in 1414, and in subsequent epidemics, because the sick wore a cap over their heads.) La vol, I.— 3 Dando, or Ladendo (in Prance, 1427). Quinte (in Prance in 1578, because the paroxysms of cough returned every five hours). Follette (in Prance in several epidemics). Ziep (in Germany in 1580, probably from zieppen, to pipe or chirp). SchafFhusten and SchafTkrankheit (in Ger- many in 1580, because the cough was like the cough of a sheep, or because the verti- go was like the sudden giddiness of sheep). Hiihner-weh (in Germany in 1580, because the cough was like the crowing of a cock). Blitz-katarrh (from the suddenness of the attack). Mai del Castrone (in Italy in 1580, because the giddiness was like the common disease " turnsick, " of the sheep). In the seventeenth century it was first called Influenza, in Italy, because it was attributed to the "influence" of the stars, and this term has passed into medical use. In 1743, it was called La Grippe in (33) 34 INFLUENZA. France, from the Polish Grj'pka(Kauceclo), a term which, hl'ie Influenza, has passed into medical writings. It has been called in Russia " Chinese Catarrh;" in Germany and Italy, ''the Russian disease;" in France, "Italian Fever," &c. A great number of other popular names have been given to it : Petite poste ; Petit courier ; Follette ; Coquette ; Cocote ; Al- lure ; Baraquette ; Generate, &c. History. — Supposed to be referred to by Hippocrates, who yet gives no perfect description. The epidemic among the Athenian army in Sicily [Ho before Christ), recorded by Diodorus Siculus (lib. xiii.), has been supposed to have been Influenza. In A. D. 827 an attack of cough, which spread like the plague, was recorded. Again, in 870, Italy, and then the whole of Europe, ' -was attacked, and the army of Charlemagne, returning from Italy, suflfered greatly f dogs and birds were both attacked by this disease. In 97(3 the whole of France and Germany was attacked by a fever, whose principal S3rmptom was a cough. In 117.3 another catarrhal epidemic was widely spread ; and in 12.39 and 1299 other slighter epi- demics are noticed. It is not, however, till the 14th century that the records became numerous and precise : — In the 14th century 6 epidemics are re- corded 1.5th (( 7 a 16th (( 11 (C 17tU f ( 16 (( 18th '• 18 ti 19th (first half) 10 " In some cases, however, the same epi- demics may have been recorded twice, though I have excluded several that ap- pear to have been so. Proljably, also, among the lesser epidemics are some of hooping-cough wrongly diagnosed as In- fluenza. There is little doubt that the apparent increase of prevalence in the last centuries is merely due to more accurate recording of minor epidemics. Of these epidemics, some have been very widely spread over a great part of the known world, as in 1.311, 1557, 1580, 1.590, 1729, 1762, 1775, 1780-2, 1830-2, 1847. In other epidemics the disease has either been partial, or not recorded in many places ; in some instances it has spread only over comparatively small tracts of country. ' Schnurrer. Clironik der Seuchen, Band i. p. 175. ' Schnurrer states that measles followed, and appeared indeed to be developed out of this epidemic, hut the records are necessarily very imperfect. The first epidemic which was carefully described was that in 1557, by Eiverius. The great epidemic of 1580 was described by Scnnert. In England the following epidemics have been recorded,' many of them with great care : 1510 and 1557 by Thomas Short ; 1G58 by Willis ; 1075 by Sydenham ; 1729- 1743 by Iluxham ; 1732-3 by Arbuthnot ; 1758 by Whj-tt ; 1702 by Baker and Rutty ; 1707 by Ileberdeu; 1775 by Fothergill, who collected observations from many physicians ; 1782 by Gray, Ilaygath, and Carmichael Smith ; 18tl3 by Pearson and Falconer, and a great number of others ; 1833 by Hingeston and others ; 1837 Ijy Streeten, Graves, and Brj-son, &c. ; 1847 by Peacock,^ Laycock, and many others.' Spread of the Disease. — Etiology. — Before entering on the consideration of the external nature of the causes, it is neces- sary to state the facts which have been ascertained in respect of the spread of In- fluenza. It has prevailed in most places of the habitable globe : in the whole of Europe ; in China, Tartary, Egypt, India, and other parts of Asia ; in Australia, Polynesia ; in North and South America, and in the West Indies ; that is to say, in both hemi- spheres and in all latitudes. It has occa- sionally occurred in both hemispheres at the same time, but more usuallj' has ap- peared successively in different places, and has been seen at some point or other of the earth's surface for two to four years, after which it has disappeared. In some years, as in 1580, 1730, 1762, 1775, its pre- valence has been so great, that almost all parts of the known world have been at- tacked ; at other times it has been more partial, affecting only a part of a conti- nent, or even a single country.'' It has been supposed, indeed, occasionally to prevail in quite a limited area, in a single city for example,^ but it is possible that local catarrhal fevers of this kind are not identical with the true influenza. When it has been pandemic, i. e. , when it has invaded a large portion of the earth's surface, its progress has usually been ra- ' Annals of Influenza, by Theophilus Thomson (Sydenham Society, 1852). I have only quoted the principal works. 2 The Influenza, or Epidemic Catarrhal Fever of 1847-8. ByG. T. B. Peacock, M.D. London, 1848. ' Since 1847 there lias been no pandemic Influenza, hut several minor outbreaks, the widest diffusion of which was in 1857-8. In Paris in 1867 (Febru.ary and March) there was a severe outbreak, characterized as usual hy great prostration. There was also an out- break almost at the same time at Strasburg. *_ See Hirsch, Hist. Geog. Pathol, vol. i. p. 286, for twenty-four examples of this fact. 5 Hirsch has collected seventeen examples. HISTORY. 35 pid, yet not to such an extent as is com- monly supposed, and sometimes it lias travelled slowly. It is said to have over- spread Europe in six weeks, and at an- other time to have taken six months or more to do so. In any particular country its progress may also he comparatively slow ; thus, between the invasion of Lon- don, and of provincial towns, or of Scot- land, weeks, and even sometimes months, have elapsed. Thus in 1762 it appeared in London in the beginning of April ; at Edinburgh in the beginning of May ; in some parts of Cumberland in June. In 1782 it attacked London in the middle of May ; Exeter at the end of May ; and Newcastle-upon-Tyne and Edinburgh in the beginning of June. In 1830-31-32, it prevailed in Moscow and St. Petersburg, and from thence took no less than eight months to spread over the whole of Germany. In Europe it has sometimes prevailed simultaneously at several points, as in 1847, when it was raging at the same time in Copenhagen, London, and Marseilles. In spreading over a large tract of country, it has often been supposed to follow a regular course ; which has been believed to be from the high north or northeast to the south and west. Thus it has been supposed to pass from Chinese Tartary to Eussia, Germany, Holland, England, Scotland, France, and then to Italy and the Mediterranean, or to America in succession, and certainly in some epidemics there has been a course of this kind. But this is by no means inva- riable, and may indeed have been acci- dental, or our knowledge of the successive steps of the spread may have been inaccu- rate. Thus the epidemic hf 1762 was said to follow this course,' and to reach Ame- rica in October, 1762, having affected Ger- many in February and March, London in April, and France in July. But Influenza prevailed in America the year before (1761) and thence passed into Europe,^ taking thus the exact contrary of the tract assigned to it, unless indeed it passed round by the icy regions of North British and Russian America, of which there is no evidence. So again it has sometimes (1775) passed from the south to the north of Europe, or from the south or west of a particular country to the north or east. Gluge,' indeed, from an examination of the epidemics of the last 300 years, be- lieved he had discovered that its course is from west to east. It is obvious that, in former times, the want of reliable infor- mation, and of intercourse between na- ' Robert Williams. On Morbid Poisons (1841), vol. il. p. 663. 2 Noah Webster. A Brief History of Epi- deraio and Pestilential Diseases (London, 1800), vol. ii. p. 44. ^ Quoted bj Hirsch, op. cit. p. 287, footnote. tions, must have rendered all evidence of dates very uncertain. The next epidemic will give more reliable information than any of the former. When it has entered any large town, it remains there for from six weeks to two months as a rule, but occasionally longer, as at Paris in 1831, when it was more or less prevalent for nine or ten months. It has never, however, failed entirely to dis- appear eventually, and sporadic cases are not seen in the intervals of the epidemics. In its course it appears to pass over seas, and it is said to have attacked the crews of ships far from land, who had not sailed from an infected port.' The exact spot on the earth's surface where an epidemic commences has not yet been made out, and two opinions prevail. One is, that every epidemic owns one un- known source, whence it spreads ; each nation, in turn, attributing to its neighbor from whom it derived the disease, the un- ' The statement that Influenza will thus break out in mid-sea, without there -being any possibility of the disease having been in- troduced on board, is a most important piece of evidence, as it would prove that the atmo- sphere can not only carry the poison, but that no degree of dilution can destroy it. Without denying the occurrence of such out- breaks, I cannot but consider we require bet- ter evidence of ships being attacked in mid- ocean. In some of the quoted instances, tlie ship had been at a port either known to be infected, or in which InHuenza was really present, though it had not become epidemic. As we are ignorant of the exact period of in- cubation, some men may have been infected before sailing. In other cases the examples are of old date, and it is impossible to feel quite sure that the evidence is correct. Such for example as the celebrated case of the Atlas East ludiaman, which was attacked with In- fluenza, on a voyage from Malacca to Canton ; Malacca being healthy at the time, but Can- ton being afi'ected at the same time as the ship. (Robert Williams : On Morbid Poisons, vol. ii. p. 667.) In 1782, Admiral Kempen- feldt's and Lord Howe's squadron, cruising at dift'erent parts of the Channel, were each attacked, although, it is said, they had been at least twenty-two to twenty-seven days at sea. There is better evidence that ships near the land have sufi'ered. In 1833 the Stag frigate was coming up Channel, and when off Beechy Head, in Devonshire, the wind was easterly and off the shore at two o'clock, the crew being then quite healthy (and it is presumed no communication having taken place, but this is not stated) — 40 men were, at half-past two, suddenly attacked with Influenza ; at six o'clock 60 men were down, and by the next day 160. (Watson : Principles and Practice of Medicine, 4th Edition, vol. ii. p. 44.) If it were certain that there had been no commu- nication with the shore, the cause must have drifted over the sea. 36 INFLUENZA. enviable honor of originating it. Thus the Italians have termed it the German disease ; the Germans, the Russian pest ; the Russians, the Chinese Catarrh ; and these names are indeed some evidence of its usual track. Ifoah Webster attributed its origin to America in 1(598, 1757, 1761, and 1781, while in 1788 he believed it arose in Europe, and several writers have fixed it in Chinese Tartary, or in India. The other opinion is, that it has no special place of origin, but may arise anywhere ; and some,' indeed, have questioned whe- ther such " autoohthonic" developments are not the rule, and whether we are right in believing in a "genetic connection" of the various local outbreaks. But surely no one can doubt the connection of the various attacks in the great epidemics of Influenza with some general and pandemic influence. If it may arise thus spontaneously in various places, no one has yet precisely in- dicated its first origin. It has been also supposed to have a cyc- lical course, and to return pretty regu- larly in periods of j'cars. The older writers thought it had a cycle of about 100 years, but it has returned much more frequently than this ; about every twenty-five to thirty-five years it has been pandemic, and lesser outbreaks have occurred more fre- quently. But no regular period can be at pi'osent perceived. In passing through a country it does not attack all parts of it ; it more usually spares the country places, but sometimes even large towns escape. When the disease enters a town, it has occasionally attacked numbers of the inha- bitants almost simultaneously. But more frequently its course is somewhat slower ; it attacks a few families first, and then in a few days rapidly spreads ; the accounts of thousands of persons being at once at- tacked at the onset of the disease are chiefly taken from the older records, in which the suddenness of the outbreak is exaggerated. Frequently, perhaps always, in a great city the outbreak is made up by a number of localized attacks, certain streets or districts being more affected than others, or being for a time solely affected, and in this way it successively passes to different parts of the city. It has gene- rally occurred in a great city before ap- pearing in the smaller towns and villages round it, and sometimes these towns, though in the neighborhood, have not been invaded for some weeks. In some cases, and perhaps a large num- ber, it breaks out after persons ill with In- fluenza have arrived from infected places. The decline in any great town is less rapid than its rise, and usually occupies 1 Biprmer.inVirchow'sHanrlbncliderPath. nnd Thei., vol v. p. 607. (18G5.) from four to six weeks, or sometimes longer. In every epidemic the symptoms so closely resemble each other, that there is no difficulty in recognizing it from the de- scriptions even of ancient and unlearned writers ; yet there are said to be certain slight differences in symptoms between different epidemics, to which reference will be hereafter made. Different epidemics have varied some- what in the number of persons they aflTect, but on the whole a large number suflfer. In London in the last epidemic (1847) it has been calculated that at least 250,000 persons suffered ; in Paris, between one- fourth and one-half of the population suf- fered, and in Geneva not less than one- third.' When the different telluric and atmo- spheric conditions which are coincident with the attacks are considtred, the fol- lowing are the conclusions : — Soil. — It prevails on every soil and geo- logical formation, and apparently equally on all. It has been supposed to be worst on marshy soils, and some have even be- lieved it to arise in very malarious re- gions, as Lower Bengal, or the plains of China, yet very malarious countries, as Holland, do not suffer more than others ; Holland, indeed, has escaped some epi- demics which have traversed Europe. Lowlands have been sometimes affected more than the adjacent hills, as in the lowlands in Jamaica, in 1802, and in several epidemics in the Lombard plains, as compared with the Blue Mountains and the Alps. Volcanic Eruptions.— Telluric Emana- tions. — Noah Webster^ and Schnurrer^ have collected the available evidence on this point, but it is entirely negative. There have been constant volcanic erup- tions without Influenza, and epidemics of Influenza without great volcanic erup- tions. It has been "thought that emana- tions of seleniuretted hydrogen from vol- canoes might excite Influenza, but no proof has ever been given of the existence of this substance in the atmosphere. Electrical Conditions. — No evidence has been collected which shows any connec- tion with conditions of telluric magnetism or atmospheric electricity ; and indeed the peculiar spread and frequent localiza- tion of Influenza seem inconsistent with general magnetic conditions. Seasons.— The disease appears at all times of the year ;* nor is there any reason ' Peacock on Influenza, p. 13, Introduction. 2 A Brief History of Epidemic and Pestilen- tial Diseases. 1800. Vols. i. and ii. 3 fhronik der Seuchen. 1825. * See Hirsch, op. cit. p. 287, for evidence on this point, but almost all writers have noticed it. SPREAD OF THE DISEASE. 37 for considering it an affection of tlie late summer, autumn, and winter, as has been stated. Temperature of the Air. — Owing to the confusion in the popular mind between Influenza and common catarrhs or catar- rhal fevers, it has been always a common opinion that Influenza depends either on a low temperature, or a sudden variation of temperature. This error has taken a long time to kill ; but almost every writer, since tlie epidemic of 1580, has examined this point,' and has decided that there is no connection between either low tempe- rature, or variations in temperature, and Influenza. As respects high temperature, it has prevailed in the West Indies at a temperature of 72^-82^ ;^ on the hot sea- coast of Java ; in South India ; in Egypt ; at the Cape of Good Hope, in the most genial season ; in the south of Europe in summer. So also there is abundant evi- dence to show that the changes of weather, which may appear to have accompanied or preceded its outbreak, were mere coin- cidences." 3Ioisture of the Air. — It has prevailed in the dry air of Upper Egypt ; in the moist air of sea-coasts, and on the sea itself, without being apparently in any way in- fluenced. Barometrical Condition. — No coincident alteration can be traced. Ozone. — Although ozone was known be- fore 1847, the observations during that year led to no result, and since that time there has been no epidemic of Influenza. But the observations hitherto made on the effect of ozone on other diseases'* seem to render it improbable that any connection will be traced between the development of ozone and Influenza. The statements of Schonbein are based merely on the efiect of large quantities of ozone artifi- cially produced, on the mucous membrane of the nose. Applied in large quantities, ozone is irritating, and may produce sim- • Salius Diversus (1580) ; Molineux (1693); Whytt (1757); Baker (1762); Haygarth (1775-1782) ; Fothergill (1775) ; Metzger (1800) ; Lombard (1831), &o. 2 Observations relative to the West India Islands, by John Williamson, M.D. 1817. Vol. ii. p. 110. 3 In his late work (Catarrh and Influenza, 1865), Seitz attributes more influence to the effect of vicissitudes of weather in causing epidemic Influenza than appears to me to be warranted by the facts. < Especially those of Shiefferdecker : Sit- zungsbericlit der Math. Naturw. Classe der Wien. Akad. July 1855, Band xvii. Seite 191. The ozonic results had no connection with any malady, and were in all cases pro- portionate to a numerical range, derived from a consideration of the strength of the wind and of the moisture of the air. See also Seitz (Catarrh and Influenza, 1865, p. 360). pie catarrh, but nothing like the specific symptoms of Influenza. Fogs and Iiists. — In some cases, as in Paris in 1075, France in 173a and 1775, England in 1782, a thick and acrid fog has shortly preceded, or has inmiediately'ush- ered in, the Influenza ; Ijut so many out- breaks have occurred without such a coin- cidence, that it is impossible to attach any weight to it. Wind. — Its main spread is not inf.u- enced by the wind ; it does not move Wita the same velocity ; it often moves against it. Yet it appears to be sometimes car- ried by the wind for a short distance. (See case of the Stag frigate, previously quoted. ) In fine, if there is any special atmo- spheric condition which invariably attends epidemics of Influenza, it has yet to be discovered, and the words of Pearson are still true : — " Between the epidemic and the condi- tion of the atmosphere, there appears to be a connection difterent from that which depends on a mere alteration of tempera- ture, or of dryness or moisture, but what that peculiar connection is we shall not attempt to explain.'" Fungi in Atmosphere.' — Abundance of flies, caterpillars, etc. — Attempts have been made to show that during epidemics there are indications of an unusual development of animal or vegetaljle life, and that "bloody or red snow," "blood rain," "flights of locusts, or insects," &c., are more common in Influenza years. These speculations have, at present, even more than usual interest, and certainly should be brought to the test of close inquiry. At present, all that can be said is that no facts of any moment exist which connect an unusual fungoid development with the spread of Influenza. We must now pass on to a difierent or- der of facts. Human Intercourse.^ — The rapidity of the spread would seem at once to negative any connection between human inter- course and the propagation of the disease ; yet there is some affirmative evidence. It does not appear to follow the great lines of commerce ; but when it has entered towns and villages in which the investiga- tion can be carried on, it is curious how ' Observations on the present Catarrhal Fever, or Influenza, by Richard Pearson, M.D. London, 1803. P. 3, footnote. 2 The presumed importation of Influenza into Iceland and the Faroe Islands, as de- scribed, especially recently, by Schleissner and Panum, as well as by older writers, is doubtful. It would seem probable that the endemic catarrh of these islands, said to fol- low each year the arrival of the first ship, is different from the true Influenza, which conies more rarely, and only when it is prevailing elsewhere in Europe. 38 INFLUENZA. frequently the first cases have been intro- duced, and how often the townspeople nearest the invalids have been first affect- ed In this country especially, Haygarth in 1775 and 1782, and Falconer in 1802, collected so many instances of this that they became convinced that its propaga- tion was due entirely to human inter- course. ' So also, when it passes through a house, it occasionally attacks one person after another. But if it is introduced in this way, it afterwards develops with mar- vellous rapidity, for we cannot discredit the accounts of many thousand persons be- ing attacked within a day or two, which is quite different from the comparatively slow spread of the contagious diseases. This sudden invasion of a community niakes it, to many persons, appear highly improbable that any effluvia passing off from the sick should thus so rapidly con- taminate the atmosphere of a whole town. Still, we must remember how singu- larly, of late years, the knowledge of the introduction of cholera by persons coming from infected districts has increased, and how very striking are the instances of this kind already recorded in several works on Influenza.^ In some cases, again, isolation or seclu- sion of a community, as in prisons, have given immunity ; or at least that commu- nity has not been attacked. inoculabilitij. — The disease is not inocu- lable ; at least, when horses are attacked, it cannot be transferred from one horse to another. (Hertwig.) Incubative Period. — All the contagions have one remarkable property ; there is a time when they are said to lie dormant, and to be undergoing or inducing in parts of the body those changes which lead at last to the symptoms of the declared dis- ' Sir Thomas Watson, M.D., whose care and accuracy inspire such faith, says also on this point : " The instances are very numer- ous, too numerous to be attributed to mere chance, in which the complaint has first broken out in those particular houses of a town at which travellers have arrived from infected places." (Principles and Practice of Medicine, vol. ii. p. 43. 4th Edition.) Sir George Baker was one of the first who noticed this fact. (Opuscula Medica ; Edi- tion of 1814, p. 27.) Cullen's term, " Catarrhus ^ Contagio," seems to me to imply, however, merely the idea of origin from a special virus. [^ May not this analogy, liowever, he, with equal facility, used in the reverse manner as an argument ? As the general history of In- fluenza seems so cogently to negative any connection between human intercourse and its propagation, therefore the occurrence of some apparent instances of the introduction of cholera by persons should be regarded as ■most probably explicable otherwise than by contagion. — H.] ease. During this period there are either no symptoms, or, wliat is more probable, they have not been determined. Such a period has been supposed not to exist in Influenza,' which has been said to strike down persons in perfect health, as with a stroke of lightning. But the suddenness does not exclude an incubative period without subjective symptoms. It is also certain that the incubative period sometimes exists. It is sometimes very short f sometimes of many days' dura- tion. Preservation from Second Aitaclc. — There is some discrepancy of evidence ; but, on the whole, it seems clear that, while per- sons seldom have a second attack in the same epidemic (though even this may oc- cur), an attack in one docs not protect against a subsequent epidemic. Indeed, it has been supposed rather to render the body more liable. Belation of other E^ndemic Diseases of Man. — It has been attempted to trace out a connection between Influenza and mea- sles, the plague, yellow fever,'' and cynan- che maligna (diphtheria). It has been 1 Biermer, op. cit. : " The disease seems to come on without an incubative stage ; the causes of Influenza do not work after many days, as a contagion ; but rapidly, like a poison."— P. 604. 2 In the Transactions of the College of Phy- sicians (vol. iii.), it is stated that in the epi- demic of 1782, seventeen persons came to London to an hotel, and on the following day three were attacked with Influenza. Hay- garth (On the Manner in which the Influenza of 1775 and 1782 spead by Contagion in Ches- ter and its Neighborhood, by John Haygarth, M.D., F.R.S.) says that a gentleman came to Chester from London, on the 24th of May, 1782, ill of Influenza; a lady, into whose family he came, was seized on the 26th, and was the first case in the town. Haygarth states, evidently with the wish to point out the possibility of a direct contagion, that the gentleman was engaged to be, and was after- wards, married to this lady. In this case the longest possible incubative period was two days. In 1782 a family landed at Harwich, from Portugal, and came to London directly ; the day after arrival, the lady, two servants, and two children were all seized. Two men- of-war arrived at Gravesend from the West Indies ; three Custom-house oflicers went on board ; a few hours afterwards the crews of both vessels were attacked. (Robert Wil- liams, on Morbid Poisons, vol. ii.) Some other cases are on record where the incubative period, if it existed, could not have been more than a single day. On the other hand, some cases are on record in which the incu- bative period must have been two or three weeks. (Ibid. vol. ii. p. 674.) " Noah Webster, op. cit. vol. il. p. 48. To some extent Sclmurrer held that there is some connection between measles and Influ- enza. SPREAD OF THE DISEASE. 59 supposed also to precede and herald chol- era. On the other hand, it has heeu stated that epidemic scarlet fever disappeared when Influenza prevailed, and reappeared when this ceased. The same fact has been affirmed of smallpox.' During its prevalence other severe inflammatory dis- eases have been supposed to lessen. With regard to all these supposed relations, the evidence is most unsatisfactory. Coinci- dences between the prevalence of different epidemic diseases must be expected, but it would require repeated instances to prove any connection. Measles constantly pre- vail without Influenza ; and if an epidemic has occasionally followed an Influenza epi- demic, this really proves nothing. The utter want of connection between cholera and Influenza is evident at a glance. So also the very imperfect knowledge we have of the relative prevalence of the acute inflammatory affections, makes it quite uncertain whether cases of simple bronchitis, rheumatism, and pneumonia really lessen in number during influenza. According to Graves (Clinical Med., vol. i. p. i25), during acute diseases persons are less liable, but they may be attacked at convalescence. It has not been shown to prevail espe- cially in years when intcrmittents have been more common, yet there may be some connection between the diseases (see Symptoms). Instances have been given in which intcrmittents seemed to disappear, and others in which the Influ- enza seemed to cause intermittents. Belation to the Diseases of Brutes. — In some epidemics of Influenza, dogs,^ horses, cats, and, it is said, birds, have been af- fected simultaneously with an epidemic catarrh. Horses are subject to an epi- demic catarrhal disease (l'827'') even when no Influenza prevails among men, and this disease, to which veterinary surgeons now give the name of Influenza, appears closely to resemble human Influenza. Its conta- giousness has been warmly debated, and it certainly appears incapable of inocula- tion, but yet some believe it to pass from horse to horse. It appears to be now gene- rally thought an epizootic affection, and dependent on a specific cause* ' See Biermer, op. cit. p. 619, for references on these points. 2 In tlie great epidemic in Australia, in 1851-52, dogs were affected in great numbers. " In this Influenza of horses which spread over almost all Europe, no cause could be found in the weather, food, or work of the horses ; transfusion of blood of a, diseased horse did not communicate it to another ; many veterinary surgeons considered it to he contagious ; others did not hold this opinion. Influenza prevailed among men in North America, Mexico, and Siberia, but not in Europe. ' Turpentine has been used beneficially in the so-called Influenza of Iiorses. After this statement of the facts con- nected with the spread of Influenza, we proceed to notice the speculative subject of the Nature of the Exciting or External Causes. — So enigmatical are the phenomena con- nected with Influenza, that caution is necessary in attempting to form some idea of what the nature of the exciting cause may be. It must be a specific agent of some kind. From the earliest times authors have come to this conclusion ; the similarity of the symptoms in different epidemics show that this agent is the same in its successive invasions. If it be connected with an unusual meteorological or atmospheric condition, this has not been detected, and cannot be at present even guessed at. At the same time this agent must be in the air ; the diffusion is too rapid to sup- pose it to be conveyed by water ; besides, water-poisoning is usually localized. It cannot be attributable to food. There remains only the air as a medium of com- munication ; and that this is so, seems also shown by the way in which it can at- tack vessels at some distance at sea. There is, then, some special agent in the air. But this cannot he a gas ; no gas could spread in this way without utter dispersion and destruction. Besides, the manner in which it is located in a part of a town, a street, even one side of a street, for a time, or affects a town without touching a village a mile or two off, is quite conclusive against the hypothesis of seleniuretted hydrogen, allotropic oxygen, or any other gas being the cause. Nor can it be any molecular matter driven through the air, arising from some un- known telluric source, for this would be equally diluted and dispersed. The agent evidently cannot own one single and pri- mary origin ; it may, indeed, issue from one spot, but all the phenomena of its spread show that it must, in its transit, reproduce itself. Otherwise, if a gas, it must he rendered innocuous by dilution ; if an organic matter, by oxidation ; if a suspended mineral matter, by subsidence. It must increase, and the more the sub- ject is gone into, the more firmly will the idea gain upon the mind, that there must be a continual reproduction of the agent, to a greater or less extent, in different places. isTow this reproduction must either be in the air or in the bodies of the sick, in which latter case the agent would be a true contagion. If it grows in the air, the only conceptions we can form are, either that some force changes successively the atmospheric elements in some way, or that the increase is a vital one, and con- sists of microscopic plants or animals. The first idea is supported by no evidence ; and as to the second, we find ourselves in the presence of the so-called fungoid 40 INFLUENZA. theory of Influenza. There are many phenomena consistent with tlie hypothesis of a vital and growing cause : me occa- sional introduction of the disease by per- sons about whose bodies or clothes the fungi may cling ; its passage at times with the wind, contrasted with the occa- sional passage against it when other modes of conveyance may be presumed to come into play ; the gradual development of the disease to a climax, and then its decline, contrasted with its occasional persistence when the conditions of growth may be supposed to be more persistently in the same place ; the entire disappearance of the disease, and its extremely rapid resus- citation when it again appears ; its birth, apparent in various parts of the world, and yet its evident incapability of origi- nating in some countries, as France and England (whither it has always passed from other lands), are all easily explicable if we assume a fungoid origin, and re- member the different conditions which can effect the development of fungi. The remarkable powers which have lately been ascribed (with what justice time must show) to those lower forms of life increase the interest with which this question must be regarded. But, on the other hand, there is a com- plete want of direct evidence, without which the argument in favor of a special living agency is worth little. It is im- possible to make a certain and assured step without some tangible evidence. Moreover, for the rapid increase of fungi we should suppose certain meteorological conditions to be necessary — a certain tem- perature, moisture, organic effluvia ; but the spread of Influenza has little, if any, connection with these conditions. If the cause be a fungus, or some allied organism, it may increase in the body as well as out of it, and if so would be found in the secretions, especially in the nasal, buccal, and bronchial mucus. In this way human intercourse would spread it. A thorough microscopic examination of these discharges is yet wanting, but pos- sibly the next epidemic may supply this link. If the agent is not a fungus, the only other ready explanation which presents itself is that of a true contagion ; namel}', that particles of the sick body being thrown off are in some special condition, or are undergoing certain putrefactive or other chemical changes, which can excite a similar action on particular parts of other human bodies. And in this case, to account for the spread of Influenza, we must believe that these particles pass off in myriads from each sick person, are ex- cessively small and light, perhaps become dried up, and floating through the air, to greater or less distances, are breathed or swallowed by other persons, and then set up in their bodies the same series of changes which the particles themselves are undergoing. This view seems to me to involve greater difficulties than the fungoid theory, i. e. , it accounts less satis- factorily for the spread of Influenza. If neither of these views be correct, then the cause of Influenza is something of which we have no conception whatever. It seems to me to be impossible at present to come to any conclusion as to the nature of the cause. [Two alternatives seem to remain for further investigation, in con- nection with the etiology of Influenza, as well as of several other epidemic diseases; especially Yellow Pever and Cholera. One of these is an expansion of the idea pro- posed and elaborated especially in regard tc Cholera, by the late Dr. Snow, of Lon- don; designated by him as the theory of " continuous molecular change;" supposed by him rather to extend than to substitute the common notion of contagion. The other, very probable, view is, that the "disease germs" of many epidemics, al- though really organic in nature, are uHra- microscopic in minuteness, and therefore not demonstrable except by their effects. — H.J Predisposing or Internal Causes. — liace has no influence, sex probably none, or, if at all, women are slightlj' more affected ; age has only a slight" effect ; young chil- dren are, it is said, rather less affected than old persons. If any special bodily predisposition is necessary, it is common to the whole human race, and apparently to horses, dogs, cats, &c., herein differing greatly from several of the true conta- gions. Persons in overcrowded habitations have, particularly in some epidemics, es- pecially suffered, and several instances are on record of a large school or a barrack for soldiers being first attacked, and of the disease prevailing there for some days be- fore it began to prevail in the town around. Sometimes, on the other hand, schools and prisons have escaped. A low, damp, ill-ventilated and un- healthy situation appears to predispose to it,' and in some instances, in hospital pa- tients, it has assumed a malignant cha- racter (Sir George Baker, Gray)". In other cases again, hospital patients have es- caped ; for example, the old people in the Salpetriere in 1837, when the younger at- tendants were attacked. It has been supposed that persons with chronic lung diseases, especially emphy- sema, and chronic heart affections, are particularly liable, but this seems uncer- tain ; it is probable that the Influenza being more serious in such persons, cre- ates the impression that they are as a ' Pearson noticed this in both 1762 and 1782. INFLUENZA. 41 class more liable. The Registrar-General has shown that in 1847 tlic increase of deaths by Influenza was much greater in the districts in which ordinarily there is a high mortality than in healthier places; this must indicate either greater preva- lence or greater severity of the disease. Symptojis. — General Course of the Dis- ease. — The symptoms of Influenza are compounded of two conditions— a gene- ral fever of determinate duration, and a marked and evidently specific affection of the mucous membrane of the nose, mouth, throat, and respiratory tract, which has also a determinate course. Individual cases difter in the propor- tion of these two conditions, and in ad- dition there may be superventions of true inflammation of the lungs or pleura, or implication of other mucous membranes, those of the stomach and intestines in particular, and less frequently of the blad- der and kidneys. It would appear that the fever has the priority, ancl that shivering or coldness down the spine, with heat and flushing and dry skin, quick pulse, thirst, and se- vere headache, very frequently usher in the attack. These symptoms precede any local signs. But it would be very desira- ble to re-investigate this point. The fe- brile symptoms sometimes come on quite suddenly, sometimes develop slowly, in from twelve to thirty-six hours, or even to four days. When they commence sud- denly, the first symptom is often an ex- treme frontal headache, with pain and aching in the eyes. They last for four or five days usually, or sometimes a few days longer, and then disappear gradually, or occasionally rather rapidly, with profuse perspirations, or spontaneous diarrhoea. Sometimes they continue ten or twelve days, but this is generally when pneumonic complication supervenes. The specific catarrhal affection usually follows the early symptoms of fever ; sometimes occurs at the same time, per- haps sometimes precedes them. It ap- pears to commence in extreme hypertemic swelling and dryness of the mucous mem- brane of the frontal sinuses, the nose, and, in a less degree, of the conjunctivfe, caus- ing intense pain across the brows, great sneezing, sometimes epistaxis and thin acrid discharges from the nose and eyes; the same condition then occurs in the pharyngeal, the laryngeal, tracheal, and pulmonary mucous membrane to the mi- nutest ramifications. Usually, perhaps, the affection commences above and passes rapidly down, but sometimes the whole tract is attacked at once. The inside of the mouth and the tongue are also, but less, affected, and the pharynx is also not so marked by byperajmia as the other parts. A punctiform redness of the mu- cous membrane of the palate, something like the eruption of measles, has been lately described by Tigri, and considered to be pathognomonic. The discharge from these membranes, when it occurs, is first thin and acrid, and sometimes bloody; it becomes afterwards thicker, more tena- cious, and at length purulent; great sneez- ing, sore throat, difficulty in smelling, vio- lent paroxysmal cough, pains in the chest; occasionally very sharp stitches in the side, which arc apparently often nervous, and not pleviritic, accompany the specific condition of the respiratory tracts. Great dyspncBa and the stethoscopic examina- tion show that there is immense conges- tion of the lungs, and often the face and lips show verj' considerable impairment in the aeration of the blood. In pure cases the catarrh is at its height on the second and third, or fourth day, and declines about the fifth to the seventh ; but cough expec- torations often remain for some time. In severe cases the disease lasts with great severity even to the tenth or twelfth day. Attendant upon these symptoms, and in proportion, it is usually supposed, to the fever, though some have thought it to be in more direct ratio to the extent and violence of the membranous catarrh, is a peculiar state of the nervous sys- tem. Very early in the disease there is a remarkable nervous depression, loss of strength, and lowness of spirits, com- bined often with great aching in the mus- cles, and severe nerve pains in different parts, which certainly give one the impres- sion that both muscles and nerves are undergoing some profound nutritional al- teration. The mind, too, becomes weak, and sometimes there is even stupor or de- lirium. In some epidemics, indeed, the early sopor or cerebral heaviness is very remarkable. These nervous symptoms often last longer than either the fever or catarrh ; hence convalescence is tedious and mental activity slowly regained. In pure cases, when the disease is over, the nasal and respiratory mucous mem- branes do not for some short time entirely recover their structure, at least if it be true that there is increased liability to common catarrh. Also if it be true that there is a greater liability in future epi- demics of Influenza, it is possible that some structural change may permanently remain. The severity of the cases differs greatly, and sometimes the affection is very slight, sometimes very severe. Consideration of the Special Symptoms. — 1. Tempcrnturc of the Body. — No observations have yet been made with the thermometer. In some epi- demics (1580, Salius Diversus) there has been intense heat of skhi ; in others (1775, 42 INFLUENZA. Pothergill) the skin has not been particu- larly' hot. But perhaps this might depend upon individual cases ; for in the same epidemic some have great, others have slight, fever. "J. Condition of the Skin. — Sweating at first is usually absent or partial. If it is profuse in the early stages, the disease is sometimes arrested. The perspiration is often sour smelling, and is said to be very acid. In the epidemic of 178'2 in London, the sweating was so profuse as to cause the name of sweating sickness to be given to the Influenza. Sudamina are sometimes Seen in great numbers, so that the case looks like miliaria. A pustular or herpetic (Peacock) eruption about the mouth some- times occurs. There is no decided erup- tion peculiar to Influenza, but occasion- ally it is said rose-colored little blotches, and sometimes urticaria are seen. There is sometimes most decided hypersesthesia of the skin of the neck and head ; this is usually coincident with severe headache. d. Nervous and Muscular Si/mptoms. — The headache is often excruciating ; fron- tal most usually ; limited to the region of the frontal sinuses, or extending more or less over the head, or over the face, (Antrim of Highmore) ; there is often great heaviness, sometimes torpor, and occasionally delirium. In some epidemics high delirium has been considered a mor- tal symptom (Iluxham in 17.37). Severe vertigo is a common symptom. There is a general lowering in the acuteness of all the special senses. The spirits are low, mind weak ; the nights restless, and this loss of sleep is not in relation to the fever ; it is seen often in patients without fever. ' Meningitis occasionally occurs, and sometimes otitis, and there is often severe pain in the region of the Eustachian tube. There are also neuralgic or rheumatic-like pains of many parts of the body, especially of the muscles of the neck, loins, legs, and the intercostals. The extreme prostration of muscular strength has been already noticed ; it is often a very early symptom, and in some epidemics has given almost a special char- acter to the disease ; the complete return of strength does not occur till after conva- lescence is far advanced. 4. Bcspirutory Si^em. — The paroxys- mal cough is one of the most distressing symptoms, and sometimes causes hernia, or abortion in pregnant women. At first dry, the cough is soon attended with stringy, often bloody sputa ; as soon as the sputa get more consistent, thicker, more opaque, and purulent, the cough lessens. In dilTerent epidemics the ' The epidemic of 1712 was attended in Tubingen by great drowsiness, and in that oiitt)rf ak the brain symptoms appear to have been unusually heavy. amount of cough has varied, but this, may be, in part depends on erroneous observa- tions, as formerly no doubt epidemic hooping-cough was confounded with In- fluenza. Djspno'a is often considerable, and is dependent either on the great congestion of the respiratory tract, or on pneumonic complications, or possibly, as ' suggested by Graves, on some special im- [ plication (paralysis ?) of the vagus. , There are often remissions in the dyspnoea, not accounted for by stethoscopic signs.' Occasionally there are orthopnoea and suf- focative attacks. Sometimes there is in- tense and oppressive feeling across the chest. The number of respirations is often great, and the pulse-respiration ratio becomes one to two-and-a-half or one to three. In bad lung cases the voice is often verj- weak as well as hoarse. At first the stethoscopic signs are almost wanting ; the vesicular murmur is feeble, even thougli the percussion note be clear ; if there be dulness, it is equal and indecti- ble. Afterwards when oedema of the lung occurs they are fine moist rales, and sono- rous and sibilant rhonchi are present in some cases. Capillary bronchitis, pneumonia (which is usually combined with pleurisy), and pleurisy are present in some cases, though it is impossible to state in how many. It has been supposed that pneumonia occurs in from five to ten per cent. ' In some epi- demics pneumonic complication is sup- posed to be more common, as in 1837 ; the pneumonia is said to be of the catar- rhal variety when it occurs during the attack (about the fourth to the sixth day), and of the croupous kind when it occurs, as it sometimes does, in convalescence (Lombard). The supervention of pneu- monia is not easily detected by stetho- scopic signs before consolidation, in con- sequence of the oedema. The same rea- son makes it sometimes difficult to detect true capillary bronchitis unless one lung is more affected than the other. Pleurisy is easily detected. Sometimes it is supposed that a sort of paralysis of the lungs occurs with great ffidema (Graves), possibly from affection of the vagus. Collapse of some portion of the lungs often occurs. That during the height of the disease aeration is most imperfect, is evident from the dark lips, congested cheeks, and great distress, which are often seen. As sequelae to the chest affisction, chro- nic laryngitis, chronic bronchitis, emphy- sema, and tuberculosis ai-e sometimes seen. Yet it is well known that some phthisical patients pass well through Influenza with- out increase of their disease. 5. Cirndatory System.— At first strong and quick, the pulse soon becomes soft, ' Biermer, op cit. p. 624. INFLUENZA. and in the latter stap;es feeble, and even slow. It is often singularly changeable within a few hours. Heart affections are not common, yet pericarditis will occur, and is then usually complicated with pleu- risy. The blood is buffed and cupped in pneu- monic complications, perhaps in all cases. (Visla.) 6. Digestive System. — iSTausea and vom- iting are sometimes seen in the commence- ment ; diarrhoea is m',K:h less frequent till towards the end, when there are often rather profuse discharges ; thirst and complete anorexia are very usual. There is sometimes pain in the right hypochon- drium, and a yellowish tint of eye and skin. (Peacock.) In some cases there is a decided icteric state of the skin. The great depression and languor is very simi- lar to that which accompanies some cases of jaundice when the bile is accumulating rapidly in the blood. Sometimes the bilious vomiting, fever, and oppression of the brain cause the case to resemble the bihous fever described by authors. There is no evidence of any splenic affection. In some epidemics these gastro-enteric symptoms have been, it is said, more pro- nounced than in others, but there is no doubt that cases of typhoid fever compli- cated with or following Influenza have often been described As a rule, in pure cases, the symptoms of stomach and bowel implications are not marked, or are caused by medicine or food. Urinari/ System. — The urine is at first scanty and high colored ; at a later period it becomes sedimentous from lithates, which are often pink ; it is believed there is no albumen nor bile, but good observa- tions fail on these points, as well as on the composition of the urine in twenty- four hours. Occasionally there is almost complete or entire ischuria. Genital System. — The catamenia are sometimes induced, and amenorrh^ea has been thus cured. Abortions are frequent, especially in some epidemics, probably from the violence of the cough. Lymphatic System. — Swellings of the parotid, the submaxillary, and sometimes the cervical glands are observed, and oc- casionally, but rarely, severe parotitis fol- lows. It is somewhat curious that either an intermittent fever has been united to In- fluenza in some epidemics, or that the Influenza has had an intermittent charac- ter. Thus in 1580 Sennert mentions that the quartan fever was joined to the e))i- demic; in 1658 Willi's states that the epidemical catarrhal fever often had an intermitting character, usually tertian, rarely quotidian. In 17G-2 Baker says that Influenza appeared under the form of an intermittent with tertian periods. In 1767 Donald Monro also saw an intermit- tent character, but not so marked as in the epidemic at Jjremen in 17(U. In 1775 he says that few persons had such distinct paroxysms as to resemble those of an ague ; but Fothcrgill (1775) states that ''in many instances the disease assumed the type of an intermittent towards its dechne." In 1803 Pearson noticed that the lassitude and depression which con- tinued after the fi^vcr had gone had an intermittent character, and were "worse every other day. The histories of the recent epidemics show no character of this kind, and it is possible that in former cen- turies the far greater prevalence of malaria impressed on other diseases a periodical character which was not in their own na- ture. But the observations are curious in connection with the opinions of those who have connected Influenza with malaria. Varieties of Ikfliteitza. — The va- rieties in different epidemics have been already referred to. In the same epidemic Influenza differs in intensity in different people. In some persons it is an extremely slight disease ; in others, a very severe one ; this is especially the case if there are pulmonic or gastric complications. So also in some cases an unusual nervous depression prolongs a case vvdnch might be otherwise a mild one, or paroxsymal cough and expectoration, or flying neural- gia, or rheumatic-like pains continue for some time during convalescence. Mortality. — This seems to vary great- ly in difterent epidemics (18:17 and 1847 were more fatal than 18.33-4 ; Graves), and is also partly, perhaps, dependent on treatment. Wierus says that the great mortality in Italy in 1580 was owing to the promptitude with which the Italians bled ; the mortality in London has some- times been severe, while it has been slight in Germany. In 1837 the rate of mortal- ity was calculated at two per cent., but it was considered that this was a very severe epidemic. There appears no doubt that mortality increases greatly with age. It is also higher in persons with chronic bronchitis, ernphysema, and chronic heart-diseases, especially dilated and fatty hearts. Mere valvular disease, without loss of power, has little influence. During the preva- lence of Influenza, other causes of death show an increase, especially pulmonary complaints, and typhoid, and typhus. This depends probably on the superven- tion of Influenza upon those affections. Diagnosis.— If the term Influenza is restricted to the truly epidemic disease which spreads over large tracts of country, there is no difliculty in the diagnosis. Although there is no special eruption as in the exanthemata, or peculiar cough as u INFLUENZA. in pertussis, or membranous pellicle as in diplitheria, the collection of symptoms is peculiar. Kor can there be any confusion between cases of epidemic cough and isolated cases of catarrh, arising usually from marked meteorological con'llitions. However com- mon such attacks, however severe and iriflmnzriid they may be in certain cases, they do not constitute an epidemic ; there is no disease spreading over the country. Moreover, the symptoms are really dis- similar in ^their mode of connection and succession. Far more difflcult is the di- agnosis between true Influenza and ca- tarrhal fevers invading a town or district. That there are such local or endemic at- tacks of catarrhal fever seems certain, and it is doubtful whether or not they should be classed with Influenza. They want the power of travelling ; they attack more slowly, and are far less common among the population. There is for the most part iess of the overwhelming pros- tration, and fewer mucous niembrani's are attacked. They appear usually to be merely the common catarrh developed into unusual proportions by changeable or severe weather, and possibly this may be the simple explanation of their occur- rence. If by the use of the thermometer a t3'pical course of temperature is discovered in Influenza, or if the examination of the excretions detects anj' special characters, the diagnosis will be easy. Till these points are determined some doubt must exist, nor does it seem to me possible to lay down any precise rules of diagnosis. There are few points more deserving care- ful study than the precise characters and causes of catarrhal fevers, localized in a town or district, and not forming part of a general epidemic. There is no other disease with which Influenza can be confounded, but during its prevalence many other diseases — bron- chitis, typhoid fever, etc. — are often called Influenza, and this probably has given rise to the opinion that during epidemics of Influenza such diseases lessen, to reap- pear at its close. Pathology. — TVe are not yet in a po- sition to discuss the pathology of this dis- ease. Does the agent enter the blood, act on the nervous system, and then by election seize upon and irritate the mucous membrane of the respiratory tract ? Or is it really a membranous local disease, acting very promptly (just as simple an- gina will act on the system at large) in the secondary constitutional effects ? At pres- ent the sequence of symptoms seems to show the first view to be more probable, viz., that it is a general disease, with a special secondar}' localization. What is the exact nature of the general disease ? The blood is buffed and cupped ; i. c, there is increase in the fibrine ; that is all that is known of the blood ; the pe- culiar changes in the nervous system and the muscles are quite unknown. What is the exact nature of the respira- tory aflfection ? If we reply, it is a gen- eral hyperemia, this is a mere translation of terms. Of the exact cause of that hy- persemia we have no idea. Is there a partial coagulation of blood in the venous system, or some affection of the vaso-nio- tor nerves leading to general dilatation ; and is the altered mucous discharge due to such change, or to some special condi- tion of the nutrient plasma as it comes from the vessels, which strikes deeply at their growth and nutrition ? The inflam- mation, if we are to give it tliat term, is evidently specific ; in what the specific character consists it seems at present vain to inquire. MoEr.iD Anatomy. — Fatal cases of pure Influenza are rare ; they occur chiefly in old persons, with old lung or heart dis- ease, or in consequence of recent inflam- matory pulmonic or cardiac complications. The results of simple Influenza seem to be general congestion of the respiratory tract, amounting sometimes to enormous congestion of the lungs, oedema of the lungs, with more or less collapse. The collapsed portion is smooth, non-cre])itat- ing, and is said to be sometimes softer than usual, like gangrene, but without fetor.' Sometimes membranous exuda- tions are found in the bronchi, not unlike those of croup. If pleurisy and pneumonia have oc- curred, the usual post-mortem appear- ances of those diseases are present. The pneumonia is sometimes lobular (or possi- bly this statement has arisen from lobular collapse not being identified) or lobar, and is often double. Progkosis.— The very young and the very old bear Influenza badly, especially the latter. Persons with chronic bron- chitis, emphysema, and fatty heart, are bad subjects. In persons without such complaints the danger is chiefly connected with the state of the lungs. Great dyspnoea, very weak voice, impossibility of coughing up the tough sputa, and "duskiness of "the face, are unfavorable signs. If the pulse be- comes early very feeble and slow, and then unequal and intermittent, it shows that the heart is not receiving its due sup- ply of blood on account of the lung-con- gestion. The fever and the nervous symptoms seldom kill, yet in some epideniics there have been frequent delirium, convulsions, ' Especially hi very aged persons : Greene, in Graves's Clin. Med. vol. i. p. 438. INFLUENZA. 45 and fainting, and these have always been found to be very bad symptoms. As favorable signs may be noted, copious warm sweats, loose so-called concocted sputa, spontaneous diarrhcea, and urine with copious red lithates. In the case of pregnant women there is danger of abortion and subsequent hemor- rhage. Treatment. — Preventive Treatment. — 1^0 means are yet known by which In- fluenza can be prevented. Unfavorable hygienic conditions, and especially over- crowding, heighten its prevalence and its severity ; but persons in the most favor- able circumstances may be attacked. Per- haps persons in well-warmed and yet ventilated houses escape best. It has sometimes been noticed that persons ex- posed by work to tlie weather suffer most : hence it may be a rule that those persons who can do so, sliould be more within the house during an epidemic ; but as bed- ridden persons are not infrequently at- tacked, this is no guarantee. Treatment of the declared Disease. — Se- gimen. — It is of great importance to have the room cool and well ventilated. Pear- son, whose little work on Influenza is one of the most practical which has ever been written, pointed out, in 1803, the differ- ence in this respect between common catarrh and Influenza. In the former case the patient is better in bed in a warm room ; in the latter case, if the patient is not too ill, it is better to get him out of bed after the third day, and to place him on a sofa. ' Draughts or chills must be, however, most carefully avoided, on ac- count of the risk of pneumonia. As there is usually almost complete anorexia, it is difficult to give much food. The common custom of giving hot beef- tea is an extremely bad one ; it invariably increases the headache and languor, and, as Pearson pointed out, any warm food which forces sweating appears not only to be useless, but to do harm. Solid meat also should be abstained from for two or three days in bad cases. Several writers recommend vegetable food for four or five days. Plenty of cold drinks, especially sub- acid fruits, oranges, lemon-juice, cream- of-tartar water, raspberry vinegar, weak citrate of potash, and citric acid flavored with sugar, barley-water with lemon juice, infusion of mallows or althea, and drinks of the like kind, should be given ad libi- tum, and when there is fever they should be iced. Very weak cold white-wine whey is a very grateful drink. Some good writers speak strongly against the prac- ' hi some of the older epidemics the prac- tice in England was to keep the patient ex- tremely hot in bed, and to eive calefacients. ISOl. tice of stimulants early in the disease, in all young persons ; the great languor and weakness often lead to their usi', but it seems probable that they do harm. If stimulants seem indispensable, claret or hock, with seltzer water, is the best. In old persons it may be necessary to use stimulants earlier and more freely. Stimulants must however be given, and often given largely, in the later stages, if the heart fails, and especially if there are symptoms of intense luug congestion and asphyxia. Brandy, with ammonia, must tlien be freely used. As soon as the severity of the fever is passing away, patients should be made to eat •, the appetite is still bad, but they will generally take food. Care should be taken not to derange the stomach by too great quantitj' or variety of food, of which there is some danger. Js^o experiments have yet been made, to my knowledge, on the effects cf cold affusion in the stage of fever ; but possibly it might be useful. The wet sheet has been used, and apparently with some benefit. For old people, Schonbein used to order warm baths or warm fomenta- tions. Keeping the air of the room moist, by conducting the steam from a boiling kettle into it by means of a tube, or by putting boiling water into flat shallow vessels, appears to ease the cough. Also, as in common catarrh and bronchitis, the inha- lation several times daily of liot steam is most useful. The old inhaler of Mudge, with the hollow handle, and the valve in the cover, or any of the new inhalers, may be used. If they cannot be obtained, breathing through a sponge dipped in hot water is the best way. Briujs. — Slight cases require almost nothing ; a little cooling saline medicine, citrate and acetate of potash, nitrate of potash, &c. In severer cases treatment must be more active. Blood-letting seems always hurtful, and this was noticed so long ago as in the epidemics of 1.580. Hardly a writer of any note has failed to make the same re- mark. The fever is not relieved, the nervous depression is increased, and the risk of the lung congestion and paralysis is augmented. Even with supervening pneumonia, in the old days of bleeding, blood was very seldom taken more than once. If cupiiing or pneumonia come on with severe pain, a few leeches or a pleu- risy glass to the painful part are often useful, but depletion should hardly go be- yond this. A dose of calomel, one to three grains, according to circumstance, repeated once, but not oftener, should be given at first, and may be followed by a saline pnrs;ative. Pearson strongly recommended this, and 46 INFLUENZA. various writers have endorsed the prac- tice. Tlie calomel generally brings away copious dark-colored motions, after which the patient is much better in spirits, and the fever abates. But neither mercurial nor other purgatives should be too freely or repeatedly given, as the intestinal mu- cous membrane is irritable. Repeated catharsis is sometimes most injurious. The substitutes for mercury, podophyllin, ialapine, &c., have not yet been tried in Influenza, and it is impossible to say whether they will be more or less useful. In children, gray powder must be sub- stituted for calomel, or, what seems better for them, clysters of warm water, with a little castor-oil, may be used. Prom the good effects of one or two doses of mercury some have proposed to continue to give mercury, stopping just short of salivation. But this is bad prac- tice ; there is no evidence that these small repeated doses of mercury are useful, and it is impossible to be sure that salivation will not come on before we are aware, with all its evils. Emetics, at the onset, have been very strongly recommended, and in the older epidemics an emetic of antimony and ipe- cacuanha was invariably given, when the patient was first seen. If there is much nausea an emetic is useful, and perhaps may be so in all cases ; but there is one disadvantage, it occasionally produces great and permanent irritability of the stomach, so that it is afterwards difficult to check the constant vomiting. Tartar emetic has been chiefly used, but it causes much depression. On the whole it seems undesirable, as a rule, to give emetics. After the bowels have been well acted upon, the best remedies to give in com- mon cases seems to be nitrate of potash mixed with lemon-juice and sugar. It seems most useful to give it highly diluted, so that it may be taken as drink. Prom 60 to 120 grains, in twenty-four hours, may be given to an adult. Supposing the chest symptoms are not urgent, nothing else need be done ; but if the lung congestion is considerable and the cough very hard, some expectorants must be used. Of these ipecacuanha seems on the whole the best, and can be combined with conium or henbane, or with the etherial tincture of lobelia. (Blakiston.) Tartar emetic, as an expectorant, has been strongly recommended, but it ap- pears to be too lowering in many cases. In the epidemic of 1847 I found it to be of little service, and sometimes to cause irritation and congestion of the intestinal mucous membrane. It is, I believe, better avoided altogether. Opium requires to be used in bad cases with the greatest caution. There has been much discrepant evidence as to its employment, but on the whole it seems, as Pearson pointed out, best to defer its use till the later stages. If given early it increases the tightness across the chest and the difficulty of breathing. At a late stage, when the expectoration is coughed up easily, and all danger of great lung congestion seems passing off, opium with ipecacuanha quiets the paroxysms of cough, and gives great ease. Sometimes, however, when the cough is extremely violent, and conium and hen- bane do no good, opiimi must be given. In fact the cough itself, simply as a me- chanical agent, excites an unfavorable eftect on the congested lung, and must be stopped. Then Dover's powder, with nitre and lobelia, should be given ; if this does not answer, the liquor morphise mu- riatis or the bimeconate of morphia with ipecacuanha, in large doses, must be used. Squills seem decidedly hurtful till quite the latter stages. If there is great tightness across the chest, sinapisms and warm bran poultices or warm water fomentations must be con- stantl)' used. Sharp stitches in the side, if pleuritic, must be treated with sina- pisms and warm poultices, or, if very severe, with a few leeches, followed assi- duously by warm fomentations. If no friction-sound can be detected, they are intercostal neuralgic pains, and are soon relieved by warmth, opium, and chloro- form, applied externally. In the latter stages, if the expectoration is profuse, the cough still violent, and the strength failing, senega and serpentaria, mixed with light wines, seem to be very useful. Ammonia must also be used. If the expectoration continue extremely pro- fuse, the acetate of lead, with a little opium is useful. Some of the older writers thought that cinchona bark was hurtful in the earlier stages, but in some of the late epidemics quinine appears to have been found useful throughout. Whether this be the case or not, it seems clear that immediately the acute stage is passing off quinine should be freely given. It does good service against the neuralgic pains which are of- ten troublesome at the commencement of improvement. [The employment of qui- nine in Influenza has now become ex- tremely common in xVmerica, even in non- malarious districts. Beginning with it upon the occurrence of the first symp- toms, doses of from three to five grains every two or three hours, until ten or twelve grains have been taken, will, if not abort, at -least mitigate the violence of an attack. Should this, with other palliative treatment, not avert or arrest the disorder at the beginning, quinine will, throughout its course, do the most good in small or moderate doses ; not more than eight or ten grains in a day. The early ubortiv-e practice, however, with quinine seems to TREATMENT 47 be well worthy of general trial, not only in epidemic Indueuza, but in those spora- dic catarrhal attacts, which, under the name of "catching cold," are common everywhere. — H.] Warm plasters between the shoulders have been much praised by some writers (Legendre). Blisters do no good, and add to the patient's sufferings. Inhalations have been tried both for the cough, sore throat, and nasal soreness. Pearson used the vapor of ether, which he had found very useful in common catarrh ; it was not so good in Influenza. Chloroform, in small quantities, may re- lieve the tightness and the violence of the cough. Inlialation of steam has been al- ready noticed. In future epidemics it would seem very desirable to try various inhalations to act on the membranes of the nose, pharynx, and lungs. It is im- possible a priori to say whether they could be of any use, but small quantities of chlorine, iodine, carburetted hydrogen, even perhaps sulphurous acid, might be tried. The naso-bronchial mucous mem- brane is very accessible to such influences, much more so than to medicines intro- duced into the blood. It may be a question also whether some local applications could not be made to the membranes of the nose and throat, such as solutions of iron, catechu, or al- terative substances of that kind. Possi- bly the local disease might be thus partly checked. The use of sulphites of potash and soda may also be suggested as a local applica- tion to the throat and nose. Complications. — It is very doubtful whether pneumonia is benefited by bleed- ing ; the pneumonia has itself a course, and cannot be cut short ; it is probably better to persevere with ipecacuanha and nitre, and to apply only a few leeches or a cupping-glass if pleuritic pain be intense. In double capillary bronchitis bleeding is hurtful ; the great danger is suffoca- tion ; brandy and ammonia, with vale- rian, and lobelia inflata, must be freely used. Sometimes, even in cases of ex- haustion, it is necessary to give an emetic, as the thick secretion blocks up the tubes ; sulphate of zinc and ipecacuanha is then the best emetic. In obstinate vomiting, hydrocyanic acid, and very small doses of morphia, with effervescing draughts, will generally sutBce. Excessive diarrhoea must be checked, but moderate diarrhoea does good, and is indeed a favorable sign, especially on the tliird or fourth day. In suppression of urine, a very hot bath and copious draughts of linseed-tea, with a little liquor potasste, or chlorate of pot- ash, must be given. if there be intense headache and stupor, purgatives, cold applications to the head and a few leeches, either to the temples or the Sohneiderian membrane, will often give relief If there be much coryza and great pain in the nose and frontal sinuses, a few drops of solution of muriate of morphia in a little water, sniffed or injected up the nostrils, will give relief If rheumatic symptoms come on, col- chicum is said to be useful (Peacock) in small doses (4 or 5 minims of the tincture of the seed), given every 3, 4, or hours, with ammonia and opium. Iodide of po- tassium with colchicum is also sometimes useful. Convalescence. — Iron and quinine must be given for some time in small doses. A very nutritious diet, beer, and wine, must be employed. Milk in large quanti- ties is very useful. Milk and seltzer water is a favorite German remedy. The skin must be very warmly clothed, as it is very sensitive. If there is much dyspnoea left behind, the alcoholic or etherial tincture of lobelia should be used. Plying pains of tlie chest are best treated by opiate fomentations, or a liniment of acetic acid and oil of tur- pentine, recommended by Dr. Stokes. If a piiroxysmal cough is left behind, with copious and rather viscid expectora- tion, ammoniacum and opium should be given. 48 HOOPING-COUGH. HOOPING-COUGH. By Edward Smith, M.D., F.R.S. Defikition. — A convulsive cough con- sisting of a series of forcible expirations, follovyed by a deep, loud, sonorous inspira- tion, and repeated more or less frequently during each paroxysm ; occurring usually in cliildliood, and once only during life, and continuing several weeks. CuUen's definition is, " Morbus contagiosus, tussis convulsiva, strangulans, cum inspiratione sonora, iterata, ssepe vomitus." It is popularly known in England as "Wliooping-cough, Kink-cough, Chin- cough ; in France, Coquoluclie, and in German}', Keuch-husten and Kik-hustcn; from the sonorous inspiration which marks it; and technicallj-, as Tussis convulsiva (Willis and Sauvages) and Pertusis (Sy- denham and Cullen). History. — It is diflflcult to believe that a disease having characters so well and easily defined could have been known to the ancients without a description having been recorded by which we might now recognize it; and, as no writer before the middle of the seventeenth century has de- scribed it, we are led to the conclusion that the disease was unknown to the fathers of medicine, or that it has acquired one of its chief characteristics since their day. Diseases having a contagious or epi- demic character, and resembling Ilooping- cough in its catarrhal symptoms, were known to Hippocrates and others before the Christian era, and have been described by Arabian, Italian, and French authori- ties down to the sixteenth century ; but, lacking the distinctive character of the Hoop, they more nearly resembled influ- enza than any other disease now known to us. Hence the history of the disease cannot be clearly traced back to a period earlier than that of Willis, from whom we have received not only the first description of it, but one which in all respects is ap- plicable to the disease as it exists at this day ; yet, as from his definition " Tussis puerorura convulsiva seu suffocativa, et nostro idiomate, chincow/h vulgo dicta," it is probable that the disease was then commonly known to the people, we may infer that it had existed in England some time before he descrilsed it. " Dr. Gibb avers, but without citing authorities, that it has been known traditionally among the French Canadians for more thnn three centuries ; and, as they are presumed to have received it from France, he affirms that the disease to which Mezeray gave the name Coqiteluclw in the fifteenth cen- tury, was truly Hooping-cough notwith- standing the absence of the distinctive Hoop in that author's description of it. Causes. — There is no known specific cause to which it can be attributed; but that atmospheric influences are its chief exciting causes may be inferred from the facts that it has often occurred as an epi- demic, and is most prevalent at certain seasons of the year. The imperfection of our knowledge in reference to atmospheric influences, other than temperature, and the absence of registration of the preva- lence of diseases which do not end fatally, prevent a more minute inquiry into this relation. The fact that Hooping-cough is, without reasonable doubt, a contagious disease, implies that a materies morhi gene- rated, or at least acting, within the body, is communicated from one to another per- son, and that the atmosphere is also the ^■ehicle for its transmission ; but as we know nothing of the nature of this mate- ries morhi within the body, so are we equally ignorant of its characters when existing without it. Further, we do not know with any precision the period of in- cubation during which the communicated poison is imperceptibly acting within the body, but it probably does not exceed ten days. The influence of childhood in the causa- tion of the disease must also be cited. In our analysis of the deaths from Hooping- cough, published in the Medico-Chirurgi- cal Transactions for 1854, it was shown that Hooping-cough was the most mortal of all diseases of children under at. 1 year; that 68 per cent, of all the deaths from Hooping-cough occurred under set. 2 years ; and that only 6 per cent, of the deaths were recorded after ast. 5 years. But here again our knowledge is most limited and vague when we attempt to analyze the conditions attending early life which may be presumed to lead to the occurrence of the disease. It is summed up in the phrase "great excitabihty or impressionability of childhood, " by which all influences are asserted to exert special power at that period. But it applies with equal force to the occurrence of other dis- eases in childhood which have but little SYMPTOMS. 49 affinity with Ilooping-cougli in its leading characteristics. Yet it accords well witla the generally adopted views as to the im- mediate cause of tlie cough, to wliicli we shall presently refer, and is further sup- ported by the fact proved in the paper just quoted, that the disease when fatal prevailed more in females than in males — in the sex in which this special char- acter of childhood is the most marked. Nature and Seat. — The intimate cause, or the nature and seat, of Hooping-cough is variously regarded, as one of the two leading characters of the disease — the ca- tarrhal or the convulsive — is the more urgent; but with literature rich in authori- ties the preponderance of opinion is in favor of the essentially nervous nature of the disease. This opinion has been held by Hoffmann, Ilufeland, Lobenstein, Lobel, Paldame, Wendt, Jahn, CuUen, Leroy, Guibert, Webster, Pinel, Todd, Gibb, and Copland. Tlie immediate seat of this nervous irritation has been very variously ascribed to the stomach (Cliam- bon and Broussais); to the lungs (Wendt and Paldame); to the diapliragm (Millot); to the pneumogastric nerves (Hufeland and Hotfmann); to the phrenic nerve (Jahn); to the medulla oblongata (Cop- land); to the brain and its membranes (Webster); and to the general nervous system (Guibert); but several of these authorities included more than one seat in their description. The most characteristic views of recent date are perhaps those of Guibert and Cop- land, to be found in the renowned Dic- tionary of Medicine of the latter. Guibert "considers that a common cough may pass into this affection by having tihe spas- modic state of the muscles of the larynx and of the diaphragm superadded to it; and, therefore, that spasm superadded to cough constitutes the disease — the state of spasm resulting from the high nervous susceptibility and particular disposition to it existing in children, and from indi- vidual idiosyncrasy." "The increased secretion of mucus he refers to an excited state of the mucous membrane of the air passages . . . existing independently of any inflammatory action . . . the nervous symptoms being the result of the spasm, which he considers the chief agent of the morbid phenomena. " Dr. Copland writes: "I believe that the disease is chiefly ner- vous in the simple cases; that it preserves this character more or less throughout, even when inflammatory complications ensue; and that in the uncomplicated state the nervous affection never proceeds beyond irritation. . . . The inflamma- tory appearances in the medulla oblongata and base of the brain may be owing to the functional relation of these parts to the respiratory order of nerves which re- ceive the first impression of disease." VOL. I.— 4 The writers of high repute who give greater prominence "to the catarrhal or even inflammatory nature than to the nervous character of the disease, are Laennec, Dewees, Guersant, Watt, and Badham. Dawson believed that the in- flammation was restricted to the glottis, whilst Desruelles, with many others, re- garded Hooping-cough as beginning with bronchial inflammation and advancing to cerebral irritation. Many writers, with Guersant, believe that the inflammation is of a specific kind ; but the chief distinc- tion which they draw between this and ordinary bronchitis is the marked char- acter of the spasm, and tlio other evi- dences of nervous irritation — evidences which coincide more with the views of those who believe in the nervous nature of the disease, than with those who con- sider the disease to be essentially inflam- matory. In a disease in which these two main characteristics exist, there are doubtless grounds for difference of opinion as to their relative importance, and particularly when their respective influences vary in diflTerent cases and in different epidemics, and when observers, by their special studies, are led to regard cases from dif- ferent aspects, as the nervous, inflamma- tory, and pathological. Those who adopt the opinion that Hooping-cough is essen- tially a disease of the blood, and is due to a morbid poison existing in that fluid, regard both the nervous and the catarrhal evidences as of equal importance, but with this difference in their aim— that the former are direct evidence of the action of the poison, whilst the latter are the throes of the system to rid itself of the poison by secretion from the mucous membrane. Without denying the existence of a spe- cific poison, and without admitting that the supposed poison is eliminated by the mucous memlirane of the bronchi, we do not doubt that that feature which gives character and importance to the disease is the nervous or spasmodic one, and that in any uncomplicated case, when this has been abated, the disease is shorn of its specific characters and dangers. Symptoms. — On proceeding to state the symptoms of the disease, it becomes neces- sary to divide them into two classes : those of the simple and those of the complicated form of the disease. Simple Hoopwig- Cough. — The early evi- dences are those of simple catarrh without anv, or with scarcely any, febrile compli- cation. They are coryza, secretion from the nose, cough, more or less severe, but not at this stage spasmodic, with frothy and watery secretion from the bronchi, lassitude, restlessness, and some diminu- tion of appetite. After a period varying from one to two weeks the cough becomes 50 HOOPIXG-COUGH. a more marked symptom — is louder and more prolonged than an ordinarj' cough, and generally assumes a spasmodic cha- racter. When the nature of the disease has become quite clear, the cough is found to occur in paroxysms, during which the body is bent forward, and a series of short, very rapid, and violent expirations occur, and are continued until the face is ex- tremely suffused and the respiration seems almost to have ceased, when a deep, pro- longed, loud, and crowing inspiration takes place. This alternation occurs two, three, or more times in each paroxysm. The attack terminates with the emission of a somewhat large quantity of semi- transparent glairy and very tenacious mucus, which hangs about the mouth and lips, and not unfrequently with vomiting. At a yet later period the pertinacity of the expiratory effort is diminished and inspiration occurs more frequently, whilst the secretion, although still abundant, is more opaque and less tenacious, and vomiting less rarely occurs. During this period the peculiar charac- ter of the sounds with the cough somewhat subsides, and in progress of time it is omitted from some of the attacks — the relative frequency gradually diminishing until it altogether disappears, and the cough has no longer any special cha- racters. In mild cases the disease may soon end ; but in more severe cases there remains much exhaustion and emaciation, with defective appetite and increased sen- sibility of the stomach, which leads to vomiting from tri\ial causes. The rate of pulsation is increased in a most marked manner during the attack, so that in very severe paroxysms it is too great to be counted ; yet it is not due to any inflam- matory or febrile condition, but to the mechanical interference with respiration. In the intervals it assumes a normal state, except when the system has become much enfeebled. The force of the heart's action is the greatest at the commencement of each paroxysm, and diminishes sensibly when the rapidity of pulsation is the great- est ; and it is also lessened when the dis- ease has been prolonged and the system much exhausted. The skin is usually soft, and at the end of a paroxysm is bathed in perspiration. It is also usually cool and highly sensitive to low temperature. Bleeding from the nose is a very fre- quent attendant upon a severe attack of Hooping-cough ; and whilst it shows how great is the interference with the circula- tion, it is often a most valuable remedy. The period of the occurrence of a par- oxysm is uncertain, but it is particularly liable after a meal, when the stomach is full and the action of the diaphragm is impeded, and when food of slow digesti- bility has been eaten. If the child be very young, the cough is excited when the nurse throws it about ; and if older, crying or seeing another in a paroxysm will bring on an attack. The paroxysms are more frequent in the day than in the night. Hence there is usually much in- terference with nutrition, and consequent loss of flesh, whilst the lassitude extends to exhaustion and prostration of the sys- tem. In ordinary cases the child regains much of its spirits and healthful appear- ance between the paroxysms, and runs about, plays, and eats almost as in health; but when the paroxysms are severe, the face remains suffused, the eja's injected, and the surrounding parts swollen during the intervals ; whilst loss of strength is proportionate to the constitutional feeble- ness and the earlj^ age of the child, the vomiting, and the duration and violence of the disease. In a typical case the catarrhal symp- toms, without spasmodic cough, continue about two or three weeks, and the spas- modic cough three to four weeks ; whilst after the spasm has ceased and the cough has become again catarrhal, the duration may be short, if the child have not been too much enfeebled, and prolonged for some weeks, if otherwise. Complicated Hooping-amcjli. — The com- plications are of two classes, viz. : when Hooping-cough supervenes upon another disease and complicates it ; and when, the Hooping-cough being primary, other dis- eases arise in its course. The former class is a somewhat extensive one, and is for the most part limited to diseases which involve bronchial afl'ections in their course ; but the latter only will be con- sidered here. The complications are of four kinds, viz. : disease of the lungs, disease of the brain, infantile remittent fever, and vital exhaustion. The last may by some be regarded as one of the sequels of uncom- plicated Hooping-cough ; but when it is considered that the almost infinite pro- portion of the cases of simple Hooping- cough end favorably, with only a moder- ate state of exhaustion, it will be thought better to regard the very exceptional occurrence of fatal exhaustion as a com- plication rather than as a sequel to the simple form. The pulmonarv complica- tions are, congestion of the lungs, emphy- sema, atrophy, bronchitis, and broncho- pneumonia. A certain amount of congestion of the lungs is found in all severe cases of Hoop- mg-cough. It is due perhaps exclusively to interference, through the respiration, with the pulmonary circulation, and it is one of the sources of danger attending the disease ; but in the degree in which it becomes a complication, the dyspnoea and frequency of respiration are increased and SYMPTOMS. 61 continue during the intervals, the dis- coloration and suffusion of the face are more marked, the pulse is feeble and rapid, and the exhaustion of the system is greatly increased. Ha;moptysis of a more or less severe kind sometimes occurs and yields temporary or permanent relief. Physical examination of the chest shows that the respiratory sounds are somewhat more feeble than in simple Hooping-cough, and there may be a shade of dulness on percussion ; but unless effusion occurs into the lung-parenchyma, the physical signs are not very marked. There are not any marked signs of fever. Emphysema, although usually regarded as a sequel of the disease, is a frequent concomitant of the severe forms, and par- ticularly in the children of parents who have been afflicted with chronic bronchi- tis. Its production is mechanical, as in the case of adults, and occurs from the forcible compression of the air in the lungs, which is eftected by the diaphragm and other expiratory muscles, whilst an obsta- cle is opposed to the egress of the air. This obstacle is most commonly only the ordinary one which exists in the larynx and pharynx, and is a necessary part of the act of coughing, as shown in my paper on the " Closure of the Larynx at its Upper Orilice," in the Journal de Phtjsio- logie, and as seen at the EimaGlottidis by the laryngoscope ;' but it may also be pro- duced by the plugging up of a large bron- chus after the part of the lung to which it leads has been distended with air. The result of this condition is to increase the dyspncea and to render it permanent in proportion to its extent, and if it exist in any considerable degree the respiratory sounds will be lessened and the resonance on percussion increased. Atrophy of a part of the lungs is a not unfrequent complication of Hooping- cough. It results from closure of one or more divisions of the bronchi, by which the ingress of air to a part of the lung is prevented, and the space thus left unoc- cupied is filled up by the undue expansion of the adjoining cells. When the part thus rendered useless is considerable, the gravity of the complication is great, and it may be detected by the diminished ex- pansion of the intercostal space, and by the absence of respiratory sounds over the part atrophied ; but when it is small, the encroachment of the adjoining structure prevents the occurrence of distinct physi- cal signs. Bronchitis and broncho-pneumonia are, however, the more frequent and fatal lung-complications of this disease. In the paper already quoted from the Medico- Chirurgical Transactions it was shown clearly that deaths from Hooping-coua;h were almost exclusively due to these dis- eases, and that they did not correspond at all with the rate of mortality from zymo- tic or nervous diseases. In both there are evidences of fever iu the \'arying decrees of heat and dryness of the skin, aiid in the rapid pulse both during the paroxysms and in the intervals. The cough is more frequent and not always spasmodic, and the dyspnoea is more permanent. Dis- coloration of the face, enlargement of the opening of the alse nasi, difficulty in speaking, and panting respiration are more perceptible as the complication is severe. The only change in the physical signs is an increase in the moist rales, whilst with broncho-pneumonia there is a more or less persistently localized state of this sign accompanied by some amount of dulness on percussion and lessened re- spiratory sounds. The general exhaus- tion and loss of appetite are more appa- rent. The brain complications are convul- sions and hydrocephalus. It has already been shown that, in the opinion of very able physicians, irritation of the brain and its membranes, and particularly of the medulla oblongata, is so common as to be an integral part of the disease. Usually, however, there are no signs of this state other than the reflex condition which excites the spasm of the glottis ; but in no inconsiderable number of com- plicated cases convulsions occur with or without hydrocephalus. The occurrence of convulsions cannot usually be predicted ; but if the child be teething or suffering from derangement of the bowels, if during the spasm the thumbs be drawn inwards, and during the inter- vals the discoloration of the face continue without lung-complication, and if there be a marked degree of exhaustion or oppres- sion following the paroxysm, or the eyes be intolerant of light, this complication may be imminent. They are in some cases due to irritation of the membranes of the brain and medulla oblongata, and in others to congestion of the brain, due mainly to interference with the pulmonary circulation. Hydrocephalus is so frequently a con- stitutional affection that the relation of Hooping-cough to it is rather that of an excitant of a pre-existent predisposition. The signs are often obscure at first, but in many cases the occurrence of drowsiness, headache and starting during sleep, con- vulsions, increased heat of skin and rapidity of pulsation, intolerance of light and lessened mobility of the pupils ; and in others the persistent disposition to vomiting on being moved, will indicate the advent of this niost important compli- cation. The breathing is more irregular and accompanied by sighs, than it is in simple Hoopinsr-cough ; and if there be no lung-complication existing at the same time, the diagnosis will not long remain 52 nooprNG-cousn. doubtful. When the convulsions are restricted to one side of the body, or when paralysis of one side occurs eitlier with or without simultaneous convulsions on the other, the evidences are still clearer. [Occasionally, even in children, (qmplexy occurs, under the violent disturbance of the circulation of tlie head during the paroxysms of Hooping-cough. Such a case occurred in the neighborhood of Phil- adelphia, a few years since, in a child not more than eight years of age, with a fatal result in less than twenty-ifour hours, the symptoms not having been previously un- fovorable. — H.] The complication with infantile remit- tent fever is most generally found when the latter disease prevails, and when there have been evidences for some Aveeks of a disordered state of the bowels. Tlie tongue is coated, the breath foul, the evacuations unhealthy, and the bowels are tender on pressure and tumefied. The patient does not recover health and strength, but, with or without introduc- tory rigors, slowly exhibits signs of fever, having the exacerbations and remissions distinctive of remittent fever, and want- ing all the diagnostic signs of bronchitis. Such cases are usually protracted in their ]-(c:ov(>ry, and demand very careful and able supervision. The complication of excessive exhaus- tion is most frequent in children of very weak constitutions, or in those which have been enfeebled by previous disease. In such prostrati(jn is a marked feature even during the catarrhal period, but when the spasm has fairly set in it is ex- treme after every paroxysm. Careful ex- amination into the state of the lungs, brain, and bowels fails to offer any satis- factory reason ; and this, ivith the absence of fever, suffices to indicate the complica- tion to which wo refer. Moreover the skin is unusually soft, cool and liable to perspiration, and the appetite is inade- quate to the nourishment of the system. Diagnosis.— The distinguishing feature which marks Hooping-cough is undoubt- edly the paroxysm of spasmodic cough, whether the sound accompanying ° it amount to a distinct whoop or not ; whilst the accidental (as opposed to essential) symptoms are the preliminary catarrh, the glairy tenacious secretion from the bron- clii, the early age of the patients, and the general course of the increase and dechne in the severity of the paroxysms. In the early catarrhal stage, it cannot be distin- guished from a common cold. Pathology.— The pathology of this disease has been already hinted at in our account of its history. In reference to simple Hoopinsr-couGfii the aim has been to determine the cause of the spasm of, i the glottis and the closure of the larynx, [ with the prolonged expiratory action of the diaphragm, whicli are the prominent features of the disease. All writers have regarded the nervt)us system as the source of this influence, and Iiave speculated upon the part whicli was principally in- volved. Thus the recurrent laryngeal nerve as afi'ecting the larynx, the phrenic as controlling the diaphragm, the medulla oblongata as controlling all the respiratory movements by the pneumogastric nerve, and the whole brain and its membranes, have each in their turn been cited as the seat of this disease. Tlie blood has by others been assumed to contain a zymotic poison which, acting upon the nervous s\stem, excites spasm, and upon the mu- cous membrane of the bronchi, causes cough, with a secretion whereby it is to be ultimately cast out. We cannot yet, however, arrive at a sound conclusion upon this question, although there are many points of striking similarity between Hooping-cough and some recognized forms of zymotic disease.' The interference with the circulation of the blood which occurs when the respira- tion is so greatly impeded and the lungs so largely emptied of the residual air as in severe cases of Hooping-cough, is doubt- less the cause of the complications both in the head and tlie lungs to which we have referred ; whilst the exhaustion which follows each paroxysm, and tlie inter- ference with nutrition, are the causes of the remaining complications. The me- chanical act of coughing whilst the larynx and some of the bronchi are closed pro- duces emphysema of the lungs and dila- tation of the bronchi ; and closure of the tubes by secretion may lead to atrophy. Morbid Anatomy.— In nearlv all fatal cases death occurs not from the Hooping- cough, but from its complications ; and the morbid signs will therefore be those of the supervening diseases, and must be sought for in other parts of this work. Dr. Copland believes that in all cases there are inflammatory appearances about the medulla oblongata ; and it cannot be denied that congestion of the bronchial, laryngeal, and faucial mucous membrane is always present. From what has been already stated, it may be affirmed that there are evidences of bronchitis or of ' [The analogy to Hydrophobia is not un- important ; in the combination of a nervous disorder with a respiratory affection ; the length of duration in Hooping-cough corre- sponding, also, in some manner to the pro- tracted incnhation in Hydrophobia. Instead of the cough, in Hydrophobia, we have spas- modic, gasping inhalations, produced by any sudden impression made upon the senses. — PROGNOSIS — TREATMENT. 5B broncho-pneumonia, with atrophy or col- lapse of lung, in by far the greater number of fatal cases. Prognosis. — The prognosis depends upon the age and strength of the patient, the severity of the spasm, and the presence of particular complications. In simple Hooping-cough occurring in childhood, with moderate spasm and with an average state of health, it may almost always be regarded as favorable, and the disease may be expected to leave no ill effects be- hind. When it occurs in an infant under 4 months old it is very liable to induce head symptoms, unless the attack be a very mild one ; and when occurring in adult life, it is more likely to lead to chest complications and to leave permanent changes in the structure of the lungs. When the paroxysms are uimsually prolonged and the spasm very severe, complications are almost sure to arise ; and if the child be feeble, the prognosis must be given with caution. The complication of bronchitis renders the prognosis unfavorable only hi propor- tion to its severity. When it occurs in a moderate degree and without inducing much dyspnoea in the intervals between the paroxysms, and at a season of the year when the temperature is not very low (the deaths from both Hooping-cough and bronchitis are inverselj' as the tempe- rature), the gravity of the case is not seriously increased ; but when it involves both lungs, and is attended by much dys- pncea and increased lividity of the counte- nance, the prognosis becomes unfavorable. Extension of the inflammatory condition to the substance of the lung adds much to the danger, from the fact that broncho- pneumonia is usually less amenable to treatment than bronchitis alone. When emphysema and enlarged bron- chi have already occurred, or when it is probable from the severity of the spasm that they will occur, permanent dyspnoea to a greater or less extent may be appre- hended. The occurrence of head symptoms at- tended by convulsions or paralysis must always render the prognosis unfavorable ; but with convulsions not due to hydro- cephalus, many cases recover. The cases in which disordered secre- tions and intermittent fever occur will certaitdy be protracted, and may leave an enfeebled state of system from which the patient will not entirely recover, although life may be continued for many years. It is probably a less fatal complication than the others referred to, but causes much anxiety both to the physician and the friends of the patient. When extreme exhaustion is present without evident cause, the prognosis should be a guarded one. Itis a fact which is not sufficiently ap- preciated, that whilst so very large a pro- portion of cases of Hooping-cougifrecover, only six other diseases in the London dis- trict during the ten years from 1844 to 1853 inclusive, were more fatal than liooping-cough ; viz., phthisis, pneumo- nia, bronchitis, typhus, convulsions, and scarlatina.' Hence at the commencement of any attack of the disease it is well to speak of the future with caution. Treatment.— There are but few dis- eases in which so many remedies have been employed as in Hooping-cough, and still fewer in which so much has been confidently asserted of remedies which differ much from each other. This is owing probably to the fact that the dis- ease, running a more or less clearly de- fined course, usually subsides either with or without medical treatment, and with or in spite of whatever remedies may have been employed, and also that many reme- dies diverse in name and appearance are closely allied in their modes of action upon the system. It is highly probable that many have been recommended on empirical grounds only ; but others have been intended to effect one of the following objects : namely, to abate inflammatory action, to promote expectoration, and the elimina- tion of the supposed morbid poison, to diminish the bronchial secretion, and to allay the spasm, directly or indirectly, through the invigoration of the general system. Those to abate inflammatory action have been leeches and antimon}' ; to pro- mote expectoration, antimony, ipecacu- anha, squills, and other emetics ; to lessen secretion, alum and zinc ; and to allay spasm directly, hydrocyanic acid, conium, hyoscyamus, belladonna, opium and mor- phia, musk, valerian, ether, and chloric ether, with various liniments supplied to the chest and back, and a strong solution of nitrate of silver to tlie throat ; to allay spasm indirectly, iron, zinc, copper, sil- ver, and other metallic salts, mineral acids, with quinine, and other vegetable tonics, and change of air. Some were probably expected to have a specific ac- tion, as tar-water and tar inhalations, the air in the neighborhood of gas-works, salts of lead and cantharides. Simple Hoopiny-cfmgh. — In the treat- ment of an uncomplicated case of Hoop- ing-cough, the chief, if not the sole, aim should be to allay the spasm, and thus to prevent complications which result from it, and reduce the disease to a common cough. As a preliminary step it is needful to 230. Medico-Chirurgical Transactions, 1854, p. 54 HOOPING-COUGH. regulate the functions of the chylopoietic viscera, to prevent or remove fecal accu- mulation, to promote a proper secretion of bile, to prevent the occurrence of an excess of acid in the secretions of the stomach and oesophagus, and to prohibit the use of indigestible or irritating food. For these purposes, castor oil, or carbo- nate of magnesia, or Dinneford's or Mur- ray's soluble magnesia, should be given daily or every second day, until the neces- sity" for their use has ceased ; and an occasional dose of one or two grains of hydrarg. c. creta may be given at bed- time. The state of the nurse's milk should be examined in the case of suckling in- fants, and at a later period the food should be restricted as far as possible to cooked milk, and given alone or in puddings. Two or three pints of milk may be taken daily, but in such a manner that the quantity given at a time shall not exceed one-quarter of a pint, and the intervals between the supplies be short. Bread should be rarely if ever given, except when cooked with milk. The use of vege- tables should l)e greatly restricted. Meat in small quantities, and cut into very small pieces, may be given to a child of three 3'ears of age and upwards ; and eggs made into puddings, and beef-tea, may I3e allowed at any age if there be a deficiency in the supply of milk. In the general management of the child the body should be kept properly warm by clothing, and the atmospheric air should not ha^'e a lower temperature than 64° either by night or day ; and so long as the aim is to allay the spasm, the patient should be kept absolutely quiet both in mind and body, or as quiet as may be pos- sible. [When the general symptoms are mild, fever and inflammatory bronchial disorder being absent, there is advantage in the child being taken into the (/pen air, in good weather, every day. Often, the paroxysms will be very few and moderate while the patient is out of doors, becoming more frequent and severe under confine- ment in the house. — H.] Such being premised, the next step de- pends upon the view Avhich is taken as to the possibility of shortening the course of the disease. Some of the most eminent pliysicians of the present day are of opinion that it will run its course, and that the duty of the physician is to conduct it evenly and safely to the end.' With this view it is only possible to use palliative remedies, such as small doses of ipeca- cuanha, with or without rhubarb ; but if a belief is entertained that the progress of the disease is amenable to treatment, the proper course is to select that sedative, narcotic, or antispasmodic agent, the ac- tion of which is the most uniiform, and the ' Sir Thomas Watson's Lectures. dose capable of proper regulation ; and the aim should be to administer it with the frequency and dose ^^•hich will allay the spasm and Iceep it niuhr rnntral without in- terfering materially with any vital action. [In American practice, us.'«ifrrti(la is used, probably, in mild or moderate cases, as largely as any other antispasmodic medicine. It may be given as soon as the paroxysmal character of the disorder is .shown, in combination with ipecacu- anha or squills. For children, a much employed preparation is the "•milk" of assafetida, in teaspoonful doses. It is a mild remedy, less powerful as an anti- spasmodic than musk, belladonna, &c., but, in ordinary cases, it seems to be often serviceable. — H.] Hydrocyanic acid has been strongly recommended by, amongst others, Drs. Granville, Hamilton Boe, Atlee, Elliot- son, and West ; and of these Dr. Roe has given the most detailed and judicious directions. He prescribes three-quarters of a minim of .Scheele's strength to an infant, ITTl. to a child aged three jears, and Ig- to 2Tn. to one aged ten or twelve years, to be given every three or four hours, or even more frequently when the effect of the previous dose has abated. He has given l^TTl every quarter of an hour for twelve hours to a girl aged ten years. He attaches great value to its action in reducing fever — a state of system which in simple cases rareh' exists ; but he also affirms that it will cure simple Ilooping- cough quickly, or at any rate abridge its duration. Laurel-water, ivhich contains hydrocyanic acid, has been given in doses of 6Tn to children and .301(1 to adults every two or three hours. Belladonna has been strongly recommended by Boer- haave, Hufeland, Guersant, Trousseau, WiUiams, Jackson, Churchill, G. A. Rees, and others. The dose of the extract re- commended varies from Jj to ^ grain for a child aged two years, and IJ- grain for a child aged four years and upwards ; and Dr. Williams, bearing in mind its action upon the iris, and the desirability of di- minishing the irritability of the bronchial and laryngeal muscles, regards the action upon the former as the'measure of the action upon the latter, and takes it as his guide. Conium was introduced as a specific remedy for this disease, and has received the support of many distinguished physi- cians. The dose of the extract most com- monly employed is 5V of a grain for a child aged four months, 5^5 to V„ for one aged one year, and j\ to 1 grain for older chil- dren, repeated every six hours. In the use of this drug, as in that of hyoscyamus and belladonna, it is customary to add small doses of ipecacuanha, and some physicians, as Guersant, combine it with the oxide of zinc or other metallic salts. TREATMENT. 55 [The siiccus hyoscyami, in doses of a few drops at a time, will sometimes act very well in quieting the paroxysms of cough- ing, especially at night. — H.] Tincture of lobelia is now given by Dr. Sidney Kinger with very good effect. The dose is 5111 for a child set. one or two years, increasing to lOTtl as the age ad- vances to ten years, and is repeated every hour. The preparations of opium which have been most generally used are the tincture of opium and salts of morphia ; but Bat- tley's sedative solution and codeia have also been much commended. In a paper published in the Edinburgh Medical Jour- nal, May 1856, we took occasion to ex- press the opinion that morphia was the best remedy in this disease, since it is more certain and uniform in its action than belladonna, conium, liyosc3'amus, and digitalis, and exerts a less injurious effect upon the sensorium and the bowels than the tincture of opium. It has already been pointed out that Drs. Roe and Wil- liams, when administering hydrocyanic acid and belladonna, understood the im- portance of giving them in doses sufficient to allay the spasm ; but in the paper re- ferred to we endeavored to explain that an essential part of the treatment was to carry this influence just so far as to Ije evident to an observer, and to maintain it during the period of treatment. With the view that the essential character of Hooping-cough, and that which leads to dangerous complications, is the spasm, and that the removal of the spasm should be the ol^ject of the physician, our aim was to cause the slightest oppression of tlie sensorium as a measure of the required effect of the drug, and to maintain it from three to six days. With children under one year of age the dose of the hydro- chlorate or the acetate of morphia should be j'j of a grain repeated every four hours ; with children between one and three years of age, j'g to j'j of a grain ; and with those yet older ^\ to ^\ of a grain. The dose selected should be repeated three or four times ; and if no perceptible drowsiness should be induced, it should be increased a step and repeated in like manner, and again increased if necessary until the dose has been ascertained which produces a very slight oppression of the sensorium. The aim must then be to maintain this efl'ect by repeating the same dose, or by further increasing it from time to time. The cases of simple Hooping-cough are extremely few in which slight drowsiness has been produced and uniformly main- tained for three or four days without the spasm having subsided, and the cough nearly reduced to that of a common cough. The plan, when intelligently carried out, has been most successful in our hands, and in those of Dr. Miiller in Germany, as well as in the practice of many in Eng- land. It is rarely necessary to add auy other remedy ; but in certain ca.ses the exhibition of carb(jnate of soda in addition to the morphia has further lessened the irritability of the larynx and promoted expectoration. A very favorite combination is that re- commended by Dr. Pearson, consisting of one drop of tiuct. opii, live drops of vin. ipecac, and two grains of carbonate of soda, to be given every four hours after the operation of an emetic. Dr. Eben Watson has proposed an ad- mirable plan of treatment in the applica- tion of a strong solution of nitrate of silver to the larynx, by which the spasm is quickly relieved. The strength should be twenty grains to the ounce, and the solu- tion applied not only to the tonsils and uvula but to the back part of the fauces, and if possible to the seat of the epiglottis. This is more difficult to effect in very young children, but in children of eight years of age and in adults it may be readily performed by de]iressing the back of the tongue until the free edge of the epiglottis is seen, and sweeping the pharynx with the camel's-hair brush or the mop charged with the solution. The application should be repeated every second day, and the spasm may be expected to subside in less than a week. The external application, to the chest and between the shoulders, of belladonna plasters and of liniments containing bella- donna, opium, or oil of amber, has been much employed with advantage ; but the effects of belladonna must be watched, and dilatation of the pupil restrained within very moderate limits. The inhalation of ether and chloroform, when diluted with air with the aid of a proper instrument, is often of great ad- vantage in cases where the spasm is verj^ severe and the patient not very j'oung. It should never be carried so far as to induce anaesthesia. The employment of metallic salts in the treatment of this disease has been very general and extensive, and those of ar- senic, copper, and silver have been re- garded as specifics. The proper dose of liq. arsenicalis is one drop daily, divided into four doses, for an infant, and one drop twice or thrice a day for a child of five years of age and upwards, and it may be given with water or decoction of cin- chona. Carbonate of iron is prescribed by Dr. Graves after recovery from inflamma- tory symptoms : but others give the sul- phate, and employ it in the early stage of the disease. In Dr. Rees's opinion it is particularly adapted to those of a stru- mous diathesis. Zinc has been given both to lessen the secretion from the mu- cous membrane and to allay the spasm. The proper dose of the oxide is one grain IIOOPING-COUGU. three or four times daily for a child aged one year, and two urains four to six times daily for those of live years of age and up- wards. Acetate of lead has been particu- larly recommended by Dr. Kees, and he affirms that 5 grain given every six hours removes the spasm on the first day of its exhibition. tSulphuric, hydrochloric, and nitric acids have all been given in this disease with advantage when uo intlammatory compli- cation existed. Of these, nitric acid has received the most recent support, and has been given in remarkably large doses. To a tumblerful of thin syrup as much dilute nitric acid is added as wU render it as sour as lemon-juice, and of this a child under one year of age may take a dessert- spoonful every hour, and an adult the ■whole tumblerful in three or four hours. So much as 9ij to 3J of the dilute acid is given to a patient ten years of age and up- wards, and lOTTL to a very young infant, when well sweetened with honey or sugar. No evil results are said to have followed, and the beneficial effect has been, it is af- firmed, proportioned to the dose. Injury to the teeth is averted by using a gargle with carbonate of soda after each dose. This plan of treatment has received the approbation of Dr. Gibb, and its mode of action is presumed to be that of a tonic, sedative, and antiseptic. Change of air is a very popular remedy, and it is affirmed that it matters little whether it be to a purer or to a less pure atmosphere, but above all others the air in the vicinity of gas-works and lime-kilns has been, even very recently, commended. Except upon empirical grounds, and in the absence of sufficient proof of the bene- fit alleged, we can advise only that change which country air may offer to children , living in towns ; and even this exerts no marked influence in otherwise healthy children until the period of recovery from the exhaustion which follows the disease. Alum and tannin have been nnich com- mended with a view to restrain the secre- tions and allay spasm. The former, when given in the nervous stage of the disease, was exceodintrly efficient in the hands of Dr. Golding Bird. His prescription was, alum twenty-five grains, extract of conium twelve grains, with syrup and dill-water to make a three-ounce mixture, of which a dessert-spoonful was given for a dose to a child two or three years of age. Tannin is given in doses of one-sixth to three- fourths of a grain, and even to three grains, combined with hyoscyamic or ben- zoic acid every two hours. Alkalies, as carbonate of potash or soda, sulphuret of potass, liquor potassse and liquor ammonisB, are oftentimes of value, when conjoined with other remedies, in rendering the bronchial secretion less tena- cious, and in relieving disordered bowels. Nux vomica and strychnine have been given with advantage in the sfage of spasm. Certain antispasmodics, as musk, valerian, and ether, are of value, but they do not so immediately and certainly relieve the spasm as narcotics and sedatives ad- ministered so as to slightly affect the sen- soriuni. They are more particularly suited to the stage of recovery from the spasm. [Some physicians, however, have found musk the most potent of all remedies for the violence of the cough in severe cases. — H.] Emetics may be employed with advan- tage in those simple cases of Hooping- cough in which there is unusual difficulty in removing the secretion from the bron- chi, whilst at the same time it is excessive in quantity and impedes respiration. But with the view which we entertain of the nature and treatment of this disease we do not think that emetics should be the chief remedies employed. Such are the remedies which have been and may be properly employed in simple cases of Hooping-cough — hydrocyanic acid, belladonna, conium, morphia, ar- senic, zinc, alum, nitrate of silver, hydro- chloric and nitric acids, — all affirmed at different periods to be specifics, or, at the least, sure and speedy remedies for this disease. With the weight of testimony in their favor we cannot deny that they have been and are very valuable agents ; and if we have given the preference to one of them, it is because by it we may the most readily and safely induce that gentle im- pression of the sensorium by which the spasm subsides. The mode of adminis- tration is as essential a part of the treat- ment as the drug itself, and the plan will succeed only in intelligent and careful hands. CompUcated Hboping-congh. — As the most frequent complication is that of bronchitis, care should be taken to watch the earliest indications of its approach. When it exists, the use of metallic, vege- table, and mineral tonics and astringents should be discontinued, and antimony or ipecacuanha in small doses should be added to the narcotic or sedative in use. If there be much febrile action, the patient should be placed in a warm-water bath up to the neck every night or every second night, and spt. eth. nit. with liq. ammon. acet. added to the medicine. With much oppression of the respiration and difficulty in removing the secretion, the occasional use of an emetic and the constant use of alkalies will be proper, and counter-irrita- tion of the chest by blisters, turpentine, or mustard should be effected. If there are evidences of the extension of the dis- ease to the parenchyma of the lung or to the pleura, the apphcation of leeches and cupping at the root of the lung or over a painful part may be of service ; but the DTPnxnEEiA: definition — synonyms. 57 use of mustard or other rubefacients be- 1 tween the shoulders will usually aftbrd the greatest relief. Even during this period it will also be needful to sustain the vital powers by good beef-tea. and as far as possible by milk, given in very small quan- tities at a time ; and great care should be taken not to carry the antiphlogistic treat- ment so far as to lower the vital powers and induce disgust for food. When convulsions occur, the first duty should be to ascertain if the teeth cause irritation, or if there be irritating matters accumulated within the stomach and bow- els. If tlie former, the gums, when tender, should be lanced ; and if the latter, the bowels should be freely evacuated and the character of the evacuations carefully watched. At the same time the patient should be supplied with beef-tea and milk. When hydrocephalus occurs, with or with- out convulsions, the treatment of the case must centre in that complication, and be such as will be elsewhere advised in this work. With heat of skin and head it will be proper to apply cooling lotions and even ice ; and should the disease be active, leeches to the base of the head should be early used. The free exhibition of mer- cury in the form of calomel in small doses, or of hyd. c. creta, must be persisted in when effusion has been diagnosed. As the bowels are usually constipated in this condition, mercurials do not readily purge, and care should be taken to induce a suffi- cient action. Moreover, a state of inani- tion from want of food must not be per- mitted. In the complication with remittent fever, care should be taken to evacuate the bowels and to correct the secretions, in addition to the use of those remedies referred to under that disease in another part of this work. The cough, which is also then unusually distressing, will re- quire the frequent cxldbition of morphia, syrup of poppies, and of tolu. As soon as possible tlie patient should have a change of air. When extreme exhaustion is the chief complication, it will become necessary to administer nitric acid with bark, or some of the metallic tonics with quassia, and to supply wine-and-water in small doses every three hours. Much care should also be taken to induce the patient to take food, in small quantities, made from milk, eggs, jelly, and meat every two hours ; and if neither the exhaustion l^e extreme nor the atmospheric temperature low, to obtain change of air and a moderate de- gree of exposure to it. The recovery from Hooping-cough al- ways demands the use of tonics [quinine in tonic doses, iron and cod-liver oil. — II.], of abundant animal food, and of change of air, and possibly also of wine adminis- tered in small doses. Sea-voyagiug is then of great service. DIPHTHERIA. By William Squiee, L.R.C.P. Lond. Definitioit. — An acute specific dis- ease, both epidemic and contagious, cha- racterized by a special inftammation of the mucous membrane, chiefly of the pharynx and first air-passages, attended with enlargement of the lymphatic glands, a rapid exudation either of fibrine or non- organizable lymph, and its deposit witldn and upon the surfaces affected. Other parts of the raucous membrane and the skin sometimes suffer at the same time, and changes often take place simultane- ously in the spleen or kidneys, albumi- nuria frequently occurring at an early period. The disease is accompanied by great prostration of the vital powers, and is followed by a remarkable series of local lesions of innervation ; the tendency to death, is by asthenia, either coincident with the disease or gradually induced, or by apncea from implication of the air- passages, which may happen as early as the second day, or as late as the second week of the disease. Synonyms. — Cynanche ; Angina, Cel- sus ; Syuanche, Aetius Aurelianus ; Ul- cera Egyptica vel Syriaca, Aretoeus ; Crustosa et Pestilentia Tonsillarum Ul- cera, Aetius Amidenus ; Ulcera Pestifera in Tonsillus, Paulus JEgineta ; Morbus Suffbcans, Viha Real ; Angina Exulcerata Maligna, Nunes ; Faucium Ulcera Angi- nosa, Mercatus ; Angina Mahgna, Here- dia; Carbunculus Faucium Anginosus, Biolan; Morbus Strangulatorius, Aetius Cletus ; Morbus Gulas _; Aphthee Maligna ; Angina Puerorum Epidemica, Bartholin ; 58 DIPHTHERIA. Prunella Alba, E. James ; The Sore- Throat attended with Ulcers, Fothergill ; Malignant Ulcerous Sore-Throat, Hux- ham ; Angina Infantum, Wilcke ; Angina Polyposa sive Membranacea, Michaelis ; Cynanche PharyngeaEpidemica, and Epi- demic Croup, Kosen ; Angina Suftbeativa, or Sore-Throat Distemper, Bard ; JIal de Gorge Gangreneux, Chomel ; Angine Couenneuse Pharyngienae, and Croup in the Adult, Louis ; Pellicular Angina, Diphtheritic Angina, Diphtherite, and Diphtherie, Bretonneau ; Pharyngite Pseudo-membraneuse, Killiet and Bar- thez ; Cynanche Membranacea ; Cy- nanche Maligna, Putrid Sore-Throat, Malignant Quinsy, England ; Garotillo, Spain ; Strypsiucka, Sweden ; Rachen- Crouj), Germany. iNTAME. — Diphtheria is derived from SujiSspa, a skin, or covering of leather. The multiplicity of synonyms has been occasioned by the undetermined nature of the disease, and its appearance at times and places removed from each other, either by considerable intervals or by imperfect communication. Fothergill has the merit of setting forth, during its prevalence in the last century, the iden- tity of the epidemic with that of the pre- ceding century ; while the Spanish and Italian physicians had already recognized its correspondence with the accounts de- rived from antiquity. Diphtherite, as signifying the special product of a specific disease, was proposed by Bretonneau. To him we owe not only the name but that energetic inquiry into the disease, as it showed itself in France during the present century, which has led to a more perfect definition of its character, and a better comprehension of its relation, than was previously possible. He at first applied the term to the whole disease, as well as to its characteristic morbid pro- duct, so soon visible in the fauces of those attacked ; but further observation, prov- ing that the local appearance was only one of the manifestations of the more important general affection, induced him, while retaining diphtherite in its more restricted sense, to speak of the general disease itself as diphtherie. We are in- debted to Dr. W. Farr for the introduc- tion of Diphtheria into our nomenclature as soon as the epidemic spread of the dis- easc> among us rendered it important that it should be designated by one general term. IIiSTOET.— There is little doubt that Diphtheria, like the other acute specific diseases, has existed as long as the his- tory of man extends. We have traces of it two thousand years ago, and the de- scription given of it more than a thousand years since applies equally to its appear- ance in our own day. Its individuality is not diflScult to recognize during its epi- demic prevalence, ait other times its dis- tinctive characters have been merged with those of scarlet fever and erysipelas ; these two diseases, though specifically different, approach at many points the nearest to it : thej-were not discriminated even in Sydenham's time ; and though scarlet fever then began to be separated and to receive an increasing share of attention, the intimate connection always observed between it and Diphtheria pre- cludes our astonishment at finding them sometimes confounded. Unmistakable evidence of the exist- ence of this special form of disease is found wherever medical science has at- tained any degree of exactness. Hippo- crates describes it, and gives us the name of probably its first recorded victim.' It attracted the attention of Asclepiades and Celsus.^ Aretasus'' is the founder both of our knowledge of and treatment of the disease ; and Aetius of Amida showed an equally familiar acquaintance with it. It is impossible to say which of the many plagues of the dark ages of history may claim this disease as its agent. After the time of Paulus ^gineta only the writings of the Arabian physicians can be appealed to, and it is not until the intellectual re- vival of the sixteenth century that we again find its traces recorded ; — as by Forrestus, in Holland, in 1557 ; Weir, in Basle, in 1567 ; by Baillou, in Paris, in 1576 ; and by Spanish writers from 1581 to the close of the century, whence is dated the first clear account of its epi- demic prevalence in modern times. The numerous and graphic accounts of many and able Spanish medical writers of the seventeenth century afford valuable mate- rials for the comparative study of the dis- ease ; and though the Sicilian and Italian writings of the same time are less original, we gather from them many important particulars. The epidemic attracted at- tention in the kingdom of Naples in the year 1618, and is described by Sgambatus, Carnevale, and Nola. The writings of Cortesius, in lG2o, and of Alaymus, in 1632, speak of its ravages in Sicilv ; at the same time it had extended into Cen- tral Italy, as witnessed by Aetius Cletus ; Severinus and Bartoline speak of its con- tinuance. The disease, if not epidemic, continued to be extremely prevalent in Spain ; and, besides the special works of Fonteccha, Villa Real, Herera, Tamayo, and Kunes, was treated of systematically by the royal physicians, Mercatus and Heredia. Scattered notices of its occur- ' Hippoe. Epid. lib. v. tex. 37. ^ Celsus, lib. iv. cap. 4. ' Aretaeus, De Causis et Signis Aoutorum Morborum, lib. i. cap. 9. HISTORY. 59 rence elsewhere appear in subsequent publioations, but it is not until near the middle of the next century that we tind it extensively epidemic, appearing simul- taneously in Italy, France, and England, as evidenced by the independent observa- tions of Ghizi, in Cremona, 1747 ; Ar- nault, in Orleans, 1748; and Starr,' in Cornwall, 1749 : it also called forth the noble essay of Fothergill,^ published in 1748 ; the epidemic had then hardly at- tained its height in England, though cases had been observed as early as 1739. It existed at Eouen at the same time, and appeai'ed more extensively in 1748,'' when the epidemic was at its height in France. Sweden suffered from it in 1755, and occa- sional outbreaks occurred there till 1778, as we learn from Michaelis. The pres- ence of the disease in North America at this time is described by Dr. Samuel Bard, who having been trained in the Univei'sity of Edinburgh to the study of medicine, re- turned to its practice in his native coun- try, and furnished, by his careful observa- tion of the cases under his care, the foundation upon which our knowledge of the disease was to be much further ad- vanced. That each of these epidemics preserved the essential characteristics of the disease as now observed, two quotations will suf- ^ce to show. Of the first, in Italy, Aetius tJletus, in the introductory chapter to his work,'' the only part of interest, says, " Morbi fades hsec est. In faucibus rubor apparere incipit, cum dolore, et febre ; paulo post prsebet se conspiciendam pus- tula, quara subsequitur cum crusta ulcus cinerei coloris, quod frequentius accidit, subalbicantis nonnunquam, vel nigrantis coloris. Ssepius sine pustula crustosum ulcus ; . . . . et in ipsis faucibus sunt, quibus ex ulcere itur in gangrenam, et sphacelum, qui ex oesophago porrigitur ad Ventriculunr, vel ex aspera arteria ad pul- moneni ; et hi difflculter respirant, et non nisi recta cervice, illi deglutire nequeunt .... ex his nonnulli profundiori somno oppress! moriuntur ; alii copiosa cum narium hasmorrhagia vita finiunt, alii absque his symptomatibus exanimantur. Morbus impuberes precipue invadit, tanta c&strage, ut familiarum multarum omnes eniori visi sint. Nulla moriendi est certa dies . . . die quarto decimo elapso non absque delicto quis emoritur — ex lis, qui pristinam valetudinem consequuntur anni, plus minus ve spatio, omnes fere mussitant, et verba difHculter efferunt. ' ' Of the next, ' Phil. Transactions, vol. xlvl. p. 435. ^ An Account of the Sore-Throat attended with Ulcers, by John Fothergill, M.D. 8vo. Lond. 1748. 2d Edition. ^ Phil. Transactions, vol. xlix. pt. 1. * DeMorbo Strangulatorio Opus, JitiiCleti, Signini. 8vo. Rome, 1636. Dr. Starr' writes in 1749 : "The morbus strangulatorius, with great propriety and justice thus denominated, has within a few years raged in several parts of Corn- wall with great severity. Many parishes have felt its cruelty, and whole families of children, whence its contagious nature is but too evident, have, by its successive attacks, been swept off. Few, very few, have escaped." "Many in the first at- tac.'ks have complained of swelling of the glands, as tonsils, parotids, submaxillary and sublingual glands, but frequently of no great importance. A few, from an internal tumor, have had a large external oedematous swelling of the subcutaneous and cellular tunic, from the chin down to the thyroid gland, and up the side of the face. Not a few early in the disorder have had gangrenous sloughs formed in their mouths, and perhaps so early in some, that the disorder was scarce com- plained of till the slough was formed, so quick has it been in its progress." And again, "I have not mentioned a foator oris, because, though. some have had it, others have had it not." The symptoms of its extension to the larynx are then given, and he goes on to say: "I have frequently examined the matter these patients have at times spit ; the greatest part was of a jelly-like nature, glairy, and somewhat transparent, mixed with a white opaque thready matter, sometimes more, sometimes less, resembling a rotten membranous body, or slough. Such a slough I have seen genei'ated on the skin of one of these patients in the neck and arm, where blisters had been before ap- plied This white surface had the aspect of an oversoaked mcmtirane, which, being oversoaked, had become absolutely rotten. The part blistered, if not quite, was in effect dry, and the flux from the slough was incredibly great I scratched the slough with my nail ; it separated with ease, and without being felt by the child. What my nail took off afforded the same appearance with the matter of the spittle before mentioned. Hence I thought I saw sufficient reason to convince me that the disorder in the larynx and aspera arteria was similar to this, generating in the same manner, and arising from the same external cause ; . . and it is likely, had the anatomical knife been employed, that what was seen on the back of one, might have been dis- covered in the arteria aspera of the other. There is a circumstance which adds to the probability of this opinion, viz., in one or more Instances these different dis- orders appeared in different subjects in the same family at the same time." A century again elapsed before the disease attained to epidemic intensity ; ' Loo. oit. 60 DIPHTHERIA. during the interval, outbreaks of more or less extent and severity oeeurred in vari- ous parts of France, Germany, Nortli America, and in England, Scotland, and Ireland ; sometimes sufficiently serious to receive full comment in the medical pei'iodicals, sometimes so isolated and rare as almost to escape notice. Paris, at the beginning of the present centurj', was a frequent seat of its appear- ance, and the death from this cause of a promising member of the Imperial family of France in that city, in the year 1807, was the occasion of a large share of medi- cal attention being directed to its elucida- tion. No real progress however was made towards that olyect until the epidemic at Tours, in 1818, received a thorough inves- tigation under Bretonneau. From this time the ^brhires Gcnerales de Medecine contain frequent reports of its appearance in various parts of France, and, by re- cording its period of greater or less preva- lence in Paris, and the details observed in the Hopital des Entants Malades, afford valuable contributions to the study of the disease : most of these notices are to be found under the heads of Croup and Epi- demic Oruup. The records of the disease in this country become less frequent after the close of the last century. Dr. ilackenzie, of Glasgow, describes two cases that came under his notice in 181.3, of throat-disease ending in Croup, and says that this kind of disease was very prevalent in Glasgow in 1819 ; he gives a careful description of it, agreeing very closely with the results arrived at by Bretonneau : these, made known in Eng- land by the publication of his work in 18:i(i,' rendered the differentiation of the two disea«es possible, and henceforth they are described apart. Dr. Abercrombie^ alludes to cases of this kind in Dublin ; he says, though not a common affection in Scotland, yet that it was very frequent and fatal among children in Edinburgh in the year 1826, and that "it is evidently an affection quite distinct from the idio- pathic inflammation of the membrane of the larynx, to which we commonly apply the name of Croup." Dr. AVeteter, of Dulwich,^ records the deaths of two chil- ' Des Inflammations Spfioiales du Tissu Mnqueux, et en particulier de la Diphth^rite, on Infiammatlon pellieulaire, connue sous le nom de Croup, d'Angine Maligne, d'Angine Gangreneuse, &c. 8vo. Paris, 1826. 2 Abercrombie, John, M.D. Pathological and Practical Researches on Diseases of the Stomach, Intestinal Canal, Liver, and other Viscera of the Abdomen. 8vo. Edin. 1828. Pp. 53-56. ' The Institute, vol. i. p. 100. These cases were published in an Appendix to Mr. Hig- ginbottom's Essay on tlie Use of Nitrate of Silver. Svo. Loud. 1829. Pp. 185-196. dren in one famil}', in a house near Lon. don, in 18ii4, and of four other cases of ulcerated sore-throat, involving the lar ynx, coming under his observation shortlj after: they "all had," he says, "an as- semblage of similar symptoms, and the common point of danger was the wind- pipe." Mr. Kyland' describes cases of the kind as epidemic in Birmingham, in the year 1837. Dr. Humphry, of C;inibridge, observed a case in the Norwich Hospital in the same year, and Sir AVilliam Jenuer^ remarks, in his Lectures on Diphtheria, "I have seen cases of it every nuvi and then as long as I have practised medi- cine." Though isolated cases were from time to time observed, any memory of its epidemic violence in this country had almost passed away when its appearance in South Wales was announced by Mr. J. D. Brown,'' of Haverfordwest ; about two hundred cases occurred there in 1849-50, of which forty were fatal. Some general conditions, which at present we are unable suffi- ciently to appreciate, including the effects of the two cold winters of 1853 and 1S54, and the intense cold of January, 1855, seem at this time to have checked its epi- demic progress, and also to have stayed the ravages of cholera in this country. Traces of it meanwhile are to be found in other countries : Denmark,* Germany, France, the North of Africa, Madeira, Teneriffe, America, and Hindostan. Dr. Jackson^ reports two cases occurring in Calcutta in 18.53, one at a later period, and also thirteen cases at the Martiniere school, five of which died. We have ac- counts of it at Lyons in 1851, at Avignon'' in 1853, of its great increase in Paris' in 1852-53, and of its reigning simulta- neously there and in many parts of France from 1855 to 1857, as a most fatal epidemic. In Boulogne alone it was the cause of 366^ deaths in that period. It was present, though not extensively, in the armies in the Crimea^ in 1855, and also at Moscow'" in the same year, and in ■ Treatise on the Diseases and Injuries of the Larynx and Trachea, by Fredk. Ryland. 8vo. Lond. 1837. 2 Jenner, Sir W., M.D., F.R.S. Diph- theria, its Symptoms and Treatment. Lond. 1861. P. 3. 3 Med. Times and Gazette, 1850, vol. i. p. 670. ^ < Beck in Oppenheim's Zeitschrift, b. xliv. s. 200. 6 British Medical Journal, 1859, p. 373. 5 Archives Generales de Medecine, s. 5, t. viii. p. 338. ' Ibid. s. 5, t. V. p. 260. s On Diphtheria, by E. H. Greenhow, M.D. Lond. 1860. P. 68. 8 Haspel, Gazette Medioale, 1855, p. 829. '" Tarassenlioff, Diplitheritis Epidemica, Med. Zeit. Russlands, p. 92. ETIOLOGY. 61 Algeria' the year following. It was epi- demic in California''' in 1850-7, and some- what later in the Northern States of America." The epidemic attained its height in England in the year 1858 and 1859, and during these two years we may estimate that -iOiOOO deaths were occasioned by it. In 18(50 the number of deaths had fallen from near 10,000 to 5202, and though they have not since reached the latter tigiire, yet the mortality from this cause in Lon- don was almost as great, and in the northwestern counties quite as great, in 1862 as in 1859. In Scotland, where the disease pre- vailed at the same time as in England, the mortality from this cause did not reach its highest until 1851. It is somewhat re- markable that though Diphtheria existed both in India and California, we have no history of any outbreak of it in xius- tralia until 1859, when Mr. James Moore'' records nine deaths from this cause, and the occurrence of 275 cases at the same time in New Norfolk, Tasmania. This part of the world is perhaps more exclu- sively in communication with England than any other. The appearance of the disease there is not until after it had at- tained in this country to its full epidemic development : moreover, though epidemic in North America, both in California and the United States, as early as 1857, it was not till 1859 that it made its appearance in Nova Scotia, the part of that continent in closest communication with this country. The severity of the outbreak at Bou- logne, the constant communication from our own shores to that place, and the number of Enghsh visitors and residents there, many of whom fell victims to the epidemic, excited reasonable alarm, not only of the advance of the disease, but of its direct introduction into this country through the medium of those afteeted. Individual cases were imported, both at Folkestone^ and Dover, without the dis- ease spreading in those localities ; its independent appearance in Wales, Lin- colnshire, Cornwall, and Staffordshire pre- cludes Boulogne from l)eing considered its origin ; yet sources of infection imported thence may have afforded new centres for the propagation of the disease, and have contributed in some degree to the deter- mination of its type. Etiology.— The records of the first half of the epidemic in England are imperfect; '_ Noteis sur la Diphtlierite. Recueil de Me- moires de MSdeciue Militaires, s. 2, t. xvji. p. 392. ' Fourgeaud, Diphtheria. 8vo. Sacra- mento, 1858. ' Boston Medical .Journal, vol. lix. p. 252. • Australian Medical .Journal, July, 1859. ' E. H. Oreenhow, M.D., op. cit. p. 09. many deaths from this cause were included in the registration under the heads of scar- let fever, croup, and cynanche maligna. A table,' publislied by Dr. Farr, in his let- ter to the Registrar-General, shows that, while in 1855-57 there are 1846 deaths registered as cynanche maligna, and cjnly 725 as Diphtheria, in the year 1858, upon the lirst introduction of the new general terin,^ the numbc^rs are 1770 as cynanche maligna, and 4836 as Diphtheria ; and that in the year following, when not only the name, but also the nature of the dis- ease was more generally understood, 9587 deaths are registered as Diphtheria, and only 597 as cynanche maligna. In look- ing through the returns under croup and scarlet fever, the two diseases most likely to be mistaken for Diphtheria, it is not difficult to infer, both from the unprece- dented numbers returned under these heads, as well as from the usual number of deaths of the two sexes from these causes being reversed, that some other disease has been included, and this varia- tion occurs in the very districts in which we have other evidence of Diphtheria being present : thus in Wales, while the deaths from croup in 1853 were 207 males and 197 females, total 404 ; for the year 1854 they were 215 males and 298 females, total 51.3 ; they then continue at or near .500, till Diphtheria is introduced into the registration nomenclature, when they sud- denly fall to 424. The same exceptional proportion is first noticed in the Cornwall district in 1854 ; in the three following years the whole number is doubled, and in 1859 undergoes the same sudden dimi- nution. The wesf-midland, north-mid- land, and eastern districts, from which at this time we have the most frequent ac- counts of Diphtheria, show the same gradual increase, and the same sudden fall ; and it cannot be doubted that of the 0220 deaths returned as croup in the year 1858, at least 1000 were Diphtheria. In scarlet fever this is still more conspicuous; tlie number of deaths mounts up from 14,229 in 1857 to 30,317 in 1858 ; and in the latter year, for the only time that I am aware of, the number of deaths of fe- males from that cause exceeds the num- ber of deaths of males. An epidemic of scarlet fever certainly accompanied that of Diphtheria, and culminated in the following year, when the deaths from it. Diphtheria being excluded, reached 19,907 ; so that we may reasonably sup- pose that of the 30,317 deaths registered under this head in 1858, near upon 10,000 were really owing to Diphtheria. The probability is that" some deaths from this cause in previous years ivere so regis- ' Twenty-fifth Annual Report, p. 178. 2 This was in tlie first Quarterly Report of the Registrar-General, No. 37. 62 DIPHTHERIA. tered : on turning to South Wales in 18.')7, we find that of 2(j7 deaths from croup, 177 were of females ; and of 349 from scar- let fever, 185 were of females ; so that in 600 deaths, chiefly of children, the ma- jority of which ought to be among males, we find an excess of 40 among females. In the second half of the epidemic, taking the four years 1859-62, the number of deaths registered from Diphtheria is 24,219 ; of these 11,229 are of males, 12,990 of females. Half these occur in the first five years of childhood, and show a nearly uniform fatality in each of these 3'ears, the first year only being somewhat below 10 per cent, of the whole number ; half the remaining number, or 25 per cent, of the whole, take place between the ages of five and ten years, and about 10 per cent, during the next five years ; in the next ten years, that is, from the ages of fifteen to twenty-five, the propor- tion of deaths does not exceed 6 per cent, of the whole ; from twenty-five to thirty- five it hardly reaches 2 per cent, and is below 1 per cent, in decreasing ratio for each succeeding decade. The propor- tional mortality from Diphtheria for each age, to the deaths from all causes, is : — 1st 2d .Ied her to be removed ; an interval of ten days was then allowed for cleansing and ventilating the hous&, when the family, consisting of mother, a weaned infant, and two other children, the eldest under four years of age, who had left the house on the first appearance of the disease, returned home ; three weeks afterwards the iufimt had symptoms of Diphtheria, and before the death of this child, which took place on the tenth day, the mother who had been constantly in attendance was taken ill, and subsequently the two other children. Infection may be disseminated tor an uncertain time by those convalescent from Diphtheria ; a girl ten years of age was removed from home at the outbreak of Diphtheria, from which three children, two younger and one older than herself, afterwards died ; two other sisters conva- lescent from the disease went to the sea- side, the one five weeks from the com- mencement of her illness, the other only three weeks, but from whom the last trace of deposit had cleared away ; they left together and seemed to be equally well : they were joined by other members of the family, and at the end of the week by the httle girl, ast. 10 ; early in the following week symptoms of the disease appeared in her, and became rapidly fatal. She was the only one of the family that had been isolated during the whole period of the illness. Sir W. Jenner' gives two similar instances : in the first, only a fort- night elapsed from the commencement of the disease to the removal into the coun- try, and within a fortnight from the date of arrival, another member of the family, some time resident there, was attacked ; in the second a little boy, after three weeks' separation from his family, joined his sisters, convalescent from Diphtheria, at a country residence to which on their recovery they had been removed. " Ten days after his arrival there, the boy sickened with Diphtheria. In this case, either the poison ^vas in the child's sys- tem when he left London, and remained latent for a month, a supposition highly improbable, or he caught the disease from his sister, after they met in the coun- try. "^ Constitutional predisposition hars a great influence in increasing the liability of families and individuals to receive the dis- ease: of two families residing in the same house several members of the one have ! sutlered, while all of the other have es- ! caped ; a difference of susceptibility is i also observed in members of the same family, and this not always in favor of the ' Loc. oil. p. 5i ' Loc. cit. p. 53. seemingly more robust. Allowing for the effects of similarity of diet, occuiiatiou, general management and hygiene, and chiefly for the degree of exposure to the same sources of infection, it is yet impos- sible to contest the effect of family consti- tution, both in favoring the occurrence of the disease and in disjiosing to its fatal termination. Great mental activity, and a high de- gree of nervous susceptibility, would seem to increase the liability to become affected; bodily fatigue, and exhaustion from any causes, predispose. There appears to be but little difference in the liability of the different classes of societj^ The presence of other diseases, as of ty- phoid fever, pneumonia, measles, erysipe- las, and scarlet fever, has a great eftect in exposing the system to the attacks of this one. The special poison of this disease sometimes produces effects short of gene- ral Diphtheria, which, however, predis- pose to the occurrence of the fully-devel- oped disease, either from the first local evidence of it being unchecked, or upon some accidental source of weakness aris- ing, as from the effects of aperient medi- cine, or of menstruation. The disease is especially likely to be established, if there be repeated or continual exposure to the exciting cause. The recurrence of Diphtheria more than once in the same subji'ct is not settled so conclusively in the affirmative as has been supposed. That the same person may re- peatedly suffer from the slighter forms of the malady, and that some do so upon the slightest exposure, is frequently observed; but when the fully-formed disease has been undergone, thinigh relapses are to be feared in convalescence, even during the whole of the subsequent period of debility, which may be prolonged for two or three months, independent recurrence is rare. Of the children that recovered from the disease at the commencement of the epi- demic, and who have been constantly un- der my observation since, no instance of a second visitation lias occurred. Such instances are recorded, one by Dr. Gull, eleven months after the first attack, and three others Ijy Dr. Greenhow,' one of Avhich was fatal, but no particulars are given in this case as to the intensity of the first attack. The development of Diph- theria agrees more closely with that of erysipelas than of scarlet fever ; the close- ness with which many of its ]3athological effects coincide with those of the latter disease makes it necessary to remark here, that the occurrence of scarlet fever offers no protection against the attacks of Diph- theria. ^ So with respect to croup: two ' Loc. cit. p. 111. ' Dr. Ballard, in Medical Times and Ga- zette, 1859, vol. ii. p. 78. SYMPTOMS. 65 instances have occurred to me, wherein children tliat had suffered severe attaelcs of croup, fell victims to Diphtheria after intervals of four and six years. Hygienic conditions induence the frequency, and even the fatality of Diphtheria, less di- rectly than they do the permanence and diffusion of the infectious principle ; want of cleanliness allows the infectious parti- cles to accumulate ; the presence of de- composing organic matters shields them from destructive oxidation in the atmo- sphere ; thus they linger in districts natu- rally rnalarious, and in those artificially so from an improper drain system, as well as in tlie close, darli, and dirty districts of large towns, and evils thus matured rest not in their cradles, but come forth and often exert their most fatal effects in homes the most unlike those where negli- gence had allowed them to lurk. [The influence of unsanitary local conditions in promoting the occurrence and mortality of Diphtheria has been marked of late years in many places in America; amongst others, in certain quarters of the city of New York. Tenement houses, contain- ing an excessively crowded population, have often been subjected to great loss of life from this as well as other '' enthetic" diseases. Foul privies, badly drained cel- lars and streets, and leaky connections of dwelling houses with sewers, favor Diph- theria, very positively, notwithstanding the specific nature of its immediate cau- sation. — H.] Stjiptoms. — Some general constitu- tional symptoms precede those occasioned by the concomitant local changes ; both may co-exist in every degree of severity, sometimes the one, sometimes the other attaining a deceptive prominence ; at ether times both are so obscure as to make the inroad of the disease remarka- bly insidious. Among the earlier symp- toms are yawning or sighing, shallow and infrequent respiration, great lassitude and debility, some aching of the back and legs, either a distinct rigor, or chilliness, pal- lor, a sense of nausea or rising in the throat, anorexia, sometimes vomiting, or diarrhoea, and in children convulsions, a sense of constriction across the forehead, or intense headache, vertigo, extreme muscular weakness, some anomalous fixed pain, an altered mental state, slowness of recollection, an indifference of manner, and an obtuseness of the mental faculties; this latter gives place to a short period of excitement, during which it may be thought that no illness is impending. There is, however, a marked elevation of temperature, which is increased at night, when wakefulness or restlessness always occurs. The pulse is accelerated, and in children or young persons may rise to 130 or even to 140 in the minute : this fre- VOL. I.— 5 quenc;y soon subsides, generally before the end of the second day ; and though the pulse continues to be quick, it is cither feeble or easily compressible. The respi- ration is never proportionately accelerated at this period. The tongue is moist, with a thin creamy fur ; the urine is pale in color, at first free, soon rather less in quantity, with scanty deposit of lithates, but still pale, and at this time it may be albuminous. The lymphatic glands at the angle of the jaw are already precepti- ble ; there is always some enlargement of the cervical glands, and redness with a little swelling of the posterior part of the soft palate, of the fauces, of the back of the pharynx, and of the tonsils. The throat is sore, deglutition is difficult if not painful, sometimes the pain is felt in the ear, and there is frequently stiffness of the neck ; very little external swelling is at this time noticeable, and there is "no dif- fused redness of the skin; sometimes little isolated red spots are found in different parts of the surface, as over the neck or behind the ears; there maybe suffusion of the eyes and slight injection of the con- junctival vessels, and a little obstruction to the nasal passage from a similar vascu- lar state of its lining membrane. Some- times this is seen at the nares to be sim- ply red, sometimes an opaque white spot may be noticed beneath the epithelium, or one nostril may be completely ob- structed, and some fibrinous exudation al- ready observable; sometimes the back of the phai-ynx will show the first indication of this in lines of opaque tenacious secre- tion, or commencing deposit is seen there, in the apices of its enlarged follicles. The earliest evidence of the disease is, how- ever, most frequently found within the follicles of the tonsils or deposited on its inttamcd and turgid surface. The first general symptoms are transient, and may be so trifling in degree as to es- cape notice, until they are intensified by the progress of the local lesion ; this will give rise to pain, heat, and soreness of the throat, with impeded function : it also excites some sympathetic febrile disturb- ances of its own, and alwaj'S increases that proper to the general disease ; where both are severe, the throat, though covered with exudation, is often the least part of the patient's complaint ; where both are slight, there may be an interval in which little complaint is made. During this in- terval, two days, there may be no visible exudation in the fauces ; the tonsils con- tinue to be enlarged and their surfaces irregular, and they, in common with the whole of the pharynx, the arches of the palate, the velum, and the uvula, are of a deep-red color and unequally turgid ; one side is generally the most affected, tlie uvula is enlarged, red, and glistening, and a mottled redness extends forwards from m DIPHTHERIA. it over the soft palate, but the rest of the buccal uieiulu'anc is pale. Sdiiic of these parts siiiju appear more tumid and glisten- ing than others, and spots at first .semi- transparent and afterwards opaque, rapid- ly form and coalesce, so that in a few hours a large surface may be covered with a continuous layer of exudation ; or the exudation is limited to one or more ceu- tres, tlie mucous membrane around Ijcing elevated and of a violet tinge of redness, until it is invaded by the same change. The raised edge is then extended, the centre Ijeing occupied by a flattened, yellowish-white, leather-like deposit, in- creasing in thickness by additions to its under-surtixee ; this is accompanied by the pouring out of a considerable amount of a more tluid secretion, while that from the surrounding mucous follicles is also in- creased and altered in quality, so that a tenacious fibrinous matter is mingled with the mucus. The cervical glands increase in volume, the submaxillary lymphatic glands especially ; a large amount of serous infiltration takes place in the sur- rounding cellular tissue, and the whole of the front of the neck becomes greatly swollen ; deglutition is involuntarily sus- pended, secretions escape in some quantity from the mouth, and even from the nos- trils, by which the lips are excoriated. The superficial laj'ers of the loc;ilizcd de- posit, partially separated and exposed to the passage and re-passage of tlie air and the warmth and moisture of the mouth, undergo decomposition and give rise to great fetor ; extravasated blood mingles with the decomposing exudation, or es- capes freely from its under-surface, or occasions epistaxis. The voice is muffled or nasal in tone ; impeded respiration may occur from the phj-sical obstacles in the fauces without laryngeal symptoms arising ; or these being slightly marked, symptoms of pulmonary obstruction come on insidiously. These processes may be gone through with great rapidity, and are accompanied by the most marked adyna- mia ; the pain in the head is intense, the restlessness and agitation extreme, vomit- ing or diarrhrea may occur, the lips and tongue become dry and brown, the pulse very rapid, feeble, and irregular ; the skin becomes cold, the firce pallid, the whole attitude is iuclicative of powerless exhaus- tion ; there is impaired consciousness, slight delirium, or deep somnolency, ancl some repeated attack of syncope termi- nates life. The elevation of temperature is alwavs marked, and characteristic ; it may be as high as 10.3° very early in the disease ; it will generally reach this point by the end of the third day, and is highest at night, when it may amount to 104^'^ then prob- ably with delirium. This temperature has uot been exceeded in uncomplicated cases. The days of highest temperature observed from the commencement of the illness have been from tlie third to the ninth or tenth. Free exudation is attended with temporary depression of temperature. De- fervescence in the severer cases recovered from has been on the twelfth and four- teenth days ; in the milder cases this has not occurred before the sixth day, though some precedent subsidence of temperature may have been noticed. In fatal cases an earlier decline of temperature has some- times been met with. A girl, aged 8, had a surface temperature of 103° on the third day, 101° on the fourth, then barely 100°, with swelling of glands, fcetorosis, and haaiiorrhagic tendency, death on the eighth day ; the day Iw'fore the temperature in the axilla was below the normal. In cases markedly asthenic the temperature of the surface i'alls, while that of the interior of the body continues to be higli : in a boy, aged "2, with a temperature of 103° in the rectum on the fifth, sixth, and seventh days of the disease, only 100° could be ob- tained in the axilla, and sometimes only 00^-° ; the temperature after subsiding to 100° was suddenly raised to 102° by acute kidney complication ; continued there two days, and was again below 100° the day before death. Anotlier boj', aged 4, with nasal diphtheria and slight tracheal im- plication, had a temperature of 103° in the rectum on the sixth day, suddenly falling to 99 ••5° on the seventh, then con- tinuing at or near 100° until death on the fifteenth day. In the apparent interval between the first illness and the distress occasioned by the throat symptoms, the high temperature is an indication of value : a child has been taken out for a walk on the fifth day with a temperature in recto of 103 '7°. A young man was found dressed and walking about on the ninth day of illness, with a surface temperature of 102° ; on being kept in bed the tem- perature fell 2° in two days ; the exuda- tion then ceased to extend, but the tonsil last affected had become turgid and more inflamed coincidently with the fall of tem- perature : albuminuria appearing here during defervescence was considered to be rather hffiraic than renal. During convalescence the temperature is low, and readily depressed : but any intercurrent affection may keep up the temperature indefinitely. The advancing asthenia is always ac- companied by a considerable increase of exudation ; it- continues while the process of exudation is going on, and is at its greatest when the separation of the dis- eased products is being accomplished ; this may be comjileted by the ninth or tenth day of the disease. The exhaustion at this period, if not fatal, is often so great as to suspend for some days the hope of recovery, to delay the process of repair, SYMPTOMS. 67 and to prolong the diseased action, so that there may be a reappearance of exudation in the fauces, or it may at tliis time in- vade the larynx. If there be any injury of the skin, the diphtheritic action, pro- bably already established there, will be continued so as to become an additional source of exhaustion. Besides the hemor- rhagic tendency at any aftected surface, spots of purpura sometimes make their appearance either widely distributed or grouped together : sometimes an earthy pallor pervades the whole surface of the skin. Where there are none of these un- favorable complications it is not rare to find that, when the exudation is clearing off from the fauces, a remarkable increase of albumen occurs in the urine. Noc- turnal delirium may occur, not only at the commencement, but at the height of the disease, when the asthenia is consi- derable. A more violent symptomatic disturbance at the commencement of the disease, occasioned either by local or by constitutional reaction, may mask the tendency to asthenia without making it less ; and should the course of the disease not be interrupted by the implication of the air-tubes, asthenia becomes the pre- vailing condition throughout all the sub- sequent illness, and may bring on a fatal result, not only at the end of the second week, but during any of the subsequent weeks of convalescence, even to the fifth or sixth from the commencement of the disease. Extension of the disease to the larynx and trachea may be the cause of death at a much earlier period ; the air-passages are specially liable to become tlie seat of the peculiar exudation of Diphtheria ; it may commence there either by indepen- dent centres of deposit, or by the spread of exudation from the pharynx to the epi- glottis, over the arytffino-epiglottidean fold, and thence downwards, even to the remotest bronchi, and be fatal, with symp- toms of sudden or of slow suffocation, in the earliest stages of the disease, or at the period of greatest exudation, towaiKls the end of the first or commencement of tlie second week. This extension often pro- ceeds insidiously when the general sj'nip- toms are of great intensity, and is only indicated by hoarseness, or weakness of the voice, and by some laryngeal quality in the breath sounds, faintly audible dur- ing both inspiration and expiration, by signs of impeded respiration, evidenced in the cedema of the face and livid hue of the lips, sometimes only by pallor, and gradu- ally deepening unconsciousness, and by the retraction of the softer parts of the thoracic parietes. In other cases the first invasion of the mucous membrane of the upper part of the air-tube is announced hy highly characteristic phenomena, simi- lar to those produced by acute laryngitis in adults, or by idiopathic croup in chil- dren, ditt'ering only in the less sharp and sonorous clan,^ of the cough, in the mure husky tone of the voice, and in the ante- cedent and concomitant symptoms. Be- sides the appearance in the fauces, and tlie dyspliagia, the sudden change from the asthenic character of the prevalent symptoms to the excitement, arterial and general, now occasioned is very striking. In other cases, chiefly among children, the disease may have set in with no great severity, the power of swallowing" and even the desire for food may be returning, and the child, no longer confined to bed, is resuming its amusements, wlien a hoarseness of voice and a noise in breath- ing are the only precursors of paroxysmal dyspnoea, diftering only from that of croup in the time of the day in which tlie first attack may occur, and in the readiness with which the child will return to play on its subsidence, but soon becominij more terrible in the unintermitting violence which it rapidly assumes, or in the sud- denness of the fatal result. The mortality from this complication alone is very great ; it has been estimated that one-half ©f the fatal cases of Diph- theria die from tliis accident ; nor is this estimate excessive when children are the sufferers ; an extension to the air-tubes, necessarily fatal to children, will some- times be survived by adults ; in the man Sheppard a cough of unequalled violence with expectoration of false membrane continued into the third week of illness. In a small proportion of cases tlie larynx or trachea has been the first seat of the disease ; in these cases and in those where the faucial deposit is small or already dis- appearing, the urine is more frequently found to contain albumen at an early pe- riod than in those cases attended with abundant exudation on tlie pharynx. In a female, aged 35, named Bowra, under Dr. Hare's care in Universitjr College Hospital for Diplitheria, in April 1805, who died of pneumonia, coincident witli slight deposit in the larynx and fauces, there was a consideralile amount of albu- men in the urine on her admission, the second day of her illness ; the next day the temperature of the surface rose to 104°, pulse 144, respiration 36 ; the albu- men increased to one-sixth, and the re- spiration to 57 ; death took place on the sixth day. The first evidence of deposit was in the larynx, and there was no ex- tension of it into the bronchi. Soreness in the front of the neck, and pain or sense of tightness over the sternum, are fre- quently complained of in these cases, and sometimes slight cedema is noticeable in front of the trachea. Albumen is found in the urine in the great majority of cases ; its presence either in large or small quantity does not 68 DIPHTHERIA. necessarily affect the excretion of m-ea : tliis is always increased during the whole pisriod of illness, and when the disease is at its height is frequently double. In one case (J. B., a young man, aged 18), on the seventh day of illness, 6U(3 grains of urea were excreted, or more than treble the normal quantity : the urine has an acid reaction, a high specific gravity, and deposits a furfuraceous sediment in which uri : acid, urates, oxalates, and sometimes phosphates, are detected by the micro- scope, and not infrequently casts of the renal tubules, either waxy or granular ; l)lood-corpuscles are rarely found, and never in large quantity. Albuminuria generally occurs early in the illness ; it may be absent and reappear more than once in its course. In a man named "\7alker, aged 42, admitted to University College Hospital, under Sir W. Jenner's care, Xov. 14th, 1804, for Diphtheria, at the end of the lirst week of illness, there was no albumen found till the end of the third week ; it then continued till death, which took place in the fifth week of the disease. In the case of J. B., albumen was present throughout the illness ; on the twelfth day it had increased to one- third, on the twenty-fourth day it was one-eighth, and then gradually lessened during the ingress of paralytic symptoms, and finally disappeared at the end of the fifth week, while the nervous disorder was at its greatest, and three weeks be- fore convalescence was established. Al- buminuria is not persistent after recovery, and does not often result in anasarca. Hemorrhage is not infrequent, and may be so profuse as to cause sudden exhaus- tion, either on the separation of some morlDid deposit of unusual depth, or from some dyscrasia of the blood favoring its ready transudation. Yomiting and diar- rhrea, generally absent after the first in- gress of the disease, may set in with gas- tralgia and great depression. Exhaustion may come on gradually without these symptoms, the pulse increases in rapidity and feebleness, and death takes place without distress of breathing or impair- ment of the mental faculties. In some of these cases, and of those yet to be de- scribed, fibrinous coagula form before death in the cavities of the heart. The liability of other mucous mem- branes and of the skin, especially when denuded, to become the seat of the changes characteristic of Diphtheria, has often a great influence on the progress of the disease ; eczema behind the ears, or in any fold of integument, abrasions or fissures at the juncture of skin and mucous membrane, leech-bites, blistered surfaces, and even those irritated by a mere rube- facient application, may become affected, and add greatly to the amount of disease against which the patient has to contend ; a cutaneous eruption, occasioned by the disease itself, is sometimes, though rarely, the seat of these ulterior changes ; the cuticle is raised, a white surface is ex- posed—this is identified with the upper layer of the cutis and does not implicate its whole depth — the skin immediately around is red and tumid ; new vesicles, sometimes sanious, are raised upon it, they burst and coalesce ; the white layer extends its surface, which is still some- what below the level of the surrounding skin ; it increases in thickness by addi- tions from below, and the upper layers soften, decay, and disintegrate ; it is accompanied by an irritant fluid secre- tion, both increase proportionally, and the extension of false membrane takes place most readily in the direction where the secretion is most in contact with the skin ; where these changes take place in some portions of the skin, towards the end of the disease, there is but little secretion formed, and no great extension occurs. At the height of the disease the extension is sometimes very rapid ; but this is less remarkable, because less constant, than the -tendency then observed to repetition. jSTot only will every abraded or irritated surface take on this action, but isolated patches of deposit may occur on the edge of the lip, on the eyelid, in the meatus auditorius, and elsewhere. Open wounds undergo a similar change, the superflcial granulations are converted into this pseudo-membranous layer, cicatrization stops, the wound becomes painful, and a copious ichorous secretion is poured out ; a fissured nipple has been the starting- point of the morbid process, and much of the surface of the breast has suffered ; the disease readily establishes itself in the vagina, where layer upon layer of false membrane may accumulate. An abraded surface of integument is sometimes covered with a granular or pulpy exuda- tion only, attended with but little fluid secretion ; the affected surfaces then con- tinue to be irritable, but do not always extend. Diphtheria has generally first appeared in the fauces, and made some progress, before other parts of the mucous membrane, or of the exposed skin, have been attacked ; instances are not, how- ever, wanting of the disease commencing elsewhere, and inducing in the pharynx, larynx, and trachea, the characteristic changes that soon become fatal. A remarkable train of symptoms often make their appearance after the disease has reached its height, and become a new- source of danger. These are the limited and varying series of paralyses, which are some of the characteristic effects of the special diphtheritic poison. An altered tone of voice and the regurgitation of fluids through the nose are frequent evi- dences of this, and hive long attracted SYMPTOMS. 69 notice ; an inability to swallow, first pointed out by Gliizi, was noticed by M. Guersaut to occur about the nintli day of the disease, and to become an embarrass- ing obstacle to recovery in cases where traclieotomy had been performed. Tliis is frequently observed only with respect to fluids ; tlierc is at this time, as shown by M. Trousseau, a loss of sensibihty in the velum pendulum palati, and probably in the pharynx and glottis. Complete in- ability to swallow from loss of power in the muscles of deglutition seldom occurs before the third or fourth week of the ill- ness ; at this time on inspection of the throat, the uvula is often found to be lax, and neither it nor the pillars of the fauces act upon stimulation ; difficulty in the in- gestion of sufficient nutriment adds to the dangers of this period ; vomiting, more- over, is possible when the power of swal- lowing is gone. Loss of power and of sensibility in the parts supplied by the par vagum occur at a somewhat earlier period than the paralytic affections of other parts of the body, and hence arise special sources of danger ; the slow weak pulse observed in the second and third weeks of illness is from this cause, and is frequently a fatal symptom. The pulse may be reduced in children to sixty or even forty beats in the minute, and the child seeming otherwise well, death by syncope has occurred suddenly, on some undue exertion ; or the heart's pulsations have gradually failed to thirty or, shortly before death, even to sixteen "beats in the minute.' I have seen a similar failure of respiration occur to a boy, aged 9, in the second week of illness, where no ex- tension of the disease to the lar^ynx had . taken place ; insjiiratory eftbrts had to be artificially excited at frequent intervals during many hours ; every few minutes the respiratory movements became more and more shallow and inefficient, until they were again stimulated into action, and even then the ribs were not always elevated ; at the end of twenty-four hours respiration was more satisfactorily per- formed ; during the second day the voice regained its clearness and force, the intel- lectual activity seemed to be more than usually quickened, the respiratory mur- mur was perfect in every part of the lung, both food and stimulant were swallowed, but the action of the heart became at first slow and weak, afterwards very feeble and rapid, and death took place on the third day from the commencement of these symptoms. Paralysis of the muscles of respiration occurring at a later period, in an adult, threatened to be fatal but for the ' SirW. Jenner, op. cit. p. 44. Mr. Adams has given valuable details of a case of this kind in the Second Report of the Medical Offi- cer of the Prtvy Council, p. 327. stimulus of galvanism. Dr. Gull reports the case of a boy, aged 11, who, five weeks from the commencement of Diphtheria, was unable to prevent the head falling for- ward, or to either side, owing to paralysis of the muscles of the neck ; he suffered from dysphagia, aphonia, and paroxysmal dyspnoea; a few days afterwards "the breathing became entirely thoracic. The diaphragm was unmoved in inspiration and depressed in expiration, indicating a loss of power in the phrenic nerves.'" Death approached rapidly by apnoea. Loss of power and irregular action of the pharyngeal muscles is not only the earliest, but the most frequent form of dis- ordered innervation. It sometimes rapidly disappears, and is not followed by other symptoms of this kind ; in other cases the power of swallowing may continue to be impaired for three or four weeks ; at first the difficulty is with liquids, afterwards it is now and then found that solids cannot be passed down, and are in danger of re- maining in the lower part of the pharynx, or of being forced up towards the pos- terior nares, while liquids find their way into the stomach, and these conditions may alternate. At this time articulation is sometimes defective from imperfect movement of the t(mgue ; tingling sensa- tions in the tongue and lips are also felt, and may continue during the fifth and sixth weeks. Paralysis of the nerves of the special senses was first observed as a consequence of Diphtheria by J. P. Hoflf- man.^ Taste is sometimes lost, more rarely hearing ; defective vision is not in- frequent ; it begins with an immovable and sluggish pupil, and an inability to read or to distinguish near objects; soon more distant objects beeome indistinct, double vision or strabismus may occur ; sometimes one eye only is affected ; these changes of vision take place from the fourth to the seventh week, and when sight is perfect the pupils again act freely. As these alterations of sense improve, numb- ness and tingling commence in the fin- gers and toes, extending gradually to the hands and arms, and to the feet and back of the legs, or even to the hips. Some degree of these sensations, with formica- tion or a sense of coldness in the extremi- ties, various degrees of ansjesthesia, or even some hyperfesthesia, may occur earlier, and before any great loss of mus- cular power. These conditions vary very much, disappearing at some parts, in- creasing and extending at others. They may pass off for a time, and reappear with the increasing muscular debility ; the sense of touch may continue to be im- paired ; anpesthesia is seldom complete except in the severest cases. The lower ' Lancet, 1858, vol. ii. p. 5. 2 Rust's Magaziu, 1831, b. xxxiii. s. 241. 70 DIPHTHERIA. extremities suffer most ; it may be impos- sible not only to stand but to move the lei;s in bed. When this degree of paralysis is not reached, the gait is ol'teu unsteady, and walking may be impossible from a loss of the muscular sense ; this sometimes interferes with the use of the hands, and the power of co-ordinating muscular move- ments. Loss of power is not to the same degree or so persistent in the upper ex- tremity as in the lower, though here also remarkable alternations are observed, one limb or one set of muscles being free to ait on one daj-, and powerless on another ; when power is regained, one muscle, or part of a muscle, may remain for a time the subject of inaction or of spasm. Ee- llex action is often diminished, but not increased. Paralysis of the bladder has occurred, not of the rectum. Constipa- tion, from paralysis of tlie abdominal nnisclcs, is a frequent condition, demand- ing attention. The first symptoms of paralysis will almost alw.ays appear before the end of the fourth week ; they generally attain their greatest degree of intensity by the seventh or eighth week ; they may not do so until the tenth or twelfth, as in fSheppard's case ; all traces of the affection may not have entirely disappeared after live or six months. Lesions of innervation are not in proportion to the extent and persistence of the local lesions, nor always the consequences of the more severe and prolonged attacks of Diphtheria only, though it is alter these that they are most likely to occur ; the_y may conduce not only indirectly, but directly, to a fatal re- sult, from progressive loss of nervous power, apart from nmscular weakness ; in these cases the period most dangerous to life is reached in the seventh or eighth week. Trousseau ' has detailed a case where didirium and convulsions at this time appeared, with ultimate recovery. ISIore frequently death by asthenia, unat- tended by symptoms of other disease, occurs ■\\-ithin this period. A peculiar pallor and opacity of the skin is often a concomitant of even the more slightly marked cases of paralysis consequent on Diphtheria. In the more prolonged cases there is always some evidence of antemia. DiAGXOsis. — A careful inspection of the fauces will, in the majority of cases, be conclusive as to the presence of the dis- ease : where a yellowish patch of exuda- tion moulded to the surface it has invaded is thus brought into view, the nature of the serious illness, which may have been obscure, is at once revealed :" where this anatomical character of Diphtheria is not obvious, the appearances in the fauces, taken in conjunction with the associated phenomena, will still be of primary diag- Gazette des Hopitaux, 1860. nostic value. It is important that the earliest stages of Diphtheria should be distinguished from catarrhal atfections. The redness of the fiiuces in Diphtheria is more intense but less uniformly diffused than in catarrhal inflammation ; the ton- sils are more tinnid, and one side is more allected than the other ; the lymphatic glands at the angle of the jaw and beneath the sterno-mastoid are always enlarged : in children coryza may be present, the vascularity of the conjunctiva is then more like that observed in measles, but there is less secretion ; afterwards, the dettuxion from the nares becomes more considerable, it is not simply mucous, but sero-purulent or sanious ; or the nares not being so much aftected, a quantity of un- equally opaque and tenacious mucus bub- bles iii the gullet, and prevents the view of the posterior part of the pharynx ; there will be pain in deglutition, as shown by the infrequency of the effort, or the grimace that accompanies it ; in either case the exudation soon extends to the larynx, and the cough, hitherto infrequent and moist, becomes frequent, dry, and croupy, and the disease is set down as catarrhal croup. For the further diag- nosis of croup from Diphtheria, see the article on Croup. Tonsillitis resembles Diphtheria in the two sides of the throat being unequally allected, and in the occurrence of external swelling at the angle of the jaw ; the con- stitutional symptoms are, however, symp- tomatic, dependent on, and in proportion to, the local complaint ; the lymphatic glands are not enlarged at the commence- ment of the attack, nor those beneath the sterno-mastoid at anj- time. A yellowish Soft secretion appears at the orifices of the tonsil ; the nmcous surface preserves a smooth, glistening appearance, and any exudation of lymph upon it is semi-trans- parent, very thin, and limited in extent; the tendency of the inflanmiation is to resolution or suppuration, the other tonsil often becomes affected in the same way, but without any similar change taking place in the intermediate mucous mem- brane. In Herpetic sore throat the highest temperature is on the second day, when it may rise to 102°, and then rapidly sub- side. In scarlet fever, the throat affection is always preceded by symptoms of severe febrile disturbance, which are persistent, and in proportion, not to the throat affec- tion, hut to the severity of the attack of fever which follows ; the chilliness and headache may not be so marked, but the heat of skin is greater, and the pulse at once attains a high degree of frequency which it maintains during the first dav'S of the illness, and until after the appear- ance of the rash, or the condition of the DIAGNOSIS. 71 throat, has removed all douht as to the nature of the disease. The premonitory symptoms in Diphtheria are sometimes not noticed in the severer cases, and when well marked do not always indicate the approach of the graver symptoms ; should these follow, the frequency of the pulse during the first few days is not maintained, the respiration is shallow and not propor- tionally accelerated, and there is neither the continued high temperature nor the same pungent heat of skin. The dimin- ished frequency and fulness of respiration at the outset of Diphtheria is often an in- dication of value when the disease is not yet fully developed. The cervical lym- phatic glands are enlarged in both dis- eases. The redness of the throat in scarlet fever is uniformly dilfused ; on the second or third day it becomes very in- tense, appearing simultaneously upon all parts of the throat and palate, and aft'ect- ing the papillse of the tongue ; both ton- sils arc equally enlarged. In Diphtheria the redness and turgescence are greatest in certain parts about to become the seat of exudation, and at the edges of the ex- udation already formed, so that it and the surrounding redness gradually advance upon the contiguous portions of the rau- cous membrane ; the papillte of the tongue are neither red nor enlarged, and the ton- sils are unequally affected. In scarlet fever exudation, both tonsils are covered witti a milk-white layer applied equally to the surfaces of both, and the soft palate and tongue may be covered with a similar layer ; this undergoes no great increase in substance, and at a certain period is detached in shreds ; it is not capable of absorption, and on its separation leaves a red and sensitive surface. In Diphtheria the process of exudation continues to be active for some time ; on its cessation, there is a separation of membranous layers of considerable density and extent, wliich may represent a cast of the surface on which the}- formed ; a re-absorption is now possible of some of the products still imbedded in the mucous tissue ; this is accomplished either without loss of sub- stance, or with superficial ulceration only, and the sensibility of the surface is dimin- ished. In scarlet fever there may be sloughing of the tonsil, and there is a tendency to suppuration of the cervical glands. There is no tendency in the in- flammation of the throat in scarlet fever to be propagated to the air passages ; the nasal tone of voice, and the regurgitation of fluid through the nose, cease on the subsidence of the swelling of the tonsils and lymphatic glands. In Diphtheria these symptoms often undergo a remark- able increase subsequently, from the para- lytic sequels of the disease. Scarlet fever has a definite course, modified only in de- gree of severity ; Diphtheria may either he arrested or modified in its course, so that the period of its duration is less definite. In scarlet fever there is a greater liability to inflammations of the serous membranes than in Diphtheria. Albu- minuria, as a sequel to scarlet fever, interferes with the excreting power of the kidneys, is attended with hajmaturia, and more frequently results in dropsy and anasarca : it is an early symptom in Diphtheria, is rarely attended witii luema- turia, seldom interferes with the excretion of urea, and does not result in dropsy. Both diseases are contagious, but while the contagion of Diphtheria has not been shown to give rise to scarlet fever, that of scarlet fever has apparently been followed by Diphtheria. They are not prophy- lactic of each other : in the late epidemic of Diphtheria, children who had gone through scarlet fever were equally liable to sufler ;' and though in some cases a se- vere attack of Diphtheria has seemed to give an immunity from scarlet fever, yet instances are not wanting of those who have recovered from Diphtheria being at- tacked with scarlet fever. Dr. Buchanan,^ of Glasgow, records the appearance of scarlet fever in a boy six years old, four clays after the performance of tracheo- tomy, and in the second week of his ill- ness from Diphtheria ; anasarca appeared in the third week ; in the sixth week con- valescence was complete. A patient suf- fering from paralytic symptoms, conse- quent upon Diphtheria, while under the care of Dr. Stewart, in the Middlesex Hospital, contracted scarlet fever, during the febrile stage of which, and the full appearance of the rash, the paralytic symptoms cleared away. This modifica- tion of a symptom peculiar to the one dis- ease upon the establishment of a condition peculiar to the other, though an instance of the distinct nature of the two, does not show any necessary antagonism between them ; not only may the one succeed to the other at very short intervals, but it would seem to be possible for them to co- exist. The appearance in the throat characteristic of Diphtheria may com- mence after the subsidence of the redness occasioned by scarlet fever, and the dis- appearance of the rash ; they may, how- ever, come on at any period of its course, and more rarelj^ the two diseases may seem to be coincident, so that the aspect of the throat on the first day may be indi- cative of Diphtheria, and with the charac- teristic rash of scarlatina appearing on the second or third day there may be a fall in the frequency of the pulse. In some epi- demics of scarlet fever undoubted cases of the disease occur without the character- 1 Dr. Ballard, loo. cit. p. 78. 2 British Medical Journal, September 1864, p. 324. vz DIPHTHERIA. istic rash. A rednoss of the skin, and more or less marked rash or eruption, readily distinguishable from that of scarlet fever, has sometimes accompanied the early stages of Diphtheria. IStercatus' mentions a rash like flea-bites in some of the Spanish epidemics, and a redness of the whole face and neck, with loss of voice and dyspnrea. Fothcrgill describes a rash, in the lirst edition of his treatise, which he says, in a foot-note^ in the second edi- tion, did not regularly accompany the dis- ease, and which is certainly not that of scarlet fever ; it agrees more nearly with that lately observed, and described by Dr. Babington, as rubeola notha, which was sometimes, though rarely, seen in cases of Diphtheria, appearing on the first day. Dr. Fuller^ communicated to the Harveian Medical Society, February 1858, the case of a child ill with sore tliroat and a rash, like scarlet fever, from the commence- ment ; on the third day there were great dyspmjsa and excitement with an increase of the rash and of the redness of the face ; by night a membranous cast of the pha- rynx was expelled, with immediate relief to the dyspno'a and a rajiid subsidence of the redness and rash, so that by the next day no trace of either remained ; recovery was rapid, there were none of the sequeke of scarlet fever, and no desquamation. Desquamation of the cuticle from the hands and feet has occurred after pro- longed illness from Diphtheria, when there has been no preceding rash. Erysipelas comes on with rigors, or chills, and headache ; there is pain in de- glutition, often extreme, and some en- largement of the cervical glands ; the throat redness, though intense, is diffused ; there is no secretion, and none of the fibri- nous exudation characteristic of Diph- theria : this form of sore throat may occur either before or after the appearance of the erysipelas on the face or head. Ery- sipelas, smallpox, and measles are liable to be followed or complicated by Diph- theria. Diphtheria may follow npon typhoid fever or any prolonged and exhausting disease ; it is important, therefore, to dis- tinguish the sordes that collect in the fauces, and the special product of thrush, or muguet, to which such cases are liable, from the exudation of Diphtheria. The matter of thrush is closely attached to the mucous membrane when it is first exuded, ' Consultationes, p. 136. 2 Op. cit. 2d edition, pp. 32, 3.S. It is not until the publication of tlie fifth edition, twenty years after this, that an error in the alteration of this foot-note, and an added paragraph to the preface, led to the confusion that has sincf existed between Fothergill's sore throat and scarlet fever. 3 British Medical Journal, 1858, p. 173. but it becomes more and more easily sepa- ral)le ; it occurs in little rounded masses, is whitish, and soon projects beyond the level of the surfai e : if artificially removed, the membrane beneath looks slightly hol- lowed, and either red or gray, but it is neither completely abraded nor ulcerated ; the buccal membrane and not the throat is specially the seat of this formation ; it acquires no great extent, nor considerable tenacity. Chemically, it has an acid re- action, is not acted upon either by acetic acid or by alkalies, and is only dissolved or destroyed by sulphuric acid ; these qualities are owing to the large parasitic vegetable growth of Oiif7?!(i« n /?//>« /is, which also give to it special microscopical cha- racters. Sordes occur in patches of un- equal thickness, verj' little (.'oherence, and no great extent, and are removable with- outinjury to the subjacent tissue, however red and tender it may be ; thej^ chiefly accumulate in front of the arch of the palate, acquire an acid reaction, and then also become the seat of the O'idhtm albi- cans. It is only when the diphtheritic exudation approaches to these local and chemical conditions that it becomes the seat of similar parasitic growths. Pathology. — The general disease and the local lesions that arise during its con- tinuance have an interdependence and mu- tual reaction. The latter are not confined to one period of the disease only; they oc- cur throughout its course, sometimes proving fatal by the \ita\ importance of their site, at others adding to its force, and prolonging its continuance. The gen- eral disease impresses a special character, not only upon the local lesions which it occasions, hut upon any concomitant mor- bid action: it is marked throughout by an elevation of the normal temperature of the body, by enlargement of the lymphatic glands and the spleen, by a varying amount of congestive action of the liver'and kid- neys, and of various parts of the mucous surfaces, as well as that of the fauces and first air-passages, where the speciahty of the diseased action is most marked, and where it sometimes expends its whole vio- lence. The local lesion peculiar to Diphtheria is most readily induced in surfaces ex- posed to the "free access of air, and though not restricted to them, it is there that it assumes its most characteristic devcli>p- ment; there is a state of blood in the ca- pillaries, a destruction of the red corpus- cles, and a formation of fibrin, as shown by the spontaneous coagulation of part of the exudation. These changes take place in close contact with the bloodvessels, and commence in the nmcous membrane be- neath the epithelium, transforming the cells of the sub-epithelial layer or of the epithelium itself, or altogether replacing PATHOLOGY. 73 them by the fibrinous exudation or false menibraue. Tlie false iiieiubrane cannot be detached without leaving a bleeding surface, which is rapidly covered with a new layer: it neither assists the cicatriza- tion of the surface on which it forms, nor ever becomes itself organized. Super- ficial ulceration results from the inter- stitial necrosis of some parts of the tissue invaded Ijy it, but there is no gangrene or niortifleation of its substance. Changes of decomposition rapidly take place in the deposit itself, with hijurious consequences, both to the lymphatic glands near, and to the system at large, from the absorption of effete matters; the site of these changes may occasion other ill etfects, by contami- nating the air of respiration on its passage to the lungs. The disappearance of the false membrane is effected partly by this superficial destruction, and partly by ab- sorption from its under surface and edges, and by return to healthy action in the vessels below. It is seldom entirely sepa- rated in this way ; a thin layer is often left, through which pink points gradually appear; soon only isolated spots of exuda- tion remain, which are finally removed by absorption, gradually effected as the pro- cess of reparation proceeds. This is some- times much retarded by the constitutional del)ility induced by the disease; and is sometimes interfered with by a retrograde process of ulceration. The extension of false membrane pro- ceeds, primarily, from the wide dissemi- nation of original centres of its deposit ; secondarily, from the invasion of contigu- ous surfaces; the morbid action may thus extend gradually in every direction, or advance with great rapidity on the parts irritated by the accompanying serous exu- dation. This may be one cause of im- plication of the air tubes,' and of that progress of the disease from above down- wards which Louis was induced to con- sider as almost the law of its extension. An illustration of the opposite mode of extension is sometimes seen when Diph- theria extends from the nose to the lachry- mal duet, and thence to the conjunctiva; or in its progress from the lower edge of the palatine arch to the uvula; the tur- gescence preceding the exudation causes the uvula to be recurved upon the side already afteeted; soon the false membrane has not only invested the whole uvula, but extends upwards behind tlie velum. Wherever false membrane is formed, some degree of inflammatory action is excited; this may either approach very nearly, ' Not only may noxious matters thus reach the trachea, but detached shreds of secretion from it maybe drawn into the smaller bron- chi, and mechanically block up, by a kind of embolism, some lobules of the lung, as pointed out by Sir W. Jenner. both m its products and symptoms, to the type of ordinary inflammation, or be en- tirely subordinated to the influence of the general disease, in which case this ])ecu- liarity is remarked— that the less marked the inflammatory condition, the more ex- tensive is the pseudo-membranous forma- tion. The evidence of the general disease next m nnportance is the existence of al- bumen in the urine. Dr. Copland, in his Dictionary, first mentions "albuminous urine" in his account of the patholoL'y of croup, which is framed to include the croupal complications of this disease. We are indebted to Dr. Wade, of Birming- ham, for demonstrating the dependence of this system upon Diphtheria. J3ouchut and Empis' soon after called attention to its importance, and Dr. Sanderson^ con- siderably advanced our knowledge of its relation to the general course of the dis- ease, by showing that the presence of a considerable amount of albumen did not interfere with the large excretion of urea, which accompanies the progress of the general disease. I possess notes of three cases confirmatory of his observation; in that of J. B. betbre referred to, thirty-one determinations of the quantities of urea and albumen were made from the sixth to the thirt3'-seventh day of the disease, by Mr. W. Dunnett Spanton, now of the North Staffordshire Infirmary, at that time (1861) residing with me. On the tenth day of the disease, when the albu- men was estimated at one-third, the quan- tity of urea was twice as much as is nor- mally excreted, the specific gravity being 1016; it was not until the thirty-seventh day that the urea fell to its normnl quan- titjr, and albumen was then for the first time absent; the specific gravity had fallen from 1015 to 1010. Subsequent observa- tions on the forty-seventh, fifty-fourth, and sixty-second days, agreed very closely with the last result. The albuminuria is not to be considered as solely dependent on an original change in the blood, but chiefly upon a morbid process in the kid- ney, which is one of the disseminated le- sions of structure occasioned by the gene- ral disease. Congestion of the Malpighian tufts is an early lesion, followed by further change in the tubercular structure of the kidney; a relation is found between these changes and the amount of albumen, but no constant relation between the albumen and the amount of blood change. In the case of Walker, where albunien did not occur till late in the disease, the blood change was extreme, as evinced by hemor- rhagic oozing from the palate, pctechire, and purpura; there was no hajmaturia a( ' L'Uniou Medicale, No. 132, 1858. 2 Brit, and For. Med.-Chirurg. Review, January 1860, p. 196. 74 DIPHTHERIA. any period, and recent disease of the kid- ney was found pud mortem. Tliat tlic function of tlie kidney may be seriously interfered witli, and even suppressed, is sliown by a case mentioned l>y I>r. Gull,' and by one reported at the rathological Society, February, 1805, by Dr. Green- how.^ Dr. Humphry "ives one instance of the occurrence of anasarca,^ but these cases are rare; albuminuria dues not per- sist after convalescence. Blood changes may be concerned in these symptoms ; that these changes are considerable during the progress of the disease is shown by the hemorrhagic tendency, by the occur- rence of fibrinous coagula in the heart and great vessels after death, by the remark- able pallor during the illness, and the ame- mia of convalescence, while the frequent affection of the spleen would point to a cause of this aglobulosis of the blood. Whether the lesions of innervation are owing to this cause, to a failure of nutri- tion in the ner\'e textures, or to a more special etiect of the diphtheritic poison, is doubtful; from the instability of the dis- ordered innervation, and the variety of conditions which it assumes, we may con- clude with ;M. Trousseau, "that the le- sion of the nervous centres is not of a very grave character." The impairment of vision is generally, as remarked by Mr. Dixon,'' due to loss of adjusting power, and there is inaction of the ciliary mus- cles; he has not found any important change in the retina. Some of the more serious and persistent muscular paralyses are owing to wasting or degeneration of the muscular tissue itself There are no good reasons for supposing that either special deterioration of the blood, or alte- ration of its quality, precedes the devel- opment of Diphtheria; a state of hyperi- nosis, if it were possible, is not that induced by many of the diseases to which Diphtheria readily succeeds; the altera- tions in the properties of the blood, ph3'si- cal, vital, or chemical, are rather the con- sequences than the cause of the disease; and it would seem that the first influence of the disease, as well as its later effects, are exerted upon the nervous system. jStORBiD Anatomy. — The special pro- duct of Diphtheria has affinities with some deposits formed in other diseases, ^vith the products of some forms of inflamma- tion, and with the bufty coat of the blood, which it often closely resembles in appear- ance and some of its physical properties. It has an alkaline reaction, swells, and ' Second Report of the Merlical Officer of the Privy Council, p. 304. " Transactions of the Pathological Society of London, vol. xvi. p. 47. ' British Medical Journal, .July, 1863, p. 4. * Holmes, System of Surgery, vol. ii. Dis- eases of the Eye, p. 766. becomes transparent in strong acetic acid, and is disintegrated or dissolved by caus- tic alkalies. It is unaltered by maceration in water, and j'ields no gelatine to it, as tested by tannin ; in this respect it differs from the bufty coat, and from coagulable tymph, and also in giving no evidence of albumen on being boiled ; it is stained brown by tincture of iodine, and assumes entirely the character of pure fibrin. It is possible to obtain solution of some speci- mens in the same way that Denis' dis- solved recent fibrin, and to find them un- mixed with other protein matters ; other specimens less fibrillated, or less recent, are not acted upon in this way. The tubes of exudation found in the bronchi will often lose their coherence on macera- tion in water only, and aftbrd evidence of albumen on boiling, which will not always be the case with the denser membrane from the trachea. Microscopically the superficial part of the exudation is made up of the epithe- lium of the membrane on which it occurs, entangled in the upper layers of a trans- parent homogeneous substance, through- out which are found some altered epi- thelium cells, granular corpuscles, and nucleolar bodies, in varying proportion ; they become less numerous in the lower layer of the exudation, in which blood- corpuscles and pus cells frequently occur. Fibrillation, similar to that of other fibrinous exudations, is sometimes ob- served on the under-surface of the diph- theritic false membrane, from the fauces. The falsi- membrane from the trachea is corpuscular throughout, as is also the pulpy and granular deposit which is some- times found in the fauces, and is more frequent in the larynx ; these deposits rapidly pass into granular degeneration. In the bronchial exudation the corpuscu- lar element difters little from that observed in the product of ordinary inttannnation there ; sometimes little flakes of fibrin are found attached to the bronchial mem- brane, but the only other evidence of its presence is the coherence of the bronchial casts. The laminated, or fibrillar, the pultaceous and the granular, or corpuscu- lar, are the leading forms of this exuda- tion ; they may present themselves in any combination under the same morbid influ- ence ; in the trachea they are always as- sociated, and either mav predominate; the fibrillated may be deposited in the mucous and submucous tissue of the larynx, 2 and the granular may be seen in ' Ardi. G«n. de Med. s. 3, torn. i. p. 171. Half a drachm of nitre to an ounce of water will effect this at a mean temperature. The solution is imperfect, viscid, coagulates in flakes at 1630 Fahr., and is strongly precipi- tated by acetic acid. 2 Dr. Bristowe, Trans. Path. Soc. Lond. vol. X. p. 323. MORBID ANATOMY. 75 the fauces together with the laminated, the less coherent deposit, misnoniinated croupous, being as truly diphtheritic as the more tough, leather-like formation. The one point common to botli is tlieir intimate relation to tlie structure of the membrane on which the\' are formed. In the case of Bowra I saw deposit in the contiguous edges of tlie true and false vo- cal cords, the sacculus laryngis Iwing free, and the commencing granular deposit in the trachea firmly imbedded in the mu- cous membrane. Dr. Wilson Fox has demonstrated, in all stages of tracheal exudations, lesions of the membrane some- times exposing the fibrous tissue beneath, botli in adults and in children. M. Hache observes' the resistance to the separation of tlie false membrane from the trachea at a certain stage, and calls attention^ to the sanguineous points found imbedded in its under-surface when removed. The condition of the tissue in which the morbid action is exerted, though of less importance than the general course of the disease, aftbrds better means of character- izing it than the exudation to which it gives rise : the unsatisfactory nature of a distinction founded upon the two forms of exudation in this disease is thus ad- mitted by the most advanced pathologists of Germany :' — "The difference which I formerly established between the croupous and diphtheritic forms, is often lost in particular cases, so that the true croup of the larynx and trachea invades the tissue of the mucous membrane, ay, very often coexists with Diphtherite at the back of the pharynx and of the fauces ; and not till the deeper bronchi are reached, or the pulmonary cells, does it become a free exudation. This is found not only in the epidemic croup of children, but also in Diphtherite occurring in typhoid condi- tions, and in hospital gangrene ; or simul- taneously with diphtheritic necrosis of the vaginal and intestinal mucous surfaces." This interstitial necrosis, or ulceration of the surfaces in relation with the exuda- tion, is the anatomical character on which the distinction between the diseases here mentioned and Croup, in our acceptation of the term, must be based. The diphtheritic deposit may occur in isolated patches, or extend continuously from the nares to the bronchi ; it may be moulded on to any anfractuosity of the nasal passages ; it may line the whole pharyngeal cavity, adhere to both surfaces of the epiglottis, cover the interior of the larynx, form a cylindrical cast of the trachea, and may thus be removable from even the smaller bronchi. More rarely it ' Bartliez and Rilliet, tome i. p. 318. 2 Ibid. p. 319. ' Virchow, Path, und Therapie, vol. i. p. 292. is found to extend in this manner through- out the a'sophagus ; in one of the two cases reported by Brotonneau,' it was strongly adherent to the upper part of the tuljc. In two of seveuty-four cases tabulated in the British Medical Journal,'' the oesopha- gus was partially affected, one with, one without extension to the air-passages. In a case reported by Dr. Morley Harrison, of Manchester,^ the false membrane ex- tended forwards to the mouth, and a patch existed upon the frainum lingufe. Dr. Bristowe gives an instance of the upper part of tjie (esophagus being cov- ered. Virchow alludes to one case ; he has seen the occurrence of false membrane in the gall-bladder.'' The tonsils are frequently the seat of this formation ; it is often detached early, but may accumulate to a surprising thick- ness, the outer surface retaining for a time the exact appearance of the enlarged totisils, and marked with the opening of its follicles. I have met with one speci- men, which it was difficult to believe was not the organ itself under examination ; every part of it was soluble in Denis' solution, and no trace of organized tissue occurred throughout its substance ; this exudation has attained to the tliickness of two-thirds of an inch.* The decomposi- tion of such concrete deposits, their varied color from admixture of altered blood, and their detachment in offensive shreds, has often given a false idea of the gangrene of the tissue beneath, which really remains almost intact. Bretonneau called atten- tion to the importance of this fact, but while he correctly described the '' ecchy- moses of no great extent, as well as the slight erosion of the surfaces on which the disease had existed longest,"^ insisted too much upon the integrity of the mucous membrane being always preserved ; but though much may be repaired before death, it is rare not to find some evidence of lesion of the mucous membrane. Some- times the submucous layer is bare and granular, without defined ulceration ;' at other times a defined ulcer exists, exposing the muscular fibres.^ M. Louis noticed erosion of cartilage at the posterior nares. The uvula and part of the soft palate have ' These cases, and two otliers occurring in cliildren with implications of the larynx, are mentioned by Bartliez and Rilliet, tome i. p. 322. 2 Brit. Med. .lourn. 1859, pp. 305-6. 3 Ibid. 1863, vol. i. p. 306. A complete cast of the tube was ejected. < Op. cit. vol. i. p. 2112. 5 Memoirs on DiiAtlieria. New Sydenham Society, 1859, p. 98. 6 Traite de la Diphtherite, p. 33. 7 Dr. J. R. Hughes, Brit. Med. Journal, 1859, p. 80. 8 Bartliez et Eilliet, tome i. pp. 259 and 287. T6 DIPHTHERIA. been lost by ulceration.' Dr. Sanderson* mentions the division of the left half of the soft palate by a penetrating ulcer. !Mr. Simon' describes a circular ulcer of the pharynx and other signs of ulceration. Dr. Ashley* observed phagedsena com- mence at one tonsil and extend to the carotid. Ulcerations on either surface of the epiglottis, and on the mucous mem- brane of the larynx and trachea, are fre- quently met with. The submucous tissue may be infiltrated with blood, with serum, or with iullaumia tory products. Dr. New- man^ reports the formation of an abscess in the palate soon after the disappearance of the superficial exudation. lu the case described by Sir T. Watson,^ pus was found in one tonsil, and this has since been not infrequently observed. Mr. Pound,' of Odiham, reports a case of ab- scess in the pharynx, and Greenhow' gi\'es one of post-pharyngeal abscess. Suppuration rarely, if ever, occurs in the cervical glands ; they are large and red, or paler, and brittle, and sometimes present a spleniform disorganization ; the swelling around them is from infiltration of serum in the cellular tissue. Dr. Bristowe' re- ports a remarkable eflusion of blood among all the tissues of the neck. Various forms of petechia^, purpura and superficial es- chars are found upon the skin, and spots of purpura, petechias, and ecchymotic staining are frequent in other parts of the body, as in the muscular tissue and under the serous membranes, as on the lung, upon or within the heart and the perito- neum. I liave met with no instance of inllammation of the serous membrane. Fattjr degeneration of the muscular tissue of the heart occurred in the case reported by Dr. Bristowe. Fibrinous coagula are very frequently met with in the cavities of the heart, ex- tending into the great vessels. This oc- currence is not limited to cases where there has been obstruction of the air-pas- sages, though they are at least as frequent in the right cavities as in the left. Dr. B.arry,'" of Tunbridge Wells, reports three cases, all in the right side of the heart ; the coagulum existed in the right auricle only in one case, and in another extended ' Greenhow, op. cit. p. 201. 2 Loc. cit. p. 191. ' Trans. Path. Soc. Lond. vol. x. p. 317. * Brit. Med. Journ. 1859, p. 490, case 60. 5 Ibid. 1863, vol. i. p. 215. ^ Lectures on the Practice of Pliysic, vol. i. p. 865. 4th edit. ' Brit. Med. Journal, 1858, p. 750. Report of Reading Path. Soc. 8 Op. cit. p. 237. ^ Trans. Path. Soc. of London, vol. x. p. 328. 13 British Medical Journal, 1858, p. 623. into the pulmonary artery. Dr. Kollo' gives the case of a soldier where, with the characteristic exudation of Diphthe- ria, fibrous polypi were found in the right ventricle. The lungs are frequently con- gested, and the seat of lobular hepatiza- tion in various stages, often sufficiently extensive to be the cause of death, even where no exudation has occurred in the air-passages. Pulmonary apoplexy is sometimes found. Where the air-pas- sages are the seat of the exudation, loljar and lobular pneumonia, the latter often secondary to embolism of the smaller bronchi, with collapse of lung tissue, and acute vesicular emphysema, have gener- ally been induced. The vessels of the brain or of the pia mater have presented fine injection in some cases ; in others there has been fulness of the sinuses, and even transudation of blood ; and Dr. Gull reports^ suppurative inflanunation of the membranes of the brain and cord, with soft, purulent lymph in the sub-arachnoid space. Dr. Humphry' has met with a small spot of suppuration on the under- surface of the left cerebral hemisphere, with softening of the adjacent brain sub- stance, attributed to Diphtheria. The liver is frequently found full, sometimes greatly congested, but is seldom the seat of disease. The stomach often presents serious • changes, its mucous membrane being softened, unequally thickened, and red from small patches of deep-colored congestion, or from extravasated blood ; sometimes these changes are found in connection with isolated patches of opaque deposit at its cardiac end, and the ceso- phagus presents abrasions of its mucous membrane when it has been the seat of deposit. Vascular injection and minute ecchymoses have been found in the small intestines, the follicular orifices are often conspicuous, more rarely Peyer's patches in the lower part of the ileum are very distinct and prominent ; sometimes de- posit and ulceration occur in the large intestines, hardly distinguishable from that of dysentery. Tlie spleen is gener- ally found full and soft, more frequently paler in color than redder, and often pre- senting a cloudy or opaque appearance on section. The kidneys may often appear healthy to the naked eye, but are very rarely found so under microscopic investigation ; they generally present well-marked, and sometimes extreme evidence of special change : this is chiefly in the intra-tubu- lar structure, and though congestion of the Malpighian tufts is often very conspi- ' Essay on Cynanche Trachealis, by John Clieyne, M.D. 4to. Edin. 1801. P. 68. 2 Loc. cit. p. 299. ' Brit. Med. Journal, July, 1863, p. 4. PROGNOSIS. 77 CVTOUS, the general aspect, sometimes mot- tled from ail irregular blending of anjemia and congestion, is more often of a pale than of a deep color ; they have not been found in the extreme state of disorgani- zation sometimes seen after scarlet fever. The tubules appear opaque, from the epithelial cells being numerous, easily- detached, and filled with an unusual amount of finely-granular material, in which oily globules are sometimes abund- ant. Some tubes are devoid of epithe- lium, and present transparent, fibrinous casts, or these are found separated from the tubes to which they correspond in diameter ; occasionally blood-corpuscles are found in the tubules ; more frequently they are filled with masses of epithelial cell's and fibrinous exudation. These changes are as noticeable in the medul- lary as in the cortical structure ; granular exudation is also found between the Mal- pighian capillaries and their capsule. The supra-renal capsules have been found intensely vascular. Prognosis.— No case of Diphtheria is to be regarded without anxiety ; every danger incident to the disease may re- sult, though the early symptoms are but slightly marked. The successive appear- ance of fresh patches of deposit, of albu- minuria, or of other signs of the disease, excites alarm, lest its next local manifes- tation should be in the larynx : the simul- taneous occurrence of many of these signs, and the increase of any of them, as of the enlargement of the lymphatic glands, and of the amount of exudation, indicate an intensity of the general disease which the young or enfeebled will hardly withstand' and which, with implication of the larynx, will be rapidly fatal. The least laryngeal quality of the voice or cough, and espe- cially of the respiration, is a sign of the greatest danger ; it may, in the strongest person, soon end in fatal obstruction of the glottis from the occurrence of exuda- tion there, or it may be the first indica- tion of the equally fatal and more insidious extension of it to the bronchi. Much exudation in the nasal passage is unfavor- able. If both nares are occluded, respi- ration must be carried on by the mouth with great discomfort ; this may be a cause of death in young children, as they are thus unable to suck. The occur- rence of hemorrhages is a bad and dan- gerous symptom ; so is repeated vomiting and purging at the commencement of the attack. These symptoms occurring some- what later, bring on death by exhaustion, and indicate either serious alteration in the blood, or that the stomach has be- come the seat of the disease. A very rapid pulse, except at the commencement, is indicative of danger ; so also if tire pulse fall below the normal frequency. Albuminuria, if unattended by any rise in temperature, is in itself not serious as long as the urine is in normal quantity, without blood corpuscles or casts of tubes, and while the specific gravity continues to be high. Any increase of the tempe- rature of the body after the first five days, or a persistence of high temperature after the first ten days, is unfavorable ; a sud- den rise may indicate danger from some intercurrent disease. There is also the danger of relapses from the slightest debili- tating causes, either in the earliest or at the latest periods of the illness. The liability to laryngeal obstruction is great- est towar'"''s the end of the first week ; it begins with the commencement of the disease, and probably continues tlirough- out ; this complication has happened as late as the fourteenth day,' and possibly later. 2 These dangers are especially treacherous, as they may occur in cases where there has been but little exudation on the larynx, and as a jaeriod of compara- tive convalescence may intervene between either the first symptoms and the laryn- geal complication, or between those of the more advanced disease and its asthenic accidents. The first impression of the general disease may be so profound as to make recovery impossible ; on the other hand, cases commencing with marked constitutional reaction, and with symp- toms generally unfavorable, such as vom- iting, epistaxis, or nocturnal delirium, may recover without experiencing the more serious consequences of the disease. Certain epidemics and certain periods of them are marked by a great fatality, and instances have occurred in which all or nearly all of those seized have died. Age and family constitution have the greatest influence ; where one member of a family has suffered severely from this disease, there is the more reason to dread its effects upon the younger members of the same family. The proportion of deaths to seizures in 1,3"21 cases reported in the Britinh Medical Journal for 1858-59, is one in seven ; among the severer cases, and at the height of any local epidemic outbreak, it was as high as one in three ; in other cases it was less than one in ten. Of the seventy-four cases collected by the Tiriiish Iledical Journal,'^ twenty-six died, — four- ' Etufle de la Diphtherite, par Of. S. Empis' Arch. Gen. de Med., 1850, s. 4, tome xxii. p. 298. 2 Cases of Diphtheria, by G. M. Humphry, M.D. Case 7. Brit. Med. Journal, July 4, 1863. Dr. Ballard tabulates one case, loc. cit. p. 55. 3 Brit. Med. .Journal, 1859, p. 498. Of eighty fatal cases occurring in Islington in 1858-59, Dr. Ballard found that in fifty-eight 78 DIPHTHEEIA. teen from asthenia, eight from implication of the larynx, three from syncope, and cue from suhsequent bronchitis. These cases were mostly severe, and seldom under treatment at their commencement. One of the most important conditions of a favorable result is the early recognition and treatment of the disease. Theeapetttics. — In Diphtheria both local and general means of treatment are required ; the cure of particular casi:s may sometimes be attributable to the one, sometimes to the other, but in no case can either be safely disregarded. The general therapeutical indications are of primary importance throughout ; they consist neither in attempts to nullify a poison by specifics, nor to expel it by ehmination, but in -withstanding the encroachment of the disease, and in sustaining the vital powers. Complete rest and purity of air are es- sential. Alcoholic stimulants are required throughout ;' they are often as service- able earljr in the disease as in that part of its course when they become indispensa- ble. A rapid pulse indicates their em- ployment, and heat of skin is no counter- indication. The limit to their adminis- tration should be calculated according to the age of the patient and the amount of bland liquid representing water that can be taken at the same time. In certain cases one or two full doses of quinine may be given, often with good effect when there is either vertigo, headache, or vomiting ; soon afterwards beef-tea, eggs, or even more solid food, can be taken, as well as the brandy or wine ; milk, in any form, is always suitable. The night must not pass without either nourishment or stimulant being given ; wakefulness or nocturnal delirium is often thus obviated ; some- times a dose of morphia or opium has to be combined with the stimulant, after the second or third night, if restlessness then persist. The condition of the fauces must be al- leviated by the free use of ice sucked or swallowed, and by any of the soothing means hereafter mentioned internally, and by moderately warm applications ex- ternally. [One of the most comfortablo and often really serviceable applications is ice, taken into the mouth in small pieces and swallowed slowly. .Some practitioners assert this to have a more beneficial effect than any other local remedy. — H.] When the patient first comes under observation, a patch of exudation may be apparent, such as to require energetic topical mea- sures. For this purpose a solution of nitrate of silver should be applied so as thoroughly to come into contact both with the patch and the turgid mucous mem- brane surrounding it. The strength of tlie solution should not exceed the propor- tion of one part of nitrate of silver to three of distilled water ; the superficial whiteness leit by it will clear off in twenty- four hours, and is easily distinguishable from the points of exudation. A mixture of hydrochloric acid and honey in equal proportions, or with one or two parts of water, is as effectual in checking the pro- gress of the exudation, but leaves a more persistent white mark. These applica- tions, when seen to be eflflcient, need not be repeated ; care is to be taken that no excess of them reach beyond where they are required. The strong acid and solid nitrate of silver are both objectionable.' Where there is much redness and pain a weaker solution of nitrate of silver, one part to eight or twelve of water, pencilled over the whole surface, tends to prevent further exudation, and affords relief to the local discomfort. Hydrochloric acid, diluted with five parts of water, may be ap- plied in the same way with the same effect. As soon as nourishment, however light, can be retained by the stomach, five to ten grains of the perchloride of iron, the equi- valent of twenty or forty minims of the tincture, should be given, with not less than half an ounce of water and half a drachm of glycerin ; this should be re- peated every three or four hours, or still more frequently, so that as much as a drachm of the iron, or half an ounce of the tincture, be taken in the course of twenty-four hours. This quantity may be reached even in children, during severe attacks. It should be commenced on the first day of the illness, or as soon as the deaths twenty-seven were from laryngeal affection, and twenty-three from exhaustion ; thus distributed as to age and period of illness : — tinder 5 Years. tJnder 10 Years. 10 Years and upwards. 3 5 1st Week. 2d Week. 3d Week. -nil Week. Laryngeal affection . . Exhaustion .... 17 13 7 5 18 8 8 8 1 3 "4 [Not, however, in every case. — H.] ' Extreme dysphagia has at once subsided on the use of solid nitr.nte to a foul or irritable 1 ulcer consequent upon Diphtheria. THERAPEUTICS. 79 patient comes under notice, and continued till the tongue becomes red and the throat improves ; when deposit has already taken place, the good eftect of the remedy will be shown, not by any alteration in the dimensions of the patch, but by a dimi- nution in the accompany hig secretion, and by an improvement of the general symp- toms ; it is not to be discontinued for some days, and may require energetic repetition if improvement is slow in ap- pearing. Dr. Druitt ' reports a case where great benefit followed upon the quantity of the tincture of the muriate of iron, ad- ministered under the direction of one of the physicians of the Middlesex Hospital, amounting to one ounce and a half in the twelve hours. Mr. Hamilton Bell,'' of Edinburgh, first proved the utility of iron in this form and quantity in erysipelas, and his brother. Dr. C. Bell, advocated its employment in analogous diseases ; hence its application in Diphtheria. Dr. Godfrey,^ of Enfield, used it in this way, and its use was further recommended by Dr. Heslop, of Birmingham ; it was em- ployed with advantage in the Boulogne epidemic, and M. Aubrun^ gives the re- sult of three years' favorable experience. Tiie solutions of the pcrnitrate of iron, or of the acetate, answer equally well when given in proportionate doses, the latter being stronger, tlie former of less strength, than the tincture of the perchloride. A local as well as a general influence is exerted by these agents ; they have a constrhiging eflect on the vessels, and their action on the decomposing exuda- tion is antiseptic ; their general effect is as much owing to a topical action on the whole gastro-intestinal canal, as to ab- sorption, for when the prescribed quantity of the persalt of iron is reduced by soda in the presence of citric acid, and so admin- istered in a soluble form little liable to decomposition, and readijy available for absorption, no favorable effect is produced ; indeed, none of the protosalts of iron are equally eflflcacious at the outset of the dis- ease. [Chlorate of potassium (mentioned further on) is regarded by many physicians in America as fihe most valuable of medi- cines in Diphtheria. It may be used early and freely ; with adults, twenty grains every three hours ; with children five years old, five grains, every two or three hours, will not be excessive. — H.] The local action upon the surfaces af- fected is certainty important ; and when the nasal passages are implicated, syring- ing them with perchloride in a solution ilightly weaker than that prescribed for a ' Brit. Med. Journ. 1861, vol. i. p. 208. ' Edin. Monthly Journal, June lb51. 3 Lancet, October 17, 1857. * Gazette Med. de Paris, Deeember 8, 1860, f. 764. draught, is essential ; half a drachm each of the tincture of the perchloride of iron and glycerine with six or seven drachms of water, may be injected into the nares by an ordinary glass syringe, the point of which is shielded by' a piece of india- rubber tubing, or into the upper part of the pharynx by means of the laryngeal syringe directed upwards. These parts may be gently and efficiently irrigated by placing a vessel of any lit hquid at an ele- vation, and inserting an india-rubber tulse from it into either nostril. When the patch is already formed, and the secretion in the fauces considerable, it is well to apply a stronger solution of the perchlo- ride, not exceeding the strength of the tincture, by means of a full-sized camel's- hair brush, both to the patch and to the adjacent surfirces. A patch of consider- able thickness, and intimately adherent to the membrane, may be touched with a preparation twice the strength of the tinc- ture, made by mixing equal parts of the liquor ferri perchloridi and of glycerine ; this application is strongly styptic, and should be confined to the surface of the exudation, which it readily penetrates : and exerts its influence upon the vessels beneath. Where the use of the persalts of iron is connnenced earlj', and persisted in, the necessity for local application to the throat is often obviated, and it is better to encounter a little difficulty in the ad- ministration of the medicine, which may be given in any degree of dilution, than to be obliged to resort to the always dis- agreeable, though often indispensable, performance of topical medication. The medicine is better given at the time of taking nourishment, the pain of s-\vallow- ing diminishes vmder its use, and its ap- plication in any vmy to the whole pharynx affords relief Difficulty of deglutition is often a seri- ous aggravation of the illness. Much benefit is derived from the application of the perchloride of iron diluted with water to the strength of the tincture, but with a further addition of glycerine, to the pha- rynx by means of a camel's-hair brush two or three times in the first twentj'-four hours. Pure glycerine' applied in this way is very soothing, and the frequent use of more simple means conduces to re- lief. A lotion of acetate of lead, gr. ij ad gj, relieves. A weak solution of tannin, with a little chlorinated soda, is useful. Lime water as a wash, or gargle if the etibrt be not too painful, alleviates ; so does the injection of cold water into the pharynx. The most grateful, and in all cases one of the most useful appliances, is ice in small pieces, dissolvinti; in the mouth. Weak solutions of borax, or of ' Dr. Maj^er, American Journal of Med. Sciences, April 1858. 80 DIPHTHERIA. alum, with honey or glycerine, or a strong solution of chlorate of i^otash, are useful where there is much tenacious secretion ; the latter salt in coarse powder, or small crystals of it, may be taken into the mouth from time to time with benefit. Auj' of these may be used either cold or tepid as may be most grateful to the patient, and when there is fetor, or the glands are much swollen, Condy's fluid (permanga- nate of potash) , largely dilutccl, or chlori- nated soda, one part of the strono; solution to twelve or fifteen parts of water, is to be used so as to wash away any detached exudation, and this by means of a syringe if not otherwise easily manageable. The strong solution of chlorinated soda may be directly applied to any foul surface not yet detached, or to any foul ulceration when there is induration of tlie external glands. The Pharmacoposial glycerine of carbolic acid is a convenient local remedy when decomposing matters are tainting the breath. The similar glycerine of gallic acid checks hemorrhage from parts whence the slough is separating. The glycerine of tannin is most useful in the earlier stages of the disease, and is a necessary application to the fauces where bark with a mineral acid in the place of iron and quinine is the general medication adopted. Semi-detached shreds of de- composing matter are to be carefully re- moved ; such matters cannot be allowed to remain with safety where they are ; they must he reduced to the smallest amount possible, and antiseptics employed until they disappear. When exudation ceases, tlie necessity for local application has passed ; some portions of deposit will be slow in clearing away, and may remain without interference ; abrasions or ulcera- tions of the mucous membrane heal most quickly when left alone. A tender sur- face is never to be exposed by the forcible removal of any adherent exudation.' All the remedies of special utility in Diphtheria are antiseptic : the stronger forms above indicated are limited in their 1 iEtii Amid, tetrab. 2, serm. 8, cap. 46 ; "Nam inscii ad quos in rebus dubiis prEeoi- pii6 liomines confugiunt, vehementiug illi- niunt, simulque inflammatum locum compri- raunt, simulque crustam detraliunt ; quod minime facere convenit, priusquam elevatam et vix innitentem crustam conspiciamus ; quod si enim adlisrentem adhuc crustam avellere aggrediamur ulcerationea magis in profundum procedunt et inflammationes con- sequuntur, augentur dolores, et iu ulcera serpentia proficiunt : itaque sicca remedia in- sufflare oportet, liquid a vero cum pinnula illinito, ita ut quantum licuerit, pinnulam penitissime immittamus." "Ex quo prse- cepto docent medici, quod ciim pueri nequeunt gai'garismatis uti, injiciantur cum siring^, medicamenta liquida." (Heredia op. Med. tom. iii. sec. 3, cap. xii.) application to parts that can be brought within the range of sight or touch. This range may in some states of the disease be extended by the use of the laryngo- scope not only in the direction of the larynx, but also towards tire posterior nares. Many of these agents can be most advan- tageously used in'all stages of the treat- ment by atomizing their dilute aqueous solutions in the manner first suggested by M. de Sales Giron. Any of the spray- producers now in use will effect this, and supply a ready means of diffusing the rem- edies over every part of the mucous sur- faces obnoxious to the disease. Dr. De- war, of Kirkcaldy, has shown that the strong sulphurous acid of the Pharmaco- pffiia may be used at short intervals with benefit, and has devised a portable instru- ment with a vulcanite tube for the pur- pose. In one case where this was used without resort to the iron treatment in a child, no laryngeal extension of the dis- ease occurred. A mixture of sulphurous acid and honey for frequent deglutition was useful in clearing the posterior nares; the fauces required an occasional applica- tion of glycerine of tannin ; on the four- teenth day acute kidney complication began, and terminated fatally on the eighteenth day. When the tincture of perchloride of iron is given (generally combined with quinine), very little local treatment other than the spray is resorted to. Besides the weak Condy's fluid, a still weaker solution of carbolic acid, a teaspoonful to a pint of water, may be used in this way ; a few spoonfuls of the latter solution is advantageously given oc- casionally as a drink. Both these liquids should be kept in the sick-room in a stronger form, both for diflusion into the air of the room by means of the vaporizer, and ready for disinfecting any secretions or soiled clothes. There are other remedies that some- times are necessarj' in checking the spread of Diphtherite, or in modifying its charac- ter. The salts of copper, as used by Are- tffius, are very effective, but their use is not free from danger. Alum in powder (the poudre crmqxde of Pommier) is as ef- fective, and both safe and simple in use ; it maj' either be used alone, or mixed with one-third of its bulk of finely-pow- dered nitrate or chlorate of potash, or with a less proportion of sugar or gum ; it may be applied to the throat by insuffla- tion, as practised by Bretonneau,' or by making it into a paste with a drop of wa- ter, and carrying it to the part by means of a rod or spatula, or on the handle of a tablespoon. When required in the upper or lower part of the pharynx, or indeed ' Archiv. Gen. de MSd. tome xiii. p. 5, and tome svii. p. 508. THERAPEUTICS. 81 on any part from the gums to the glottis, that best and safest of all instrunieuts, the end of the finger, may be used for this purpose ; in the same way, with the pro- tection of a little cotton-wool wrapped around it, the other local remedies can be carried to any spot determined upon, with- out at the moment requiring the aid of sight. Calomel has an undoubtedly use- ful topical effect, as is seen in its applica- tion to cutaneous Diphtherite. Any sore on the skin should receive careful atten- tion, as, however trivial at first, it may seriously compromise the prospect of re- covery, either by spreading or by deepen- ing so as to lay bare the subjacent struc- tures. In addition to the requisite escha- rotics, cotton-wool should be used as a dressing ; greasy applications are inju- rious. The care given to the local treatment will fail of success, the diseased action checked at one part will reappear, or again extend rapidly, if the general con- dition necessary for a safe conduct through the illness be disregarded. Chil- dren, when improving, must continue in bed ; it is the only place where they get rest of limb. There must also be pre- cautions against fatigue from over-amuse- ment or excitement. The period during which rest is to be enjoined is not merely while exudation remains, but while any symptom of the disease continues, such as slightly elevated temperature, excess in the excretion of urea or urates, or albu- men in the urine ; care is still more neces- sary in providing against any undue ex- penditure of strength during some of the after effects of the disease. As long as solid food cannot be taken, it is to be noted with the greatest exacti- tude that the quantity of the liquid nour- ishment and of stinmlant administered in the twenty-four hours is equal to the esti- mated requirement of the patient ; the less the quantity of nourishment, the greater must be the dependence upon the stimulant. The youngest children may require a teaspoonful of brandy every two hours ; a child of three years old two tea- spoonfuls. This may be given diluted in any way and in very small quantities fre- quently repeated. Older children take it best mixed with iced water or soda-water. Champagne is often a good substitute ; port wine requires dilution, except for adults, who also find good claret, red hock, or some of the stronger Hungarian wines, suitable. The quantity of stimu- lant ordered must be considered in rela- tion not only to the immediate necessity that may exist for its employment, but also to the probable course of the disease and the strength of the patient ; a mode- rate quantity, repeated at regular inter- vals, is of most service in maintaining the Strength of the patient where all the VOL. I.— 6 symptoms are well marked ana likely to go through their full stages ; at certain crises of the disease, or where some symp- toms only have attained great promi- nence, the benefit that results from a bold resort to stimulants is surprising, and the efiect is the more marked, if their use had up to that time been neglected. Where the exudation is checked and is first sepa- rating, 1 have known the determined deglutition of four pints of beef tea and nearly two pints of port wine, in little more than twelve hours, by a temperate young man, teacher in a school, put a stop to further illness. Mr. M 'Donald,' of Bristol, relates a case where bottled bitter-beer being the stimulant ordered, nearly eight pints were taken (twelve pint bottles were emptied) in the course of one night, with a like good effect. At a further period of the disease, when the separation of the deposit is completed, extra stinuilants are required to combat the restlessness and depression then some- times extreme. Sleep, at all times neces- sary, is at this latter period of the illness to be carefully conciUated. Opiates are well borne, and are now more likely to procure sleep than when the first symp- toms in the throat are most troublesome ; their use for several nights, when the diminished exudation reveals injury of the mucous membrane, may do much to prevent the exhaustion at this time so dangerous, and upon which stimulants, beyond what is necessary for support, seem to have but little power. Quinine and bark are particularly serviceable ; the former may be combined with iron if its use be still indicated, the latter with the mineral acids. Quinine can be given to children in powder, and in solution is often advantageously added to the nu- trient enemata that must so frequently supplement the inadequate amount of support otherwise received. Brandy is occasionally to be administered in this wa3', care being taken not to set up an irritability of bowel that might interfere with the continued employment of a means of sustaining life that so often be- comes a necessity in the treatment of this disease. Aperients are seldom required at the commencement of the illness, and during the earlier stages their effects are injuri- ous ; for then the waste of tissue is most active, and the impediment to the recep- tion of nutrition the greatest. It has been a matter of frequent remark that exuda- tion in the throat, already stationary, or even diminishing, has at once extended after the moderate action of aperient medi- cine. The only indication for their em- ployment would be occasioned by inter- current disease, which would give rise to > Lancet, 1858, vol. ii. p. 539. 82 DIPHTHERIA. a greater elevation of temperature than usually obtains in uncomplicated Diphtlie- ria; otherwise several days may be allowed to pass without action of the bowels.' The appearance of albuminuria does not call for their administration. Mr. Spanton found an increased excretion of urea fol- low the action of a purgative. Diarrhoea frequently demands attention ; opiate in- jections, or small doses of opium with bis- muth, will generally suffice; alum in bo- luses is mentioned by Brctonneau; small doses of sulphate of copper with opium are best in severe cases. The constijia- tion of the latter stages of tlie illness re- quires stimulating enemata, friction to the abdomen, and galvanism. Salines are contra-indicated. I have seen no good result from tlie administra- tion of the alkaline remedies recommended by some French autliors in the earlier stages, nor from the use of the iodides or bromides in the later. Ammonia, in con- tinued doses, is injurious;^ as a stimulant it is useless. The diaphoretic action of salines is not required, and their diuretic action has an unfavorable influence upon the specific irritation of the kidney. Diluents and acid drinks should be con- tinued while albuminuria persists ; and though stimulants are then not always to be withdrawn, they are not to be inju- diciously augmented. The hot air bath applied to the body only, without removal from bed, or warm packing to the loins, is serviceable in this complication; the ap- pearance of blood-corpuscles or of tube casts in the urine indicates the adminis- tration of iron with the mineral acids, and the addition of cod-liver oil. Mercurials, if continued till their gene- ral effect upon the system is produced, are productive of much mischief; Breton- neau's second memoir gives evidence of this. The carefully regulated action of them may be usefully opposed, when de- sirable, to some of the inflammatory com- plications of the disease. Salivation rather favors than checks the rapid extension of the special exudation.' Bleeding is specially to be avoided; the worse effects of the disease seem to have been more extensively developed in many of the cases where this was practised.'' Antimony also is prejudicial. When the progress of the disease under ' Niines gives a caution against aperients at the latter stages of the illness, lest the death of the patient should be attributed to their use. Heredia, torn. iii. o. 3, cap. xi. 2 See also Huxham's " Dissertation on the Malignant Ulcerous Sore Throat." Lend. 8vo. 1759, p. 53 et seq. s See Lancet, 1838-39, vol. i. pp. 726, 728, for two cases illustrative of this. * Memoirs on Diphtheria, pp. 50, 97. Arch. G6n. de Med., tome xvii. pp. 494-7. the influence of appropriate general treat- ment seems most encouraging, death may suddenly threaten from impeded access of air to the lungs ; relief then depends upon energetic local treatment, the same gene- ral means not being neglected. Symp- toms that, did we not know their cause, would suggest the free employment of bleeding or antimony for their relief, ma}', if their cause is patetit upon inspection of the throat, be cfflcientlj' obviated by a styptic application to the extending exu- dation, or to the orifice of the glottis itself, and their increase or return prevented by the free use of iron and wine. Nor are these to be entirely suspended if the mis- chief be altogether within the glottis. Where this is the case the symptoms are more gradual in their appearance, and may sometimes be alleviated by giving chlorate of potash, four grains,' to a des- sertspoonful of water, by the insufflation of alum, or by the application of it to either surface of the epiglottis, or of gly- cerine to the edge of the glottis: the diffu- sion into the throat of a strong solution of chlorate of potash, or of sulphurous acid, by means of a vaporizer, may also be use- ful. It will depend upon the type of the general disease whether one or more doses of calomel are to be administered ; the laryngeal symptoms once established, the resort to an aperient may be advisable, and calomel is the best that can be em- ployed; where calomel will bear repetition emetics are also admissible. Senega may be used with this object. If ipecacuanha is chosen, ten grain's of sulphate of zinc should be added. When secretion is abundant, alum, as elsewhere directed," or sulphate of copper (five grains to the ounce of water), given in divided doses (a teaspoonful only for young children), is the best and most effectual. Emesis is not to be frequently repeated, and it is only when readily induced that it can be other- wise than prejudicial. Keal and obvious relief, with increasing fulness of the chest expansion, is not only the encouragement forgiving these means a trial, but the sole warrant for trusting to them for the relief of the temporary exacerbations. They must not be trusted to implicitly, as at any moment it may be evident that ths obstruction is beyond their influence. Tracheotomy should be performed when- ever the increasing recession of the softer parts of the thoracic parietes shows that the cause of obstruction to the entrance of air is increasing. In the greater num- ber of cases, if the local medication of the glottis and larynx do not suffice to obviate the danger, tracheotomy, performed early, ' [Twenty grains, in a tablespoonfnl of water, every three hours, will he better.— H.] " Vide Treatment of Secondary Croup, Vol. SCARLET FEVER: DEFINITION. 83 is much more likely to be successful than after the use of remedies that in any way impair the vital powers. A delay that admits of secretions accumulating in the bronchi is dangerous, and extension of the disease to the lung is the one insurmount- able obstacle to success. Where the ef- fects of the obstruction are more suddenly induced, tracheotomy, performed at the very last moment of apparent life, may save it. No degree of severity in the gen- eral disease should interfere with this means of averting threatened death from asphyxia, unless the presence of some other complication, necessarily fatal, can be demonstrated. I recently saw a case in consultation with Mr. Adams, in which, had it occurred at the commencement of the epidemic instead of towards the end, I should have decided against tracheoto- my, concluding that it must end fatally; although unconsciousness had set in be- fore commencing to operate, the child, six years old, recovered. At some periods of an epidemic, success less frequently at- tends this operation than at others ; at the Hopital des Enfants Malades,' in 1851, tliere were twelve recoveries in thirty-one operations; in 185.S only seven recovered in sixty-one cases; in 1856 tra- cheotomy was performed there fifty-four times, with success in fifteen cases.'' Of 466 operations at this hospital in eight years there were 126 recoveries; these were generally operated upon as soon as the laryngeal symptoms were decided.' The result of M. Trousseau's 200 opera- tions gives a similar success of more than one in four, while in the cases operated on by him in private practice one-half have recovered;'' of nine such cases in 1854 seven were cured.' Of forty-two cases reported by Professor Rosen of Tubingen,'^ nine- teen recovered. In six of the cases as- phyxia had advanced too far before the operation; and of the subsequent deaths, one took place from pneumonia, fifteen days after, and one from albuminuria in the third week.* Dr. Buchanan writes, "I have performed tracheotomy twenty- one times with the result of seven recove- ries; and if it be rememl)ered that the pa- tients were all on the poiut of death from suftbcation, it cannot but be regarded as an encouragement to tlie sui'geon to en- deavor to save life by operative interfer- ence in the later stages of this most fatal disease." After the operation the chief condition of success is efficient support. The tulje must remain in the trachea for at least a week; liquids are to be given in the form of sop ; and nutrient enemata with brandy will generally be required. A little steam should be diffused in the apartment, and the tube lightly covered with gauze or porous woollen material. In adults, larjmgotomy is often sufficient; in one case that occurred to me, the ad- mission of air in tliis wa}^ sufficed to expel the exudation so speedily, that no tube was required. The after-treatment of Diphtheria re- quires great care in proportioning the amount of exertion to the degree of strength existing. Good food, good air, and tonics are necessary. Galvanism may be required when an important function is impeded from muscular inaction. [Strych- nia, used with proper caution, will be as likely to be beneficial in post-diphtherial paralysis as in any other form of paralytic disease. — H.] SCAELBT FEYEE. By Samlel Jones Gee, M.D. Lond. Definition. —An acute pyretic dis- ease, specific in its cause and course, and best characterized by a peculiar exanthem hereafter to be described. The earhest record which we possess of the existence of Scarlet Fever bears no more ancient date than a.d. 1556, the ' Arch. Gen. de M6d., 3. 5, tome v. p. 360. 2 M. Andr«. See art. Croup, Vol. III. ' Ediu. Med. Journal, vol. v. p. 417. * CUuique Medicale. Paris, 1861, p. 414. year wherein Ph. Ingrassias published a description of a malady which had been previously recognized by the common peo- ple, and named by them Rossalia. It is ' Trousseau, De la Traclieotomie dans la Periode extreme du Croup, &o. Arch. Gen. de M^d., s. .5, tome v. p. 360. " Sydenham Society's Year-book, 1863, p. 278. ' On Tracheotomy in Diphtheria. By George Buchanan, A.M., M.D. Glasgow, 1865. 84 SCARLET FEVER, possible that examples of a severer type of the same disease formed part of the famous epidemic of malignant angina which raged, sixty years later, in tlie south of Europe ; in Germany, about this time, Sennertus witnessed what he con- sidered to be the rossalia of the Italians, and what we may readily admit to have been our Scarlet Fever. In 167G appeared Sydenham's short chapter on "Febris Scarlatina," and by the end of that cen- tury the disease had been described in every part of civilized Europe. Catjses. — I. Contagion is the only known cause of Scarlet Fever. In de- gree of contagiousness, the disease takes a place between measles and hooping-cough above, and typhus fever below ; diphthe- ria being very far below. The contagious material may be taken up by clothes, and retained by them for a great length of time. Sir Thomas Watson narrates an instance in which a strip of flannel re- mained contagious for at least a year ; and Ilildenbrand was infected by a cloak which, after exposure to the disease, had been put aside for eighteen months ; hence we may assume that the morbific principle of Scarlet Fever is anything but volatile or unstable. Which being so, affords an answer to the important ques- tion : When does a person wlio has re- covered from an attack of the disease cease to be contagious ? To speak strictly, not until those natural fomites, the epithe- lial scales, which were existing at tiiie time of the fever, have been removed ; or, what is nearly the same, not until desquamation has ceased. And in the fact that, under ordinary circumstances, these epithelial scales are all but permanently contagious we have an explanation of the tenacity with which danger clings to materials of any but the closest texture. Uncovering a scarlet fever patient in the direct rays of the sun, a cloud of fine dust may be seen to rise from the body ; contagious dust, which, no doubt, subsides into every cre- vice near the bed. The distance at whicli the disease may be communicated is com- monly said to be not more than a few feet ; yet considering the slight volatility of the poison, one is quite prepared to admit the possibility of what is said to have occurred, — namely, of the contagion hav- ing been conveyed hundreds of miles by letter, or similar means. In like manner a person, himself not liable to the disease, may become a travelling disseminator of contagion : a trite observation, the appli- cation of which to practice is easily over- strained. [The contagion clings long to rooms and houses ; sometimes even for many months. — H.] II. Such being the exciting cause, it is required that the subject be apt or predis- 130sed. 1. This aptitude does noc exist, as a rule, in those who have passed through one attack of the disease ; still the possibility of recurrence and relapse is admitted on all hands. 2. Of persons not protected by a previous attack, whether the liability to contract the dis- ease diminishes with increase of years or not, is not easy to say. The affirmative is probably true, yet no age is exempt. The percentage of deaths at different ages, according to Dr. Richardson, is, — Under 6. From 6 to 10. 10 to 20. 20 to 40. 40 and upwarilB 67-63 24-43 5-52 1-73 0-66 Indeed all experience goes to prove that the majority of scarlet fever patients are of an age between eighteen months and six years. The relative proportion of cases of Scarlet Fever to all cases of illness, is greatest from four to nine years inclu- sive, and is, moreover, within those years, nearly stationary. 3. The two sexes are equally liable to Scarlet Fever ; women after puberty suffer more frequently than men, because more exposed to contagion. Scarlet Fever appears at any season ; but in England especially prevails, as Sy- denham says, at the end of summer ; or, more strictly speaking, from the middle of September to the middle of November. lucubatioii Period. — The duration of the incubation period partakes of that irregu- larity which attends most of the points which go to make up the history of Scarlet Fever. Trousseau relates a case which seems to prove that the incubation occa- sionally lasts no longer than twenty-four hours ; this we may accept as a mini- mum. Positively to fix the maximum is impossible : probably seven days are rarely exceeded ; but I have myself been witness to facts which did not admit of explana- tion otherwise than by presuming that the incubation period may sometimes last three weeks. Rilliet and Barthez are of the same opinion. Symptoms. — Scarlet Fever is some- times so mild as to escape the observation of both patient and physician, or, again, is sometimes so severe as to kill inevitably within twelve hours : another illustration of the wonted irregularity of the disease. Between these extremes lies a mean or typical form (here first to be described), in which all the characteristic symptoms are well developed, and none excessively: a description of the abnormal forms will follow. In the last place will be noticed the complications and sequelae which may supervene upon any form of the disease. ORDINARY SCARLET FEVER. 85 Oedinaet Scarlet Peveb. I. Invasion Period. — That stage which precedes the eruption of the rash. The onset (except in mild cases) is sud- den, so that it is often easy to fix the hour, almost the very minute, at which the disease began. The symptoms are : 1. Sore throat (the first symptom noticed by most adults) ; tenderness at the angles of the lower jaw and stiffness of the neck soon follow. 2. Vomiting, the warning children give, but not so common with adults ; it may be repeated many times, becoming ultimately bilious, yet not prognosticate, as a neces- sity, severity of the ensuing disease : ac- tive diarrhoea sometimes concurs. 3. Pyrexia. The first febrile symptom is often, not always, a sensation of chilliness ; never a rigor ; the face is pale. Flushing of the face and great heat rapidly succeed ; a temperature of 104'75O may be reached on the first day. Pulse remarkably fre- quent, and frequent out of proportion to the height of the fever ; for the pulse of a child to reach 160, or even more, on the first day of the disease, in prognosis, sig- nifies nothing ; in diagnosis, Trousseau thinks the symptom might be of some value. Respiration in proportion to pulse ; no cough ; no lachrj'mation : coryza before the appearance of the rash is very un- usual. The tongue, mostly covered with a light white fur, except at the tip and edges, which are red, in some cases re- mains quite pale, clean, and moist ; there are loss of appetite and thirst in marked instances of the diseasfe. Skin hot, not necessarily dry. 4. Nervous symptoms are present, languor, sleepiness by day (especially in children), disturbed sleep at night, nocturnal delirium ; headache, not severe, frontal ; aching of the limbs. Convulsions even may precede the rash in non-malignant Scarlet Fever ; coma, according to Valleix, is a frequent pre- cursor of the rash of the normal disease, and Sydenham makes a similar observa- tion. Lastly, in mild cases, mere poorli- ness the day before the eruption is often the only premonitory symptom. The duration of this stage is, as a rule, from twelve to thirty hours. In trivial cases the rash is sometimes the first symp- tom of the disease. Not rarely the dura- tion seems to be longer than the maximum given above ; but proof is difficult ; and the difficulty hes in fixing the time of oc- currence, not of the first invasion symp- tom, but of the eruption ; sometimes the rash recedes for a short time, and then comes out again. In a case observed by Trousseau, the rash did not appear before the eighth day, upon the cessation of most unusual prodromata, squinting, infrequent pulse and stupor, with headache, and vomiting. II. E)-iiptive Period. — 1. The Rash. The normal exanthem consists of small dots, in color bright scarlet, most intense at the centre of the dot, fading towards the periphery ; confluent by their mar- gins, so as not to leave any skin of normal appearance between ; not elevated to the touch ; conjpletely disappearing under pressure, and rapidly reappearing when the pressure is removed. The rash some- times comes out over the whole body at once, but is mostly at first limited to a much smaller area, especially to the sides of the neck and the upper part of the chest. Occasionally the eruption appears first on the legs. The most common de- partures from the type are the following : The color may be deep, purplish, dusky (this being, alone, no sign of malignancy) : in such a case add numerous flea-bites, and the disease may be (and has been) mistaken for typhus fever. On the other hand, the color may be very pale. The puncta are sometimes set so closely as to produce a uniform blush, in larger or smaller patches : this condition is con- stant indeed on the cheeks, and often seen on other parts of the face, and below the knees. Again the puncta may be per- fectly discrete. Wherever there is hyper- semia there must be swelling of the cutis, not commonly perceptible, however, sim- ply because the spots are confluent, but when they are discrete, it is not impossi- ble to feel their elevation (sc. papulosa) ; in the latter case, should the color be at the same time more purple than usual, the rash of measles will be closely simu- lated. This swelling of the cutis must not be confounded with other occasional accompaniments of the rash, — namely, a cutis anserina, and a subcutaneous swell- ing, which is sometimes present to a notable degree in the eyelids, hands, and feet, and which may persist for a day or two after the rash has gone. The eruption reaches its maximum ex- tent and intensity on the third or fourth day of the illness (occasionally as early as the second) ; begins to fade on the fourth, fifth, or sixth day ; and lasts altogether from five to ten days. When the nail is firmly drawn over the skin in which the rash is present (over the belly or thigh is best) a white streak soon follows, lasts a minute, and then disap- pears ; a very firm stroke brings out a middle red mark, and two lateral white streaks. The phenomena have been thought to be pathognomonic. But are they really peculiar to scarlet fever ? Does the "white streak" show more than that the skin is injected, whereby the effect of a contraction of the small vessels in the cutis is heightened, and of a dilata- tion, obscured ? Miliaria are frequently, but far from constantly present. They are most com- 86 SCARLET FEVER. monly met with about the sides of the neck and upper part of the chest, hut may be nearly universal. Occasionally they are so thickly set that the epidermis is de- tached by a rough touch. They are not connected with unusual sweating, but rather with the age of the patient and the amount of eruptive swelling of the cutis ; the rash rarely being intense in an adult without the presence of miliaria. They dry up in a day or two and desquamate. 8c. pemphigoidea seu pustulosa is de- scribed by continental writers. Large patches of urticaria sometimes come out while the proper rash is still present. When the skin is pulled upon, the rash does not always altogether disappear ; a j^ellow stain may be left, or all grades be- tween this condition and actual petechise. Like a dusky rash, petechise alone do not indicate malignity. 2. The iSiire-thmat is always present to some degree. In a typical case, exami- nation of the throat detects increased red- ness of the soft palate, uvula, and tonsils, sometimes of the posterior wall of the pharjmx, and of the tip of the epiglottis. These parts are swelled also, but the amount of redness and swelling is often disproportionate ; the latter may be so great that the tonsils meet in the middle line, and thrust the uvula forwards. Such great swelling is due to causes over and above the hypereemia, namely, (1) CEdcma ; this is most notable in the uvula, which from gravitation of the se- rosity becomes clul>shaped. (2) Excess of secretion : this enlarges the tonsils ; 2Mst mortent they are found to be sur- charged with thick yellow matter ; during life the same secretion often appears at the mouths of the tonsillar crypts, or is exuded so as to cover the surface with a uniform layer. Superficial ulceration of the tonsil sometimes coincides. More rarely the matter does not escape, and, liquefying, causes an abscess in the tonsil, as earl}'', it may be, as the sixth day. The mucous membrane is either dry and shin- ing, or coated with thick mucus, which clogs the fauces. Ulceration of any part of the throat, other than the tonsils, be- fore the iifth day, is very uncommon in cases which are not, for other reasons, classed under the gravest forms of the disease. There can be no question that the majority of "ulcers" and "sloughs" observed during the first four or five days of Scarlet Fever are nothing but excess of the secretion of the part smeared over the surface ; and likewise no question that the dire sloughing and gangrene described so well by the older writers (e. g. IIux- ham, Heberden), and on their authority still attributed at times to Scarlet Fever, appertain altogether to diphtheria. To quote the words of Armstrong : " The first four or five days there will be seldom either sloughs or specks about the tonsils; but merely an increased secretion of mu- cus, some of which often adheres to the part and looks like an ulcer. But when the fever continues longer, or runs higher, specks generally form about the tonsils, which are finally converted into super- ficial ash-colored sloughs." Ulcerative angina, then, either occurs in cases con- spicuous far more by the symptoms called malignant, or is a sequela, an epiphenome- non, supervening after the cessation of the specific disease. The lymphatic glands at the angles of the lower jaw become enlarged and ten- der; ill fact, inflamed. In severe cases the connective tissue around is involved, and puffy; but neither brawniness nor suppu- ration occurs before the rash has begun to fade. DiflScult deglutition, snoring, and alter- ation of the quality of the voice (it is thick and nasal), are results of the swell- ing of the throat. Kennedy once saw a child carried off by oedema glottidis within thirty hours from the onset of the dis- ease. In favorable cases the angina will re- cede with the eruption, and have disap- peared by the seventh day, the tonsils perhaps being left rather swollen, but pale. The lymphatic glands often remain large for some time. 3. The Pyrexia. — The height attained by the fever has been subject to singular exaggeration; the fiery hue of the erup- tion, and the great dryness of skin often present, conspiring to mislead the ob- server. The mercury of a thermometer placed in the axilla never rises above 106° Fahr. , rarely above 105°. The fever cer- tainly runs higher than in measles, and very much higher than in diphtheria, but on the other hand does not reach the de- grees which are often observed in ague, typhoid fever, rheumatic fever, and py- aemia. On the day when the eruption begins to fade the fever frequently sub- mits to a complete crisis, as indicated by the temperature not rising above the nor- mal for twenty-four hours ; should this crisis not occur, the pyrexia is prolonged for an indefinite period. (The tempera- ture of a healthy child may reach, but does not rise above, 99°.) In two cases the thermometric crisis occurred on the fourth day, in four on the fifth, and in three on the seventh. So, out of the cases observed by Dr. Ringer, the temperature of two became normal on the fourth day, of seven on the fifth day, and of one on the sixth day. In the rest the pyrexia was prolonged beyond the eruptive pe- riod. "The pyrexia slightly remits in the morning, and, rising in the course of the day, reaches its highest point about bedtune." (Armstrong.) A similar fore- noon remission and afternoon exacerba- ORDINARY SCARLET FEVER. 87 tioii takes place in health. Yet the Scar- latinal Fever is continual; the remission is not at any time complete until (in un- complicated cases) the final crisis. The severer the fever the more tritiiug the re- mission. 4. The Alimentary Canal. — (1) Tongue. The fur present during the invasion pe- riod becomes thicker on the second and third days, and then begins to clear oil' from before backwards, so as to leave the tongue deep-red, broad, smooth-looking, and dotted over with elevated papillae; a condition sometimes met with in other diseases (especially those attended with suppuration), when a thick fur clears oft' quickly. Both the earlier furred and later papillated condition are often absent. (2) Vomiting during the eruptive period is rare, except in the severer forms of the disease. Constipation, easily overcome, is the rule, but diarrhoja a not infrequent exception. Tympanites is sometimes present. Thirst and anorexia occur in well-marked cases. 5. 27i-e Bespiratm'ii Organs. — (1) Coryza, thin or mucopurulent, may supervene at any period of this stage, and is not neces- sarily a grave symptom. (2) It is rare to detect the physical signs of bronchitis or pneumonia before the rash begins to fade. Cough due to the condition of the fauces is common. The frequency of the respirations is proportionate to the py- rexia. 6. The Pulse maintains the frequency of the invasion period, and may reach 144 in an adult, ICO in a child, or even more, ^^■ithout any serious import. The fre- quency does not increase as the disease progresses, and it falls with the tempera- ture. 7. r/ie Urine. — (1) The water is dimin- ished in quantity, (li) Urea. In an in- dividual case of Scarlet Fever the most trustworthy standard of the amount of urea excreted by the person in health is derived from estimations made while he is kept in bed, and upon unaltered diet, for a week or ten days after the crisis. We must exclude all observations made upon cases in which the crisis of the pyrexia did not occur within the first week ; and hence, in order to obtain suf- ficient data, the observations should be begun upon the urine of the third daj' at the latest. The following cases fulfilled these conditions : — Wnicht Water, TJrea, CM. Sod. Sex. Age. Kilograms. cub. cents. gramiues. grammes. 7 yrs. 22i 1 1st to 4tli pyrexia 377 14-28 2-21 Boy 5tli to 12th apyrexia 450 15-02 4-59 I 2d to 4tli pyrexia 551 18-83 0-97 Boy 5 yrs. 16^ 5tli to fltli apyrexia 709 13-33 4-69 ) 2d to 5tli pyrexia 316 16-17 0-67 Girl lOJyrs. 27J 6tli to 13tli apyrexia 567 19-64 4-38 (minus 1 day) per 24 liou rs. These figures suffice to show that there is no necessary increase in the quantity of urea excreted during the pyrexia. (3) Chloride of sodium is more or less dimin- ished, sometimes very much, sometimes very little. This diminution cannot be connected with any known concurrent condition. The salt is not subsequently passed in abnormal quantity. The dimi- nution mostly ceases suddenly on the fourth, fifth, or sixth day. (4) Phosphoric acid undergoes very decided changes in quantity, which, normal, or a little more than normal, during the first three or four days of the disease, on the fourth or fifth day is notably diminished, for the four subsequent days remains at a half or a third of the normal, and then assumes the standard of health.' These changes bear no relation to the temperature or any other condition yet discovered ; the same phenomenon of diminished excretion of ' These remarks are based upon daily ob- servations by Neubauer's process in eight cases of Scarlet Fever. phosphoric acid at the climax of the pyrexia, or soon after, appears in ague, measles, and probably in other febrile diseases. (5) Uric acid. The only suit- able case in which I was able to make a daily estimation by weight of the uric acid manifested a great diminution (al- most a suppression) in the quantity of the acid on the second and third days, a re- turn to the norm;il on the fourth, and a great excess on the fifth day (the last day of pyrexia) ; after this the normal was re- sumed. It is highly probable that similar changes always occur in Scarlet Fever of any severity, as is judged from less exact observations upon several other cases. Sediments of uric acid and of urate of soda are common. (6) Pigment is not necessarily increased in quantity. (7) The occurrence of albumen during this period is considered under the head of Kenal Dropsy. 8. The Skin.— Dryness is a frequent but by no means a constant condition : the patient may sweat ; but for a sweat to follow a trivial exertion, say the move- SCARLET FEVER. ments of delirium, is a bad sign. Dry- ness signifies, not tliat tlie secretion of the skin is diminislied, but that it is rapidly evaporated. 9. Yellowness of the conjunctivoe, ten- derness over the liver, and evidences of bile in the urine, are occasionally present ; and when present, devoid of prognostic value. It is rare that the spleen can be felt enlarged. 10. JSfervous Si/stem. — An agitated man- ner, moderate frontal headache, and de- lirium, are common enough in ordinary Scarlet Fever. The deUrium ("noctibus aliena loqui") which occurs during the evening exacerbation is not a grave prog- nostic, yet delirium is a prominent symp- tom of some of the worst cases of the disease. The duration of Scarlet Fever is said by Valleix to be from ten to forty days. But what is the necessary duration of the spe- cific disease, the Scarlet Fever, as distin- guished from the possible duration of the illness, common sequelae included ? If we bear in mind that, in regular cases, the pyrexia often wholly ceases while the eruption still stands out well, I think we may agree with Heberden that the disease rapidly recedes after the seventh day, nay, I would add, that the specific disease even ceases then. The sore-throat may abate with the eruption, or be prolonged beyond, just as the catarrh of measles may increase on the eighth day of that disease. III. Desquamation Period. — After the rash has receded, certain deviations from health are observed in all but the mildest cases. 1. If the pyrexia cease by the seventh day, the pulse falls in frequency often to below the normal : irregularity is common when the nervous symptoms of the prior periods have been well marked. The temperature often remains for a week or ten days below the point which it reaches subsequently. The urine is dilute, defi- cient in phosphoric arid, and often defi- cient in acidity ; earthy phosphates pre- cipitate, and vibriones form. All these conditions of pulse, animal heat, and urine, indicate an exhaustion of the vital energy. The tongue, if it have been cha- racteristic (as is said), becomes, in the second week, more natural, and often as- sumes a delicately furred, silvery appear- ance. 2. Desquamation. — "With the disappear- ance of the rash, the skin does not regain the characters of health ; the epidermis is dry and shining, has lost its pliability, and is easily thrown into fine wrinkles. Desquamation begins in a day or two : the chin, sides of the neck, and upper part of the chest are mostly the parts first to desquamate. Where the cuticle is deli- cate, it becomes everywhere scurfy, and j is so thrown off: where thicker, it is raised and removed in small isolated patches, ■ which increase in size by a continuous des- quamation of their niargin, until they meet, and so leave the whole surface des- quamated ; and lastly, where the epider- mis is very thick, it is undermined in large flakes before it is cast off. The amount of the desquamation depends very much upon the previous intensity of the rash : where the latter has been slight, there the former may be almost absent. Miliaria cause an abundant and early desquama- tion. The duration of desquamation is from a few days to a month or two. 3. The throat, in favorable cases, loses its redness ; but the tonsils may remain swelled for some time : in like manner the lymphatic glands cease to be tender, and gradually diminish in size. Such is normal or regular Scarlet Fever ; it remains to trace the disease to its ex- tremes, of severity on the one hand, and of mildness on the other. And first of Scarlet Fever of abnormal severity, com- monly called Malignant Scarlet Fever. But before going further I must enter my protest against the manner in Avhich the epithet "malignant" is used, or rather abused, with regard especially to Scarlet Fever, but also more or less to many other diseases. Malignity has almost ceased to have any real meaning, and all that some of the greatest physicians have written upon the subject seems to have been written in vain. This is not the place for me to discuss what malignity really in- tends, however much I may feel inclined to do so : in what follows I shall simply strive not to misapply the term in the case of Scarlet Fever. The severer forms of Ordinary Scarlet Fever merge into a tj-pe of malignity characterized by excitement, followed by exhaustion. There are all grades of se- verity between this, the least grave form of malignity, and that which places Scar- let Fever almost on a footing with Asiatic cholera and the plague, that form in which a preliminary period of excitement is hardly to be perceived, so rapidly does collapse follow upon the onset of the dis- ease. Ti/pe I. — The malignity is deutero- pathic, secondary to a state of ataxia or excessive disorder of the functions of the nervous system r in the nomenclature of Armstrong the malignity is inflammatory. The invasion symptoms are all weJ marked, yet even from the first, those which are to be referred to a disturbance of the nervous system predominate, — delirium, agitation, sleeplessness. The LATENT SCARLET FEVER — SEQUELS. 89 premonitory stage over, the rash comes out well, the sore throat is considerable, the fever runs high. Delirium remains, exists at all times, and is active ; the pa- tient throws himself about, gets out of bed, sings loudly ; his mind is confused ; his eyes bloodshot ; pulse frequent, full and soft ; extremities warm ; vomiting after food is a prominent symptom ; there may be diarrhoea or coryza. But depres- sion follows in a day or. two, the delirium is much less active, the person lies mut- tering, the pulse becomes small, weak, and still more frequent, the face gets dusky, the cutaneous circulation is remarkably sluggish, swallowing is imperfectly per- formed, vomiting may persist, the belly is tympanitic. Lastly, stupor supersedes delirium, and death ensues. Sometimes the fatal issue is accelerated by a sudden attack of convulsions, the pulse ceases to he perceptible, the whole surface is blue, coma follows. Tyjje II. — The malignity is protopathic (congestive, in the phrase of Armstrong), the vital debility is primary and sponta- neous, the disease goes straight to the source of life. The patient becomes sud- denly pale and faint, vomits ; the vomit- ing is repeated with short intervals, the bowels are relaxed, the hands twitch, there are great anxiety and feeble deli- rium. In a very few hours the depression is extreme, the whole exposed surface feels cold, yet the temperature of the arm- pit is febrile ; the pulse is very small and frequent. Perhaps, for a time, the pa- tient seems to rally ; he sits up in bed, but his pulse remains very frequent, and his feet cold ; a faint rash may appear. Depression returns, the face becomes pale livid, and perfect stupor (interrupted by convulsions) supervenes ; pulse is exces- sively weak and frequent, respiration re- markably irregular, sweats break out, the skin is cold and mottled ; these synqj- tonis precede death. The duration of the whole illness may be less than twenty- four or even less than twelve hours. Tlie temperature of the body in the rec- tum and axilla is maintained at a tolera- bly high fever standard, but I have not yet observed that extreme elevation of temperature which is to be found in some cases of rheumatic fever, tubercular men- ingitis, sun -stroke, and injury to the brain. It is not given to any physician to observe with sufficient closeness many •cases of protopathic malignity in Scarlet l^ever ; by far the most unconmion form of the disease. A child who died in this manner twenty hours from the onset of illness, afforded a temperature in the axilla of only 104° an hour and a quarter before death. Half an hour previously the temperature had been 105° : this was the highest degree observed, though the temperature was taken at intervals of about two hours. It is manifestly untrue to say that the vital debility is due to hyperpyrexia ; they would be merely con- comitant conditions in any case in which they should both occur. Excluding the examples of these well- marked types of truly malignant Scarlet Fever from the whole medley of cases which arc loosely called malignant, there is left a large and heterogeneous caput mortuum which consists in part of cases attended by unusual or unusually severe local lesions, and in part of cases which certainly may lay a sort of claim to be re- garded as instances of a prolonged malig- nity. The latter class of cases runs "a course more or less of the following kind. For the first day or two the attack docs not seem to be unusually grave ; but about the third day tlie patient is alternately restless and heavy, pulse frequent and feeble, expression vacant, face pale and thick-looking, mouth very tender, sweats follow a slight exertion ; coryza, diarrhii'a, tjanpauites, ulceration of the tonsils, and dysphagia, supervene, some or all ; deli- rium is frequent, emaciation proceeds rapidly, and the patient dies exhausted, it may be during the first week, or not till far on in the third ; the prolongation being due partly to the local processes set up and partly to inability to rally. The rash in Malignant Scarlet Fever is of small prognostic value ; it is often abundant and of a bright color ; in the worst cases no rash appears, but none would be expected, death occurring before the second da}'. The tonsils mostly ulcer- ate early, even on the first day. The py- rexia lasts to the very end. Latent Scarlet Fearer. The symptoms are so ill-developed as to be not characteristic or not observed. Ex- amples of Sydenham's Scarlet Fever — disease by name alone — hold a mid place between this latent and the regular forms. How mild soever the primary disease, the gravest sequelae may ensue. [Popularly, scarlatina is, in some places, supposed to be the proper name for an unusually mild form of Scarlet Fever. It is important for physicians to correct this error, as it induces a want of care, not only in regard to the patient, but as to exposure of otliers to the contaj;ion. There seems to be no doubt that the mildest cases may, by contagion, give rise to others of the greatest severity ; and, also, that very light cases may be followed by considerable dropsical effusions. — H.J Sequels. As symptoms of the desquamation pe- riod, I have described sundry sequels of 90 SCARLET FEVER. Ordinar}' Scarlet Fever which are con- stant, and the necessary results of normal precedent conditions : there remains for consideration a long list of sequelae which are inconstant in their occurrence, and tlierefore mostly looked upon as complica- tions of the disease. The distinction may he somewhat artificial, but it is in the present state of knowledge convenient. I. Swe-thront. — Any sore-throat which may be present during the decline of the rash, or after it, is due either to a simple persistence of the ulcerated condition of the tonsils, which has been described as an occasional symptom of the eruptive period, or to the establisl)ment of a new form of lesion. In the former kind of sore- throat, the ulceration tends to progress deeply rather than widely, and bubo is a frequent concomitant. The latter kind supervenes most frequently on the sixth day, sometimes a day or two later, but never after the end of the second week : in very many cases the fauces have pre- viously escaped grave implications ; then, at the time specified, one or several small grayish patches, surrounded by a vivid red margin, appear on the tonsils, uvula, or arches of the soft palate, sometimes on the hard palate or the tip of the epiglottis. At the same time the fauces are swelled and reddened, deglutition gives pain, the lymphatic glands at the angles of the jaw become larger and tender, the connective tissue is pufty. The epithelium of the tongue is sometimes raised in patches. The excoriations go on to heal or to ulcer- ate. If to heal, the pellicle becomes thicker, so as to look like a false mem- brane, the surrounding redness abates, and in a short time, when the scab is thrown oft", the mucous membrane is left uniform in surface. In the other alterna- tive, when the pellicle is removed, the deeper layer of the mucous membrane is left exposed, ulceration ensues at this spot, and thence may spread far and wide ; in the worst cases the tonsils are destroyed, the cartilage and bone in ihe vicinity are laid bare, dysphagia ensues, the fluids re- turn through the nose. The state of the sides of the neck corresponds : in the favorable cases the swelling gradually dis- appears ; in the severe, all distinction be- tween gland and connective tissue becomes lost, a " collar of brawn" extends around the neck (scarlatinal bubo), softening en- sues at places, and here the skin will slough in order to give exit to a shreddy sero-pus ; yet the swelling is not dimin- ished until large sloughs of the connective tissue come away, and the skin (it may be of the whole neck) is left floating over the parts beneath, and perforated in numerous holes. The suppuration reaches down- wards into the mediastinum, or, spread- ing upwards, invades the paroticl glands, passing along the interstitial connective membrane, and dissecting out the salivary lobules. Hemorrhage from the large ves- sels of the neck sometimes occurs to in- crease the complication. The rapidity with which the hard brawny swelUng will establish itself is remarkable : a neck which was only pufiy one day may be hard the next ; a semi-comatose condition is often produced : the veins of the eyelids are turgid. The majority of cases of ex- tensive sloughing of the connective tissue die ; symptoms not directly connected with the throat are apt to supervene, par- ticularly vomiting and diarrhoea. Simple suppuration is a mucli less grave result ; and indeed a very considerable amount of firm swelling of the neck may be resolved without suppuration. II. Coryza. — Coryza, which persists into or supervenes during the second week, is an important symptom, indicative of a niorbici state of the mucous membranes in general. The direct consequences of coryza are often serious, and especially the extension of disease along the Eusta- chian trumpet into the tympanum ; when this cavity is filled with pus, the mem- brane bursts or sloughs, and an obstinate otorrhoea results. Fistula lacrymalis is much less common. Worst of all is the coryza, which is indicative of nasal diph- theria, a complication comparatively in- frequent. III. Otorrhoea. — Otorrhoea is of two kinds. The first is that otorrhoea which begins in the external meatus ; the dis- charge, which is whitish at the onset, soon becomes purulent, while the lining mem- brane everywhere thickens. The second kind of otorrhoea is that which follows coryza; ulceration of the lining membrane of the tympanum, necrosis of the bone, facial paralysis, incurable deafness, and abscess of the brain, these are conse- quences not uncommon : the discharge is purulent from the first; when injections are used, they pass from the nose out at the ears, and the reverse. Hemorrhage from the internal carotid artery is a rare sequel. IV. Diarrhoea. — This sometimes coin- cides with the decline of the rash. Bloody stools and excoriations of the anus and buttocks may be the consequence of this, as of other kinds of diarrhcea. V. Bronchitis and Pneumonia. — Com- plications more common in the second than the first week, and mostly preceded by coryza. Severe bronchitis is not neces- sarily fatal ; when it is fatal, we always find lobular pneumonia superadded. Pri- mary lobar pneumonia sometimes occurs. VI. Abscesses. — Convalescence is often put back by the formation of one or more abscesses ; if they are very large or numer- ous, they may be the immediate cause of death, and even when they are small and solitary the local results are sometimes grave. For example, on the back of the SEQUELS. 91 hand, an abscess as it closes leaves the tendons glued to the neighboring parts. Or again, behind the pharynx, an abscess may cause death, especially in infants. The symptoms of post-pharyngeal abscess are dysphagia, return of fluids through tlie nose, some stiflhess of the neck, one side of which may be fuller than natural, and dyspncea. Any one, or even all of these symptoms, may be so slight as not to attract attention. The finger passed into the pharynx feels a soft tumor pro- jecting in the middle line or somewhat to one side. Should the abscess burst spon- taneously, sudden suffocation may ensue. Abscesses about the neck are nearly always, if not always, the result of in- ternal ulceration. VII. Mheumatism. — Towards the end of the second or beginning of the third week, we occasionally observe a consider- able increase or a re-establishment of the pyrexia, and at the same time an affection of the joints; the latter consisting in great tenderness and elastic swelling (more around than in the joint), with or without redness of the skin; the patient sweats at times, perhaps profusely; the serous mem- branes are prone to inflammation. There are all grades of severitj' between transi- tory pain in a single joint and painful swelling of nearly all the joints of the body. A similar complication may attend tlie eruptive period, but is less common; it is common enough for adults to com- plain of great tenderness of the muscles while the rash is present. The swellings are mostly resolved, and then the patient recovers; but sometimes suppuration oc- curs around and in the joint. Suppura- tive rheumatism is fatal. The nature of this complication must, at present, be left an open question, whether the disease be really rheumatic, or whether it be pya3- miaL VIII. Benal Dropsy. — Scarlet Fever is very often followed by albuminuria, drop- sy, and a form of nephritis; three acci- dents which it is convenient to group to- gether and to view as collateral symptoms of a more general condition. 1. Condition of tlie Urine. — The propor- tion of cases of albuminuria seems to dif- fer with difterent epidemics: albumen was at no time present in the urine of six out of twelve children, the whole of whose urine was saved and examined daily by myself, from the decline of the rash to the fourth week; Abeille found albuminuria in one- third of the cases examined by him; in the experience of Begbie, Newbigging, and Holder, the occurrence of albuminu- ria was a rule without an exception. In twelve cases I tested the urine daily throughout the fever and the convales- cence; in one, albumen appeared on the fourth day, in one on the eighth, and in none was' albumen detected for the first time after the twenty-first day; four cases occurred during the second week, seven during the third. In eight out of twenty- one cases observed by Abeille, the urine became albuminous before the sixth day ; Jaccoud has noticed albuminuria as early as the second day. In the two above- mentioned Instances of the occurrence of albuminuria on the fourth and eighth days, the abnormal condition of the urine was present for one day only; in the ten other cases the duration of the albuminu- ria was at least a week. In most of the examples of the more enduring form of the disease it is easy to distinguish three stages, each characterized by a peculiar condition of the urine. Stage 1. — The quantity is diminished (total suppression for several days has been observed by others now and then), the specific gravity is increased in propor- tion to the concentration, urate of soda is precipitated, the color is unchanged, and, when any saline deposit is dissolved, how- ever turbid the urine be with organic matters, it is not at all smoky: the urea is diminished in quantity beyond the pro- portion of the diminution of the water; the relative lack of chloride of sodium is greater still ; albumen is present ; when the diminution in the quantity of urine is considerable, the microscope discovers casts, some clear and perfectly free from granules or epithelium, some finely gran- ular, but hardly any blood disks or renal epithelium ; when the disease is less se- vere (and in all cases as this stage is pass- ing away), there are renal epithelium and epitheliated casts, with a few blood disks. The amount and the duration of the di- minution of the quantity of the urine in this stage are to a great extent prognostic of the future course of the disease. Stage 2. — The quantity of urine regains the normal, and soon exceeds it ; there is a perfect diuresis; the specific gravity falls low; the urea and chlorides return to the standard, or nearly so; the urine becomes bloody (from slight smokiness up to the deepest brown); the amount of albumen is relatively less, though it may be abso- lutely greater than in the earlier stage, and is not proportionate to the depth of the color of the urine ; the microscope shows blood disks, hsematoidin crys- tals(?), renal epithehum, epithehated and granulated casts. As this stage passes off the urine becomes clearer, less red, and more yellow (passing through brown and green) ; the albumen lessens. Stage .3.— The diuresis continues, but the smokiness disappears ; though dull with excess of organic fiocculence, the urine is normal in color ; the albumen gradually disappears. Even after albu- men has ceased to be present, it mostly happens that for some time the quantity of urine secreted is above the normal. 92 SCARLET FEVER. In mild cases the distinctions of the stages are necessarily ill-marked ; some- times the urine is at no time diminished in quantit)-; sometimes, although the first stajj;e is ^vell marked, the urine is hardly at any time smoky; sometimes the third stuge never comes to an end, or in other words the urine remains permanently al- buminous; a sudden increase in the depth of the bloody color of the second stage often occurs, without the quantity of albu- men in the urine being proportionally in- creased; the urine returns to its prior con- dition in two or three da3'S. A class of cases, by far the worst of any in a prog- nostic point of view, has been exemplified by several children who, when iirst they came under observation, brought a his- tory to the effect that two or three months previously they had had Scarlet Fever (perhaps so mildly that the nature of the illness was ignored at the time) and that after the lapse of several weeks dropsy had supervened, not suddenly, but gradu- ally, increasing from day to day. The urine is normal in color and specific gravity, clear or with some excess of flocculence, not necessarily diminished in quantity ; but the amount of albumen present is very large ; verjf little is to be seen by the microscope, and that little is not characteristic. The steps by which this stage is reached have not yet been observed ; so far as the writer has seen the condition is permanent and resists all treatment.' 2. The Dropsy. — Dropsy or hsematuria is the first symptom which arrests the at- tention of the inexpert. The former is very uncertain in occurrence, and is often almost wholly absent from first to last ; when it is the first symptom noticed, it supervenes rather suddenly in the third week, and especially towards the end of that week. Dropsy is mostly preceded by albuminuria for a day or two ; occasion- ally the dropsy precedes the albuminuria very rarely, when both symptoms have been present, the albuminuria nearly wholly (possibly wholly) ceases and yet the dropsy remains, in some epidemics, dropsy without albuminuria at any period is common. Philippe of Berlin did not once find the urine albuminous in more than sixty cases of scarlatinal anasarca (quoted by Jaccond). The dropsy as- sumes the forms of— (1) Anasarca, which may be general or limited to the eyelids, backs of hands, and bottom of back : cedema glottidis is a very rare result of scarlatinal dropsy. (2) Serous dropsies, which occasionally precede the anasarca : ' 8oon after the first edition of this volume was published, Dr. Weber read a paper upon some cases of this kind before the Medical and Chirurgioal Society. Transactions vol. xlix. p. 199. when peritoneal, the effusion is of no great practical moment : the diagnosis of pericardial cftusion depends upon physi- cal examination ; dyspnwa, intermitting lividity, indistinctness of the pulse, and a tendency to syncope, may or may not be present : pleural dropsy, hydrothorax, is a more common and formidable complica- tion. A child whose anamia and ana- sarca have shown a tendency to increase, and who has a slight cough and some sonorous rhonchi over the lungs, suddenly becomes much worse, vomits repeatedly, dyspnoea and li\idity ensue and rapidly increase, verj' little urine is passed; the distress is painful to behold ; and death rapidly follows, mostly within twenty- four, sometimes within six hours from the first exacerbation of symptoms. Post mortem both the pleural cavities are found to contain a great excess of serum, which is perfectly clear, or floats the network of a delicate coagulum ; sometimes lymph is present, the evidence of pleurisy hereafter to be described. The lungs are collapsed but oedematous also, dark iron-gray on section, and capable of imperfect insufHa- tion. 3. General Sympto^ns. — (1) Pyrexia ac- companies the onset of renal dropsy, and is high in proportion to the sevei'ity of the symptoms; in mild cases pyrexia is almost absent : it is rarely prolonged into the second stage of albuminuria. All the more chronic cases of renal dropsy are, when uncomplicated, apyretic. The attendant symptoms are heaviness, dry skin, troublesome vomiting, parched lips, and constipated bowels. (2) Aneemia is mostly a marked symptom after the py- rexia has passed off. Children who are dropsical look more pale than those who are not. (3) Ura;mia: convulsions and coma supervening upon scarlatinal dropsy are more often symptomatic of the onset of some local inflammation, than indicative of ursiemia. Indeed true urse- mic convulsions are not very common ; when they do occur they induce a fatal issue in a minority of cases : on the other hand the prognosis is most unfavorable when the convulsions merely assume the place of a rigor. The cause of renal dropsy is unknown : that exposure to changes of temperature will insure dropsy when the urine is albu- minous (or rather, perhaps, when that condition which tends to produce albumi- nuria is present) has been admitted by most observers ; but that a chill is a fre- quent cause of albuminuria is a dogma much more disputable, and apparently disproved by the fact that albuminuria is a sequela almost constantly present in some epidemics and almost constantly ab- sent in others. IX. Serrrns Inflammations. — They mostly, not always, are accompaniments DIAGNOSIS. 93 cither of iilbuniinuria or of the rheumatic state. 1. In the latter, tlie pericardium is espeeially prone to inflame, a complica- tion which, by itself, does not render a prognosis unfavorable. 2. In albumi- nuria, pleurisy is the most common. One or both pleuroj are inflamed, the lymph effused rapidly breaks up into pus, and in most cases, death ensues in a few days ; yet occasionally a chronic em- pyema is the result. States intermediate between pure hydrothorax and pleurisy are sometimes met with. Pneumonia is frequently combined with the pleurisy. In the pericarditis and peritonitis likewise the lymph has a great tendency to become puriforiu. It is not rare to And all the serous membranes inflamed at once. 3. Occasionally pleuro-pneumonia, pericar- ditis, or peritonitis supervenes, and there are neither dropsical nor rheumatic symp- toms present. Yet such sequelte are especially apt to occur in what may be termed the rheumatic period ; that is, the second week. 4. Systolic cardiac mur- murs sometimes spring up during the ill- ness : they are heard with greatest inten- sity at the apex or the second left inter- space. Keither albuniinuria nor rheuma- tic symptoms necessarily accompany the development of the apex murmur : nay more, it can hardly be said to be proved that the occurrence of a systolic murmur at the apex of the heart is always due, in these cases, to endocarditis. These apex murmurs in my own experience persist for a month or two at least, — persist as long as the patient is under observation. Sometimes possibly dilatation of the heart originates in an attack of Scarlet Fever. X. Other SeqiielcB and OompUcations. — (1) Sloughing of the cornea is an accident of which the occurrence may probably be always prevented. (2) Hemorrhage in consequence of a sloughing Ijubo, of de- struction of the pars petrosa, or in the form of hsematuria, has already been described. Epistaxis is an occasional phenomenon. Here may be mentioned that variety of Scarlet Fever which many writers, probably somewhat biased by the analogy of smallpox and measles, have been very ready to admit into their noso- logy, I mean Sc. hsemorrhagica ; a form of the disease which must be very rare (ex- cept, perhaps, in certain epidemics), — so rare that the occurrence of a passive hemorrhage from several mucous mem- branes at once might make one with jus- tice suspend a diagnosis of Scarlet Fever until the notion of possibly having to do with variolous roseola was discarded. I have known Variola hsemorrhagica to be mistaken for Sc. hsemorrhagica, and the truth not appear until, in course of time, those who had deaUn^s with the case were tliemselves attacked by smallpox. (3) Gangrene. Cancrum oris is a very uncommon sequela of Scarlet Fever. Gangrene of the pharynx is said to have occasionally supervened. Sloughing of the skin over a bubo is much more common ; so also is gangrene of blistered or ulce- rated parts of the skin. Here may be classed such sequete as necrosis of parts of the jaw-bones, and hip-disease. (4) Tubercle. Scarlet Fever by no means tends to develop tubercle even in a sul)- ject predisposed. ('>) Other acute specific diseases. The eruptions of Scarlet Fever and measles may appear at the same time upon the same patient (Rillietet Barthez, iii. 281). SmaUpox has been known by the same writers to complicate Scarlet Fever. I myself have made this observa- tion ; a girl of three had hooping-cough ; about a week after she began to whoop she became very feverish, — this was on April .5th ; on the 6th and 7th she vomited beyond what the cough would account for ; on the 8th an indubitable varioloid eruption appeared upon her, and on the 9th, a rash which possessed in every re- spect the scarlatinal character. In an- other girl of two and a half I saw the eruptions of Scarlet Fever and varicella appear upon the same day. I have known the long course of typhoid fever to be broken asunder, as it were, by an attack of Scarlet Fever. Diphtheria is a comparatively frequent sequela : the pa- tient seems to be in a fair way of recovery, when an acrid discharge from the nostrils is noticed, the neck swells again, the py- rexia returns : death is inevitable {Graves, Clin. Med. i. 318 ; Trousseau, i. 15) ; this complication may ensue as early as the fifth day (EiUiet et Barthez, iii. WS). The writer has seen diphtheria supervene upon the chronic dropsical cachexia, the new disease here also inducing rapid death. Lastly, Scarlet Fever may be intercurrent during the acute period of rheumatic fever, and neither disease be perceptibly modified. [Although much more rarely than is the case with diphtheria. Scarlet Fever may be followed by partial paralysis ; es- pecially of the lovver limbs. This is sel- dom of a very severe grade, but it may require weeks, or sometimes months, to pass away. — H.] Diagnosis.— During the invasion pe- riod the diagnosis depends upon the pre- sence of vomiting or angina, and the al> sence of sneezing, lachrymation, or pain in the back, in a person who has been taken ill suddenly, and has not previously suttered from Scarlet Fever. The fre- quency of the pulse, and severity of the nervous symptoms from the first, are sometimes valuable aids to diagnosis. The rash may be confounded with the eruption of measles, smallpox, typhus, roseola, miliaria, or urticaria. Measles 94 SCARLET FEVER. ma J' be wrongly suspected when a Scarlet Fever rash is of a darker color than usual, and especially when it is discrete also. And, contrariwise, in several cases of measles I have been perplexed bj- the ex- istence of a scarlatiniform rash upon the body several hours before the proper erup- tion of measles appeared. The roseola which precedes smallpox occasionally causes an error in diagnosis. The resem- blance which the rash of Scarlet Fever occasionally bears to that of typhus has been alluded to previously. To know that the minute vesicles of miliaria and the confluent wheals of urticaria are not un- frequently mistaken at first sight for Scarlet Fever rash, will suffice in most cases for the diagnosis. Eeviewing some of these statements, and bearing in mind how closely the rash of Scarlet Fever and of measles may simulate each other, that the two diseases may concur, and that symptomatic roseola is not always easily distinguished from Scarlet Fever on the one hand or measles on the other, it is fair to conclude that at least some sup- posed cases of a disease which has been called rubeola (rbtheln, roseola febrilis) are attributed to an impossibility in the diagnosis. ' Scarlatinal angina is indistinguishable per .se from ordinary simple erythematous sore throat, or from pellicular angina (pharyngeal herpes) which forms so large a proportion of the sore throats popularly styled diphtheritic. The swelling which occurs about the joints during the first two or three days of the disease is sometimes very consider- able, while the rash is pale or absent; such Scarlet Fever has been mistaken for rheu- matic fever. Surgical Scarlet Fever. — It has been doulsted by some whether the scarlatini- form rash which sometimes follows opera- tions is really scarlatinal. The eruption appears from the second to the sixth day after the oper.ation, and, in the cases which have caused the doubt, is very fugitive, the first and only symptom. Yet, that the disease really is Scarlet Fe- ver, would seem to be proved by the fol- lowing observations : first, that the dis- ease occurs in epidemics ; secondly, that in a given epidemic a severe case occa- sionally relieves the monotonous recur- rence of the very mild form ; thirdly, that a precisely similar scarlatinilla attacks, in the same epidemic, patients who have not been subjected to operation, and who have no open sore ; and lastly, by way of a veritable experimentum crxtcis, that, how- ever freely these patients are exposed to Ordinary Scarlet Fever contagion after- wards, they do not contract that disease. ' [See article on "Rotheln." — H.] Morbid Anatomy. — Scarlet Fever does not possess any distinctive anatom- ical character which persists after death: the alterations of texture found post mor- tem are common to other pyrexiie. The furred tongue indicates a condi- tion, similar in kind, if not in degree, of the mucous membrane of the whole ali- mentary canal; there is an excessive for- mation of epithelium and concomitant hyperemia of the sub-epithelial layers ; casts of the gastric tubuli are to be de- tected by the microscope in the vomit. (Fenwick.) From the frequency of co- ryza, pulmonary catarrh, and pneumonia, we infer that the respiratory mucous membrane does not escape. A peculiar change in the muscular tis- sue has been described by Zenker ; a change more constant, as it would seem, in typhoid than in Scarlet Fever. The puffy swelling which sometimes precedes the rash or coincides with it, may indicate a direct implication of the connective tissue. The spleen, the lymphatic glands, the tonsils, and the lymphoid (solitary or agminated) glands of the stomach and intestines are swollen and injected ; the tonsils and the gastro-intestinal glands sometimes go on to ulcerate. In this place may be just mentioned the leuehfe- mic deposits which have been detected here and there. The liver and the kidneys are involved to a slight degree ; a little cloudiness of the cortex of the kidneys by no means indicates the existence of albuminuria. The kidneys of renal dropsy will be de- scribed under the head of Kidney Dis- eases. The cerebral symptoms are, so far as is known at present, unaccompanied by anatomical change. Prognosis.— I. Prognostics derived from pre-existing conditions. — 1. The social posi- tion of the person attacked has no influ- ence upon the course of the disease, which is quite as fatal among the rich as among the poor. 2. Family constitution seems to influence Scarlet Fever to a degree which can be hardly overrated ; that one or more members of a given familv have succumbed, renders the prognosis m the case of any other persons in that family who may chance to be attacked, very grave. 3. Pregnant women are said to be peculiarly exempt from the liability to contract Scarlet Fever ; but the puerperal state predisposes to the occurrence of not only Scarlet Fever, but Scarlet Fever of a very fatal form. The rate of mortality seems to differ in different epidemics ; but whether of thirty-six patients attacked all die (Trousseau), or the mortality be twenty- five per cent. (MacCliutock), or all of nine PROPHYLAXIS — TREATMEN'T. 95 patients recover (Blakely Brown), the prognosis cannot be too guarded. 4. A scrofulous vulnerability of the mucous membranes or the lymphatic glands greatly adds to the gravity of the prog- nosis. 5. A previously feeble state of health by no means predisposes to a bad type of Scarlet Fever — almost the reverse ; certainly the majority of cases of Sc. maligna are in persons of previously robust health. 6. Age and sex have no effect. The epidemic constitution does not always afford trustworthy aid in a particular case. II. Prognostics derived from the actual disease. — The number and the gravity of the possible complications and sequete of Scarlet Fever should render the prognosis very wary even in the mildest cases. Excluding the malignant forms, we iudge of the severity of the disease more from the number and severity of the local lesions, than from the height of the py- rexia or the color of the rash ; each addi- tional local lesion, complication, or se- quela, being an addition to the gravity of the prognosis. Bubo and coryza are the most formidable symptoms of the first ten days, rheumatism and albuminuria of the next ten days. There are no guides to prognosticating the probability of the occurrence of bad sore-throat, rheuma- tism, or renal dropsy. If on the first day of defloreseence of the rash the fever still keeps up, we must attribute it to a new or an increased local lesion, and this will mostly be found to be anginal. The gravity of a brawny bubo is always great. A tendency to relaxed sore-throat does not predispose to bad angina. In most cases in which coryza has appeared on the fourth or fifth day, the secondary sore- throat will ensue to a certain extent. Of the patients seen by MM. Rilliet and Barthez, all who during the first fifteen days of the disease exhii5ited convulsions, convulsive movements, rigidities, in other words, symptoms referable to the locomo- tive apparatus, have died ; according to my own experience, the prognosis which might be derived from this statement would be too unfavorable. The nocturnal talkative delirium (noctibus aliena loqui) is, no doubt, as Heberden says, an unim- portant symptom. But when delirium becomes more active than this, more con- stant, more independent of surrounding things ; when attended by restlessness, sleeplessness, drowsiness, or by vomiting and diarrhoea, it is impossible to dissemble the grave significance of the symptom. Suppurative arthritis is a most serious accident ; multiple abscesses are much less grave. In the renal dropsy, moderate oedema pulmonum and pleural effusion may be recovered from. The reader will find many other prognostics under the heads of the sundry symptoms. Prophylaxis. — Removal from all sources of contagion is the most obvious, the surest, and probably the only means of preventing (Scarlet Fever. The pro- phylactic virtue of an infinite number of fumigations and drugs has been vaunted from time to time, but fruitlessly, with one exception, namely, belladonna ; yet even of that remedy the reputation, not wanting the support of hundreds of obser- vations tabulated, has in the present day sunk very low. Inoculation by means of the blood, the fluid of the miliaria, or the secretions of the fauces, has been practised in a few cases, and so far, appa- rently, not without fa\'orably modifying the disease thereby communicated. With reference to the purification of materials which have been exposed to Scarlet Fever, it may be here remarked that the morbific principle isdestmyed by a heat considerably below the boiling- point of water. Teeatjient. — In the following pages I shall endeavor to trace an outline of the plan of treatment ordinarily adopted at the present day. It will be impossible not to omit mention of many curative means which may be of real value ; in a common disease, not very powerfully con- trolled by any therapeutic method, the remedies which have been and which are employed nmst be innumerable. To know the natural course of Scarlet Fever is a great guide to the appropriate treatment; for, although we cannot abridge that course, we can be prepared for the occurrence of different accidents at difier- ent stages, and so be able to meet those accidents from the very first. Provided that no complications occur. Scarlet Fever will terminate favorably within a week from the onset of the disease. Among the complications we must place the malignant form of the disease, and also any unfavorable pre-existing condition, such as the puerperal state. The regimen of acute diseases must be put in force. The patient should be kept in bed, as a rule to which there is no ex- ception ; the bed-clothes should be those to which he has been accustomed in health, and no more ; carpets, curtains, and porous materials must be removed ^ the bed-room should be carefully venti- lated (in part by an open fire), bearing in mind that there is no special reason to fear cold during the first week ; the whole surface of the body should be sponged with tepid water once or twice a day, and subsequently to grease the skin with mut- ton suet often brings comfort to the pa- tient. The diet is "to be unstimulating, consisting of milk, broths, the farinacea, an egg, light puddings ; drink should be freely supplied. Purgation is to ba avoided. 9b SCARLET FEVER. In many cases a consideration of the previous and tlie present condition of tlie patient will indicate the administration of wine : the child seems low, the pulse is not only frequent but soft and feeble, there is possibly coryza present. At the same time full doses of carbonate of ammonia should be gi\'en, in milk, every four hours. And it must be conceded that no great harm comes from the moderate employ- ment of stimuli, even when they are not absolute!}' necessary. AVhen the throat is much inflamed, great relief may be aflbrded by either of the following methods of treatment. The first is to cause the patient to use ice freely ; he is to allow lumps of it to dis- solve in his mouth. Under this treatment tenderness of the submaxillary glands sometimes passes away in a few hours, an improvement which is an index of that which has taken place within. Ice can be easily given to patients above five or six 3'ears of age ; but the second remedy is one which is inapplicable in the case of children ; I mean the inhalation of the steam of hot water. Puffy swelling of the neck may often be removed by external applications of spongio-piline wrung out from hot water, or of hot linseed-meal poultices, frequently renewed. In like manner coryza is a sj^mptom which, when treated early, may thereby cease to be of evil omen. To check the coryza is to check, in the majority of cases, that worst form of otorrhcea which proceeds from the destruction of the tj'ni- panum. In patients above eight years of age, the valuable method of washing out the nostrils introduced by Dr. Thudichum may be employed. An ounce of salt is dissolved in a pint of warm water, and this solution, contained in a vessel a little raised above the head of the patient, is conveyed by means of a flexible caoutchouc tube into one nostril ; respiration being carried on through the mouth, and all at- tempts at swallowing forbidden, the fluid passes out freely by the other nostril.' In young children we are reduced to the expedient of syringing the nasal fossae with a weak solution of nitrate of silver (gr. V. to §j) once a day when the coryza is troublesome. Of the remedies employed in the treat- ment of the malignant form of Scarlet Fe- ver, there is one which stands out from among the rest, the cold aflusion. Yet it is not of equal value in all cas-'s; from the days of Currie downwards the ataxic form of the disease, characterized by de- lirium, diarrhcea, vomiting, full pulse, and great heat of skin, lias been recog- nized as the special indication for this active treatment. The patient is to be ■ For fnller particulars refer to Dr. Thudi- chum's paper. Lancet, Nov. 26, 18(34. seated naked in a bath, two or three buck- etfuls of water at 71)'^ F. are poured o^■e^ him quickly, so that the affusion does not last longer than half a minute ; he is then returned undried into bed, and laid between blankets. The first aflusion hav- ing had a markedly beneficial eflect, should the indication symptoms return in the course of the same day or the next, the water treatment may be repeated, and this even two or three times if necessary. When this treatment has been objected to, or has seemed too bold, I have seen very good results follow from packing the patient in a wet sheet for an hour. A still milder method remains to be men- tioned, that of occasional cold sponging. Ammonia and brandy are nearly always needed, sooner or later, by these patients. [Cold sponging is often very useful in non-malignant, open cases, with high tem- perature and inflammatory eruption. It may be practised more than once a day ; but is especially serviceable for the pro- motion of sleep at night. Some practi- tioners prefer inunction with lard, or the application of glycerin, when the irritation of the skin is gnat. — H.] In the primary adynamic form all treat- ment will be baffled. The cold aflusion is the only means which has seemed to me to be of even momentary benefit. Hot mustard baths, which would at first sight appear to fulfil the indication better, may be tried ; strong tea or coffee, brandy, ether, camphor, are to be given internally. The treatment is much the same, and also, unhappily, the prognosis, in adyna- mia, sequential to an excited state. A full description of the treatment formerly adopted (and not, perhaps, without suc- cess) in cases such as these, will be found in the pages of xVrmstrong. [Certain cases of a dangerous kind, at- tended by stupor, without reduction of temperature or marked feebleness of pulse, are best treated with purgatives and diu- retics. A good combination for this pur- pose is that of jalap, digitalis, and squills. In the more prolonged adynamia, qui- nine is a useful addition to the remedies just mentioned. A most nutritious diet arid a rather liberal allowance of wine will often enable such patients to recover. _ The Hippocratic remedy of warm affu- sion to the head is most soothing in the nocturnal delirium and sleeplessness. However favorable an attack of Scarlet Fever, the patient should be kept in bed for three weeks from the commencement of the disease ; he may then get up, but he should not leave his room for another week. Even after four weeks have elapsed he is not free (if we are to believe some observers) from all danger of albuminuria. If on the morning of the fifth or sixth day any ulcerous appearance that the TREATMENT. fauces may have previously presented does not show signs of yielding, it is vi^ell to cauterize the morbid surface. For the tonsils undiluted hydrochloric acid is to be used ; for any other part of the soft palate, solid nitrate of silver. The latter caustic is to be applied to those excoria- tions which are apt to appear about this time or later. It need hardly be added that these potent escharotics are, as a rule, to be used once for all ; if repeated four or five days at least should have elapsed since the previous application. The ex- ternal swelling should be assiduously fo- mented while in the puffy stage, for as soon as brawniness sets in, anything that may be done will be of very small service ; poultices are to be continued, but the oc- currence of suppuration will hardly be thereby hastened. As soon as suppura- tion has occurred, however small the spot to which the process is limited, an incision should be made to let out the pus ; the poultices being afterwards resumed. The abscess should never be allowed to open itself. In the worst cases of Scarlatina anginosa, openings and counter-openings will be required ; a free discharge of sloughs and ichor affords the patient his sole chance. Should hemorrhage occur, the wound is to be stuffed with lint soaked in the solution of the perchloride of iron ; this moderate pressure will stop the bleeding, which is more often venous than arterial. All cases of otorrhoea are to be treated by syringing the meatus gently with warm water three or four times a day. Should a discharge either from the ear or from the nose become chronic, quinine and sul- phuric acid are the drugs indicated. The suppurative tendency likewise is an indication for quinine, and an abun- dance of fresh air and substantial food. All abscesses are to be opened early. A post-pharyngeal abscess should be evacu- ated if possible (and it mostly is possible) through the neck ; should this be im- practicable, a cut must be made with a guarded bistoury through the posterior wall of the pharynx upon the vertebral column — an operation devoid of risk, if performed with ordinary care. The mat- ting together of tendons is remediable to a great extent by fomentations, friction, and passive motion. The treatment of the rheumatism is that of its symptoms : Dover's powder for the pains, diluents for concentrated urine, aperients if necessary, cotton - wool or poultices round the affected joints. Alka- lies are not of any special value. The treatment of intercurrent pericarditis is often difficult ; whether local blood-let- ting is admissible, and when counter- irritation more or less severe should be used, depend entirely upon circumstances beyond the local inflammation. VOL. I.— 7 The remedies to be employed at the on- set of renal dropsy may be thus arranged in order of importance. First come active purgatives ; elaterium is good, but the uncertainty of the ordinary drug often causes the loss of much valuable time ; compound jalap powder in doses of not less than a scruple to a child of six or eight years of age, repeated at intervals of eight hours, until the bowels act freely, is altogether more trustworthy. The hot- air bath, preceded by a hot-water bath and a dose of autimonial wine, may be used every night so long as the quantity of the urine is much diminished. After four or five such baths the strength of the patient should be carefully estimated, and the baths continued or not accordingly. Dry-cupping, not practicable in the case of children, would no doubt deserve trial in older patients. Vomiting is an inter- current symptom which will perplex the practitioner ; not the least valuable rem- edy will be found to consist of ice swal- lowed in the lump. Diluents should be given as much as possible. It may as well be observed that there is a concen- tration of the urine which is due to insuf- ficient ingestion of liquids or to excessive sweating ; to drhik water freely is all that is needed in such cases to increase the quantity of urine. [Lenionade is not only an agreeable, but a useful diluent in such cases. Among diuretics, digitalis is most valued by some practitioners. The late Dr. L. Gebhard, of Philadelphia, after a very extended ex- perience, considered it one of the best of remedies in Scarlet Fever. Several prac- titioners have reported well of the use of quinine in considerable doses, in scarlati- nal dropsy. — H.] The less acute stage of albuminuria (called the second in the previous pages) requires an altogether different plan of treatment. The bowels nuist not be con- fined, but purgation is no longer neces- sary. Hot-air baths have little or no beneficial effect upon the condition of the urine. When there is much hematuria, gallic acid in sufficient doses may be tried ; it should be discontinued if it does not bring about a decided improvement in four or five days ; to diminish the quan- tity of albumen as such, gallic acid has little if any power. Quinine has at times a remarkably good effect in these chronic cases. But upon the whole no remedy is equal in value to the perchloride of iron. Counter-irritation to the loins will be use- ful, and generous diet necessary. In the great majority of cases the disease tends to wear itself out in time. When exten- sive anasarca is present, the whole condi- tion is more grave ; should the drojisy tend to the lungs and pleural sacs, the danger can hardly be exaggerated. We must try laxatives and diuretics so long DEXGUE, OR DANDY FEVER. as the anasarca remains simple. The liot- air bath may be used cautiously, but there comes a time when it will increase the anasarca rather than diminish it. "When acute hydrothorax or pleurisy with eft'u- sion occurs, the question of paracentesis presents itself, but is rejected not only by experience, but also on a priori grounds ; both sidi's are involved at once, and the lungs mostly- sutter as much as the pleura;. Sloughing of the cornea would probably be preventable in many eases by the sim- ple expedient of keeping the eyes shut, as recommended first by Trousseau. DEXGUE, OR DANDY FEVER. By William Aitken, M.D. Definition. — A febrile affection, sui generis, commencing suddenly, and asso- ciated from the commencement with se- vere pains in the large and small joints. About the third day a peculiar cutaneous eruption or efflorescence appears upon the palms of the hands, rapidly spreads over the whole body, and rarely continues visi- ble beyond twenty-four hours. A distinct remission succeeds, but relapses are nu- merous, and the disease may thus persist about two months marked by prostration and cachexia, its course being character- ized by intervals, or remissions, and the exacerbations marked by rheumatic or neuralgic-like phenomena. SYNONY:\rs. — Scarlatina Rheumatica, Cock ; Exanthesis Rosalia Arthrodynia, Cock ; Dandy Fever, ICatives of West In- dies; Dunga T3ouquet; Bucket; Epidemic Inflammatory Fever of Calcutta, Mellis ; Eruptive Epidemic Fever of India ; Too- hutia, iSTatives of East Indies ; Three-day Fever, Xatives of East Indies ; Rheu- matic Fever with Gastric Irritation and Eruption, Furlonge ; Eruptive Articular Fever; Eruptive Rheumatic Fever; Plan- taria ; Febris Exanthematica Articularis; Giraffe, on account of the stiff holding of the neck ; Epidemic Anomalous Disease, Stedman ; Peculiar Epidemic Fever; Colo- rado, on account of the red spots ; Exan- thesis Arthrosia ; Stiff-necked Fever ; Broken-wing Fever ; Break-bone Fever. History. — During many months pre- vious to October, 1824, there prevailed in Calcutta an epidemic fever so impartial in its attack that few remained untouched by the distemper in a population of nearly half a million of beings. Passing from the East Indies the disease was next heard of in 1S27-8, amongst the islands of the Archipelago and in the Southern States of North America. Between the mouths of September and January of these years it prevailed in the islands of St. Thomas and Santa Cruz. Almost every individual in a population of 12,000 persons is reported to have suf- fered. (Stedman, Ed. Med. and Surg. .Journ. Oct. 1828.) With few exceptions the disease spared no one of either sex, of any age, or complexion, or caste. The new-born infant, the young child, the aged, the weak, the robust, the rich, the poor, all were alike the objects of attack. Physicians too, invariably became pa- tients, and hence perhaps the details of symptoms in the epidemics of this disease are so extremely minute ; and although the disease was a very painful one, it was not one dangerous to life. The attacks were invariably sudden. In families of ten or twelve persons (including servants), a half or even eight members would lie down at once (Furlonge, loc. cit. vol. xxxvii. 18.32). Attention was therefore inmiediately arrested by epidemics of such a disease, and the general public, not less than medical men, were curious to learn the natural historjr of a disease with fe- brile characters so peculiar, and in results so unlike the epidemic or endemic fevers of tropical regions with which the physi- cians of the "East and West Indies had been familiar. When the disease first at- tracted attention in Calcutta, it was gene- rally believed that notliing of precisely the same nature had ever existed there before, unless the disease known to the native "conductors" of India by the name of " the Three-day Fever" were of the same nature. (Cavell, Trans. Phys. Soc. of Calcutta, vols. i. and ii.) For the earliest accounts of this disease we are indebted to the physicians of the East Indies, and especially to Drs. James jSIelhs, Kennedy, Twining, Cavell, and J. Mouat ; and the natural history of the fever given by them was subsequently cor- roborated, in all essential particulars, by the physicians of the Southern States of SYMPTOMS. 99 North America and those of the West In- dian islands, more especially by Drs. Sted- man, Cock, and Furlonge, in these islands, and by Dr. Dickson, of Charleston, in America. [Dr. Benjamin Rush first de- scribed it as occurring in Philadelphia in 1780. — H.] "When the disease was first described by Dr. Mellis, he was disposed to regard it as "inflammatory fever;" but he found that such a name did not fully indicate the peculiar characters of the fever ; nor could it be identified as ex- actly similar to the fever described by CuUen under the name of Synocha ; nor to the fever described by Good under the name of Caunia ; nor to the Febris acuta sanguinea of Hoffinan. Many different opinions have accordingly been enter- tained regarding the nature of Dengue. By some it was considered as a rheumatic fever ; by others as a remittent. Some regarded the complaint as measles ; others as scarlatina. Some considered the fever synocha, with gastric irritation and an eruption associated with it, similar to that which in some constitutions follows fish- poisoning. Treatment therefore varied, alike in principle and in detail. But rather than subscribe to a definite name in any then existing nosology, the physi- cians who first described Dengue preferred comparing the phenomena of the peculiar cases thej' saw, as regarded their symp- toms and secjuelpe, with diseases of a simi- lar kind ; and so the first records of the history of this disease are peculiarly valu- able when the speculations with which they abound are eliminated. Symptoms. — Commencement^ Develop- ment, Duration, Termimitian. — The inva- sion of this disease as a rule was very sudden, and the progress of successive phenomena was rapid. Lassitude, drowsi- ness, heavy sensations in the eyes, fre- quent yawning, slight vertigo, a sense of coldness creeping down the back, or of numbness in the extremities which be- came cold, occasional rigors, pains in the head in most cases confined to the fore- part, or most severe there, acute pain in different parts of the body, sometimes in the larger nmscles and joints, and occa- sionally in the smaller ones, such as the fingers and toes, are among the pheno- mena, one or other of which, or several combined together, suddenly expressed the commencement of the disease ; and in the several epidemics whose histories have been recorded, some of these pheno- mena were more prominently marked than others. As a rule, however, the attac'ks were so sudden that no sensation of any deviation from the usual health indicated the approach of the malady. It often happened that people had a most .violent attack, with severe headache and burning pains in the temples, within three hours after having boasted of their escape from the disorder. (Twining.) In general the patients woke out of their sleeii'with great pain in the head, loins, shoulders, arms, wrists, hips, thighs, and ankles, fingers or toes. (Mouat.) Acute pains in one or both knees, in the ankles, the wrists, or in all of these joints at once (though in general only one was at first affected), marked so suddenly the invasion of the disease, that the symptoms would first express themselves as the person walked along the street. (Stedman. ) The motion of the joint was at first arrested, partly by stiffness, and partly from the pain caused by movement ; and in cases where the symptoms commenced in the lower limbs the patient ft'U to the ground. The most usual mode of attack in the "West Indian epidemics was expressed by a sud- den stiffness, amounting to pain, in one of the fingers — generally the little finger. The stifihess increased, spreading rapidly over the whole hand and up the' arm to the shoulder, so that in a few hours the fingers of both hands became so swollen, so stiff, and so painful, that all attempts to bend the joints were useless. At later periods in the various epidemics the ap- proach of the fever was indicated at least a day before by anorexia, languor, listless- ness, and a white tongue. A dry heat at the scrobiculus cordis was among the earliest symptoms noticed by Twining. The face was soon flushed — a phenomenon often observed by others before it attracted the attention of the patient. Intense headache followed upon the burning sen- sation in the forehead. The eyes became watery and the conjunctiva suflused. The whole countenance appeared bloated and swollen, the face assumed a scarlet hue, and the surface of the skin was every- wdiere flushed. The signs which then predominated were a chilliness extending over the whole frame, quickly followed by pain and weariness in the limbs, a general sensation of stiff'ness or soreness, with a heaviness over the eyes so excessive as to render the effort to open them painfully oppressive, and a headache so severe as to be beyond description. (Cavell. ) Pres- sure over the eyes increased the pain, but light did not affect them. The eye-balls appear to the patient as too large for their sockets, as if ready to start from the head, and the pain in them so intense as to cause extreme distress. The expression of the eyes was ferrety. The lobes of the ears were likewise greatly pained. (Cock.) The rapidity of the pulse, the aspect of the tongue, and the condition of the skin, each of which at first might not seem to be much influenced, yet rapidly passed from their normal condition. The pulse, soon after the accession of the fever, was in most instances above one hundred per minute, becoming more 100 DENGUE, OR DANDY FEVEB. frequent, full, hard, and strong, till it averaged about thirty or fortj' beats per minute above its normal rate, within six hours after the fever became expressed. Twining once observed it 140 in an adult whose usual pulse in health was eighty beats per minute. In some instances its force was so greatly increased that the temporal arteries were felt and seen to beat with violence. In children it was often so extremely rapid as to be indis- tinct and weak. Respiration was rela- tively extremely hurried ; while determi- nation of blood" to the head was consider- ably increased, as indicated by bleeding at the nose, increasing redness of the face and eyes, confusion of thought, and some- times delirium. The tongue soon became of a scarlet color, at the sides, furred with a white or brown coat in the centre, so that in a few hours it appeared as if covered with a dense white paste, or with a thick dirty- white coating, always moist, and asso- ciated with a disagreeably bitter taste in the mouth. The bowels were generally confined at first, while oppression at the prfficordia, nausea, vomiting of viscid mu- cus and of bile were present from the commencement, and continued for some time. Irritability of the stomach was often indeed so very great that it retained anything with difficulty. The desire for food was inconstant. In some cases ap- petite was entirely gone ; but not infre- quently in children, the desire for food was increased. Thirst was not commen- surate with the distress from other symp- toms. Extreme prostration of strength became apparent at a very early period of the disease, and with i-apid increase of pain in the loins, with not less severe pains in the muscles of the limbs, espe- cially the legs, attended with a remark- able degree of anxiety and jactitation. The febrile anguish was extreme, with aching in the back of the neck. In short, suft'ering from pain was a leading feature in the accession and course of the attack of Dengue. The debility, the restlessness, and the general soreness rendered every position alike uneasy and intolerable, not less distressing to the patient than alarm- ing to the spectator. (Twining.) Such was the excruciating nature of the pains, that few had fortitude sufficient to sup- port them without complaint. (Cock.) These pains have been known to shift from one part of the extremities to another ; sometimes attacking the patient in his knees, or in his toes, sometimes in one knee or toe, and sometimes in another ; each new invasion of a part being accom- panied with twitchings of the muscles of the part affected. So sudden were the attacks of pain in a fresh place, that a person ntight be calmly conversing with you when he would suddenly scream out from the severity of returning pain. (Cock.) In some cases the headache and the pain in the back and loins were the most distressing sj'mptoms, although not at all times equally severe during the first twenty-four hours. These pains would frequently subside a little to return in paroxysms with redoubled violence. It was, indeed, a disease of extreme severity as far as relates to the sufferings of the patient ; but having regard to the result of the disease, as affecting life, and com- pared with its universal prevalence, it was a fever of unexampled benignity. Such were the phenomena which, more or less severely expressed, marked the ac- cession of an attack of Dengue ; but to- wards the end of the first twenty-four hours the symptoms, which had gradually increased in severitj', began to abate. The headache and flushing of the face somewhat subsided. The heat became more general and burning all over the ex- tremities, to the relief of the head in some degree. With this remission of the pyrexia, the headache after the second day became still less, and the pains in the loins and other parts were attended with less jactitation ; the character of the pain was changed to that of a dull aching kind, gradually leaving the fingers and ankles, and the toes last of all. During the first two nights there was little or no sleep, in consequence of the pain and febrile an- guish ; and although for several succeed- ing nights sleep was in most cases still interrupted by thirst and pains in the loins and legs, extending down to the toes and fingers, yet there was little or no disturbance of the intellect. Great pros- tration of strength ; general debility of the whole system ; weakness of the stomach, of the loins, of the limbs, of the knees, and of the joints generally ; continued pain in several joints, large and small, sometimes limited to a finger only ; oede- matous swelhng of the extremities ; and general cachexia— denoted the exhaust- ing and debilitating nature of the malady. The debility was so great that sudden death during the period of remission or of spurious convalescence was known to occur in some instances during the epi- demic in Calcutta. The debility was not diminished by the sudden occurrence of perspiration, which during the early hours of the febrile accession had been sujipressed, and, although this return of perspiration was accompanied by warmth of the feet and a remission of all the more distressing symptoms, yet the prostration of strength was all the more apparent. The urine was now copious and pale- colored ; and the evacuations from the bowels, even if freely moved by remedies, were of a dark green color, or even black, glutinous, scanty, and always offensive. During the three days following this re- SYMPTOMS. 101 mission, the patient, in the more severe cases, lay in a state of extreme languor, but irritable and restless ; but as there are no records of temperature in tliis disease, it is not known if fever was entirely absent during the remission, although it is sometimes stated to have been so. It is ratlier to be presumed that the tem- perature did not fall to the standard of health ; for although there was no acute suffering yet the feelings were said to be very different from tliose of health. Thirst continued to prevail in some, and the desire for food did not return. The sense of taste seemed entirely lost ; while in some cases little aphthous sores, on the inside of the lips and on the edge of the tongue, rendered attempts at eating pain- ful in the extreme. (Stedman.) About the end of the third day the febrile phe- nomena again expressed themselves with even increased severity, compelling the patient to return to lied if he had ventured to leave it, deceived by the apparent but treacherous and spurious convalescence. With this febrile exacerbation, the cuta- neous system exhibited remarkable and peculiar phenomena. With great turgid- ity of the skin an eruption or rash ap- peared on different parts of the body. Tlie appearance of this rash has been variously described : (a) As an efflorescence, beginning at the palms of the hand, and gradually spreading over the whole body. In gene- ral appearance this efflorescence differed considerably in different cases. In some it consisted of blotches of red-colored skin, resembliua; in appearance, something be- tween measles and scarlatina. In some it was raised perceptibly above the sur- face of the skin, imparting a distinct feel- ing of roughness and elevation to the fingers passed over the eruption. In severer cases more obvious local swell- ings accompanied the efflorescence, and a distressing tingling of the skin resolved itself into an itching so intense, while the eruption disappeared, that the sufferers were almost driven to distraction. As a rule this efflorescent eruption remained only for about a single day, beginning to fade on the second "day, and before the third morning it was generally entirely gone. Some degree of desquamation fol- lowed, generally in proportion to the intensity of the eruption. One instance is on record, in which a man eighty years of age had the eruption in so severe a form that the cuticle came off in fiakes like pieces of parchment, leaving the sur- face of the body quite red. (Stedman.) The itching was extremely distressing, and the patient was in the utmost misery. In old men, the desquamation from the scrotum was attended with most intolera- hle itching, and in some of them the tes- ticle became swollen to a great degree. In others, extensive abscesses formed beneath the skin, probably of the nature of the pyogenic fever of Tessier and Jenner, and popularly regarded as "the dregs of the fever." In the epidemic at St. Thomas's, two children, each about Ave or six months old, died from the irritation at- tending the di-squamation of the cuticle. The true skin, so exposed, was red, raw, and exceedingly painful from the inflam- mation of its texture. (h) About the third or fourth day an crj-thematous eruption appeared on the hands and feet (Cock), accompanied with swelling of those parts. This eruption gradually extended over the rest of the body, continuing for about thirty-six hours, when it faded, and the cuticle peeled off as in scarlet fever, leaving a considerable degree of soreness. Tlie soles of the feet were sometimes rendered so sore, that walking, for many dajs after restoration to health, was attended with pain. The pains were apt to remain after the eruption had completely disappeared, and to become fixed in one or more of the joints, where they would remain for several months with morning and evening exacerbations ; the pains then were most severe. Sometimes the glands in the groins were swollen and painful. (Cock.) (c) Dr. Furlonge regarded the eruption as altogether symptomatic of the gastric disturbance, lie observed that its hiten- sity and extent were proportional to that disturbance; that those who were ''known dyspeptics" had the eruption more exten- sively than others; that literary or seden- tary people and those whose occupations were such as to derange the chylopoetic organs, suffered most from nausea and other symptoms of gastric disorder, and in them the eruption was always more ex- tensive and marked. This eruption, he thought, resembled measles elevated with papuiaj and wheals; a sort of hybrid be- tween urticaria and rubeola, and of its nature similar to that which is known to attend the gastric disturbance from fish- poisoning. (Ed; Med. and Surg. Journ., p. 52, 1830.) {d) Dr. Mellis regarded the eruption as similar to roseola or to the lichen simplex of Willan. [e) Dr, Twining regarded it as resem- bling rubeola; while in some instances it resembled patches of an inflammatory ap- pearance, in others a papillary, and in one or two instances that of a vesicular erup- tion. In many instances little more than a flush attended the febrile excitement, ( f ) Mouat says of the eruption, that it is like ervthema papulatum, or purpura simplex not disappearing on pressure, and resembling roseola miliaris or lichen tro- picus, (g) In some cases there was said to have been no eruption (Cavell); but when 102 DENGUE, OR DANDY FEVER. the short persistence of the eruption is taken into account, it is not improbable that it may have been overlooked in such cases. In most cases indeed discolora- tion of the skin vras evident from the iirst; and it seems to have been characteristic of Dengue that the eruption which at- tended it assumed many characters. In one case the eruption might be referred to the class papula, in a second to exan- themata, in a third to vesicula, in a fourth to bullae, and in a fifth to that of wheal. But whatever the form of the eruption, all the cases were attended during its con- tinuance with very high excitement of the vascular system, which at last suddenly subsided, leaving the patient convales- cent. The eruption came on suddenly and vanished suddenly, hence it may have been very often overlooked, or its charac- ters might not have been observed, for it does not seem to have gone through any definite changes or marked stages. In some cases it appeared simultaneously with the febrile symptoms, in others not till twenty-four or thirty hours after- wards, and in two or three instances after all fever had apparently subsided. When- ever it appeared the color of the eruption was similar, and the amount of the sur- face covered by the rash of various extent. In proportion to its early appearance it generally portended a further mitigation of the more distressing symptoms, and more especially if the efflorescence uni- formly covered the whole body and the extremities. When the eruption was only partial on the body and less on the ex- tremities, but increased about the chest, neck, and face, there was, for the most part, some increase of feverishness, more uneasiness and anxiety, with aggravation of headache. It remained persistent for a comparatively short time, and had for the most part considerably faded at the end of twenty -four hours after its first ap- pearance, although it might continue ob- vious for two days. It was always at- tended with some degree of heat or itchiness, particularly wTien the minute exfoliations of the cuticle began to sepa- rate during the period of desquamation. It seemed to be chiefly in cases where the eruption remained persistent beyond two days that it assumed the aspect of urtica- ria, affecting more particularly the extre- mities; the fingers and toes, hands and feet being swollen, red, and affected with dis- tressing itching and burning, combined with febrile exacerbations and extreme de- bility for twenty-four or thirty-six hours. Associated with the eruption, some pa- tients had boils; others had small acumi- nated vesicles with hardened bases. Chil- dren suffered most from urticaria, and in them large watery vesicles sometimes led to the formation of ulcers. In one case the sloughing was so deep, the ulcers so foul, and the fever so high, that, convulsions supervening, the case terminated by death. In most instances, if not in all, as in the epidemic at Suzuratte, the throat and fauces were so affected as to make deglu- tition painful. The secretions from the lungs and salivary glands were very co- pious, unhealthj' in appearance, and dis- tressing to the patients. The salivary glands were in some much swollen (the parotid as early as the fourth day), and the discharge of saliva in some instances amounted to ptyalism, although mercury had not been taken. It was also observed (Mouat) that very small doses of calomel frequently induced disagreeable ptyalism. The disease was not considered to leave the patient till he had suffered from a second and even a third relapse or parox- ysm of fever. The relapses were each at one time considered as separate attacks of fever; but the history of subsequent epi- demics showed that these several parox- ysms, each nearly equal in severity (al- though it was not noted where the eruption repeated itself), combined to con- stitute one and the same attack of a fever marked by such peculiar remissions and exacerbations. There were also daily re- missions observed by Dr. Mouat, there being two or even throe paroxysms in twenty-four hours. Few recovered, under three months, from the debilitating effects of the attendant fever and the aching pains in the wrists, fingers, toes, and an- kles. Tardy recovery, and the tendency to repeated relapses, were characteristic phenomena. In these periods of exacer- bation the third days were decidedly "critical" (Kennedy); the pains in the limbs would abate, and the capability of taking food would return; but the furred tongue, the foul taste, and the disordered stomach generally continued for ten or twelve days after the final remission. The secondary prostration of strength evinced itself in proportion to the constitutional powers of the patient. Temales in vari- ous periods of pregnancy went through the severer forms of the fever without any tendency to abortion. Although the actual temperature of the body in cases of Dengue has not yet been recorded, there is reason to belifjve that the fever reaches its fastigium at a very early period — probably within three days ; and during this period the surface of the body is subject to an irregular distribution of the blood, so that while the hands and feet are cold, the rest of the body, and particularly the head, may be intensely hot. During the height of the fever the head and eyes seem to indicate the great- est suffering, but the whole body is racked with pain, especially in the joints. Not an inch of the body from head to foot seems to have been exempt from suffer- ing ; hence the American name of " break- ETIOLOGY AND PROPAGATION TREATMENT. 103 bone fever." In some eases the features, especially the eyelids, were swollen and distorted, associated in one or two in- stances with profuse ptyalism. But al- though the skin in cases of Dengue felt intensely hot to the touch of the observer, yet the patient experienced feelings of intense cold during all the ditfereut stages of the disease. When it prevailed as an epidemic at St. Thomas's, although the weather was extremely sultry, yet the pa- tient felt the warmest coverings (of two or three blankets) scarcely enough. Etiology and Propagation.— The origin of Dengue is unknown. The dis- ease is said to have been first noticed in Bangoon about the end of May or begin- ning of June, 1824 ; and on the lOtli of June a large portion of the troops em- ployed on the expedition under Sir Archi- bald Campbell, then at "Rangoon, had been ordered out to attack the Burmese, and were thus exposed to incessant heavy rains for four-and-twent}'" hours. The disease extended in various direc- tions, not only to Calcutta, but to Chitta- gong in the southeastern extremity of the Province of Bengal, and to Guzerat, in the Presidency of Madras. It was par- ticularly severe in the large and populous towns of Benares, Patna, andChunarghur, and prevailed generally from Buxar to Benares, Churnar, and Mirzapore. In all of these places it seems to have become epidemic during or subsequent to the existence of heavy rains, associated with the close cloudy heat of sultry weather. Heat, moisture, and stagna- tion of air seem to have been always as- sociated with the origin and transmission of the disease. Stedman implies that the disease was imported into the free port of St. Thom- as's, and the accounts of the disease gen- erally show that it was propagated from place to place in the course or route of human intercourse. It travelled from Barbadoes to Jamaica. It raged in America and the East Indies. No dis- ease, indeed, with the exception of influ- enza, ever had so wide a diffusion. From St. Thomas's it proceeded upwards to Barbadoes. It seemed by the mode of attack as if something were applied which in a moment had the power of destroying the balance of health, and of producing a disease, the symptoms of which were so appalling at first sight. Protracted debility, with long-continued pains in the limbs, were the invariable sequelte of the fever. In several instances, tedious visceral disease, mainly of a sub- acute form, especially of the liver, with jaundice, were associated with the pro- tracted duration of fever. Hemorrhoidal artections sometimes preceded an attack of subacute hepatitis with slight jaun- dice. Returns of pains in the extreme joints of the fingers, distension of the ab- domen, anorexia, slight tenderness of the belly, and thirst, betokened the advent of incipient visceral disease. In a few cases the eyes were affected with ophthalmia. (Mouat.) Partial anchylosis is known to have oc- curred in the fingers of the hand. (Cock. ) Diagnosis. — While the severe pains, on the one hand, caused the disease in some instances to be regarded as rheu- matic, the paroxysms of the febrile attack and the intercurrent remissions, on the other hand, caused the disease to be con- sidered as one of a malarious nature. But there was to be noticed the peculiar eruption already described, which, com- bined with the other characteristic phe- nomena, at once stamped tlie disease as one sui generis. The suddenness of the attack, the redness and the watering of the eyes, the acute pain in all the joints, rendered excruciating on the slightest touch, the scarlet or crimson efflorescence on the surface, its ephemeral duration, the disease sparing neither age, sex, nor habit of body, its seizing the acclimatized as well as those recently arrived, stamp Dengue at once as a disease different from the endemic remittent fevers of the coun- tries where it has prevailed. The diag- nostic differences from measles and scar- latina must be studied in connection with the natural history of those diseases. Dengue attacked indiscriminately those who had suffered from scarlatina and those who had not. (Cavell.) Treatment. — Amongst the natives of India, Dr. Mouat had convincing proof that the disease was protracted and se- vere when no remedies were used. Pros- tration and severity were evinced in the great emaciation, the more extreme de- bility, the severer pains and the swollen extremities and the longer duration of the disease, in those cases left to run their own course. Experience has proved that emetics and free eliminative remedies (especially pur- gation) insure an early freedom from fever. Time is no doubt an essential element in relation to the cure of the disease, which seems to run a specific course, and may be aided or retarded by remedies. These remedies have been on the one hand (1) bleeding, on the other hand (2) purgation and eliminative medicines. Twining did not resort to general blood- letting, but in several of the earlier cases in which the head was much effected, he sometimes applied a considerable number of leeches to the temples. A further ob- servation of the progress of the epidemic and nature of the fever convinced him, however, that even leeches were by no lOi ROSEOLA. means necessary, "as other cases with symptoms parallel in nature and severity were as speedily remedied without leech- es. " He considered that general bleeding was not adapted to the treatment of this fever. Cold affusion he also considered a hazardous remedy. The experience of Cavell also proved that depletion did not afford the relief expected of it. So also, Mouat records that bleeding did not cut short the disease, nor mitigate the symp- toms. It added to the exhaustion of the patient ; it impaired the powers of diges- tion ; it induced vertigo during convales- cence, with a tendency to fainting, dis- tressing dreams, and bad nights. It was only of use in cases of local affection of the lungs, liver, or intestines. With reference to purgation, Twin- ning's experience showed that a moderate dose of calomel, combined with an active dose of colocynth and scammony, and re- peated every twenty-four hours, till the evacuations icerefree, and of a more natural and healthy color, were the remedial agents he observed to be followed by the best effects. The use of purgatives ia this way was indicated by the stools being of a dark-green color ; and with tlie dis- appearance of greenness from the stools, the symptoms were ameliorated. Calo- mel is never to be given alone. It is probable that calumba, rhubarb, and soda, combined in equal proportions, will equally answer as au alterative remedy. The eliminative action of purgation is to be obtained without the result of watery purgation ; and so far as the use of purga- tives is concerned, the only objection that is urged against them is the aggravation of the pain which they cause by the mo- tion which their action entails. But the skill of the nurse and the physician must be combined to obviate this very second- ary consideration. Eliminative remedies in an opposite direction were also shown to be of use. Emetics of tartar emetic and of ipecacuanha discharged large quantities of bile, relieving the pains of the head and of the hmbs almost immedi- ately. An emetic given at first always relieved the head and eased the pains; and this evacuation, followed by purga- tion, or even au open state of the bowels, tended greatly to facilitate recovery. A free, open state of the bowels is then best preserved by a dose (every two hours) of tartar emetic and sulphate of magnesia ; or a compound of jalap powder or of sul- phate of magnesia with infusion of senna. (Mouat.) In thirty-six hours after the action of such remedies was obtained the fever was subdued with less prostration of strength than by any other treatment ; but if no bile followed the emetic, the symptoms were not relieved, and it was necessary to repeat it till the bile was discharged. In the cases where ophthalmia was a consequence, leeches applied to the inner membrane of the eyelids sufficed for the cure, with free and repeated purgation. After the bowels were freely opened, a light febrifuge mixture of sweet spirits of nitre, nitrate of potass, tartarized anti- mony, and colchicum, was attended with benefit, given every two hours, with an occasional effervescing draught, a pedilu- vium at bedtime, and ten to fifteen grains of Dover's powder. After all the acute symptoms had subsided, forty to sixty drops of the wine of colchicum, with twenty-five drops of laudanum, always insured a good night's rest, and thirty drops of antimonial wine were now and then added to the draught. (Furlonge.) Tonics (such as infusion of calumba, qui- nine, iron, or strychnia) ought to follow the free action of the bowels. Cordials, stimulants, and good diet, consistent with the habits of the individual patient, must also be thought of, and remedies of a local kind to allay the itchiness of the skin may also be of service ; such as emulsions of almonds, with hydrochlorate of ammonia and corrosive sublimate judiciously com- bined and carefully applied. EOSEOLA. By Hermann Beigel, M.D., L.R.C.P. Lond. D'ETTNiTiox. — Roseola is a disease cha- racterized by the appearance on the skin of spots, separate from each other, of a roseate, scarlet, or dusky red hue ; of minute size, like marks made by the point of a pin ; but which may exist in such large numbers and so close together as to form large patches, of most varied shapes. These are not raised above the surface of the skin ; are not communicated by con- CAUSE COURSE. 105 tagion ; and are generally unaccompanied by fever. AVillan Is known to have described seven forms of Roseola, which number has been raised to twelve by Bateman, Bayer, and Wilson. Whoever wishes to take the form and hue of an irritation of the skin or any other part of the organism as a basis for classification, can, with great facihty, introduce hundreds of new species into medical science. But whether science would gain anything by our calling a pneumonia, in which the inflamed part of the lung is round, pneumonia circularis, or if triangular, pneumonia triangularis, is another question. Quite the same may be said in reference to roseola annulata and punctata ; and if the words a'stiva and autumnalis express anything, which may be taken as a basis for division, we might just as well And in the 365 days of the year material for a division into the same number of forms, not only of Roseola, but of any other disease. Classifications of this kind, which neither define correctly nor are of any utility, ought to be banished from medical science. Those who know the former unpractical, incorrect, and cir- cumstantial classification of ulcers, and compare it with tliat of the present time, simplified and based upon correct observa- tions — admitting what influence nomen- clature has on treatment — will acknow- ledge the necessity of a judicious division in other spheres of medical science, and particularly in dermatology. We may observe Roseola in the course of different, mostly feverish, diseases (Ro- seola symptomatica), or independent of diseases (Roseola idiopathica). The Symp- tomatic Roseola is a part of the disease in the course of which it occurs, and is there- fore excluded from our consideration. We have now only to speak of Idiopathic Ro- seola, which rarely requires medical inter- ference, but which gives us an important hint in reference to the pathology of skin- diseases in general. Cause. — Anything which weakens or lowers the action of the nervous system, and this for a long time, may cause Ro- seola. Severe illnesses — such as typhus or syphilis — which change the vitality of the blood and nerves ; bad nourishment, and general debility, are the common causes of R. symptomatica. Idiopathic Roseola is brought about in a similar manner, but the action of the nervous system is weakened for a short time only. Kot only errors of diet, but some particular kinds of food may produce Roseola. I know a lady who has a regular attack of Roseola, of seven to eight hours' duration, after eating strawberries, and this without any other disturbance ; an- other lady who can voluntarily produce Roseola by getting hot through dancing or other exertion and by drinking water afterwards. The eruption constantly ap- pears in about half an hour, causes no other disturbance, and disappears after several hours. I attended a child who was troubled by hooping-cough. The milder attacks passed as usual, but the violent ones, during which the whole body of the little patient took a dusky hue, al- ways brought on Roseola, which after a few minutes disappeared. That sudden changes of temperature may produce Roseola is well known ; and its appearance during dentition is remark- able. Sometimes it comes and goes so quickly, that a child, while teething, may exhibit five or six attacks during the course of one day. These attacks are usually unaccompanied by any pain. At the first appearance of the eruption, an anxious mother may send for the physi- cian ; but, so transient is its duration, that often, when the doctor comes, there is nothing to be seen. I am attending a family of two little boys and two daugh- ters, and both of the boys have exhibited the phenomena of Roseola to a very high degree. The boys, who are strong and healthy, exhibit it at the commencement of every trifling indisposition, and this quite independently of dentition. Tlie girls, who are twin-sisters, have not suf- fered. It is not rare, however, for Ro- seola, in some women, to precede every menstrual period. It would appear, therefore, that Roseola depends immediately upon changes in the vitality of the blood and nerves ; and we may be tolerably sure that if another Willan — endowed with Jussieu's capacity for observing nature — should appear, we should find Roseola, and many other skin diseases, ranging among the diseases of the nervous system. Course. — Idiopathic Roseola appears almost feverless ; yet feverish symptoms may exist, although they never reach a high degree. Headache, excited pulse, constipation, want of appetite, disturbed sleep, itching may occur, but their occur- rence is rather the exception than the rule. In the majority of cases Roseola idiopathica occurs suddenly, over a large surface, and without marked forerunners ; it remains a few hours or days, and either disappears as suddenly as it came on, or turns into a more dusky hue, becomes at length pale, and a fortnight may expire before the last spots vanish. But it may happen that the rash disappears on one part of the body while new spots make their appearance on another. In other cases a few little red dots may occasionally be discovered and increase in number until the body is partially or to- tally covered with them. I never saw slowly developed Roseola disappear sud- 100 MEASLES. dt'iily; but slowly as it came. The mu- cous mi;mbranes may participate in tlie eruption, but tliis is mostly observed iu dentition, when tliese membranes are al- ready affected. That the same individual may repeat- edly )jc subject to the eruption, is evident from the above statement. Diagnosis. — Roseola bears the greatest resemblance to flea-bites, and to those partial inflammations of the skin which are caused by the stings of other insects. But bites and stings are distinguished from Roseola by the black central spot which, in an early stage, is clearly seen in almost all of them. Erythema Roseola differs in the fact that its confluent spots are raised above the level of the healthy skin. With measles and scarlet fever Ro- seola cannot be easily confounded; for be- side the symptoms proper to those exan- themata, the skin, in the latter, is in a state of turgescence, and forms a red basis for the eruption, whereas in Roseola the skin between the spots is healthy. Its ex- tremely mild course, independence of epi- demic influences and character, and the absence of catarrhal phenomena, are suffi- cient to distinguish Roseola from measles. Prognosis.— Idiopathic Roseola is a slight aftection which never reaches a de- gree causing anxiety. Even in those cases where Roseola occurring during dentition is accompanied with fever, we scarcely have a right to refer the latter to the eruption, as it forms a symptom, which often occurs in dentition without being followed by Roseola or any other eruption. Treatment. — Cases in which Roseola idiopathica requires medical interference seldom occur. The eruption comes and dis- appears without any disturbance of the general health. But if there exists a local irritation which keeps up the eruption or causes its recurrence, then, of course, it must be removed. Ascarides, which often cause Roseola, must be expelled ; gentle laxatives will be applied against constipa- tion, and impaired appetite improved by carbonized water, soda, seltzer water, and by dilute mineral acids, particularly phos- phoric acid. If during dentition the ne- cessity arises to lance the gums, it will not be Roseola which necessitates this proceeding. MEASLES.^ By Syda^ey Ringer, M.D. Definition. — An acute febrile conta- gious disease, mostly occurring in epi- demics. It generally attacks the patient but once, but sometimes again occurs after the interval of a few months, or many years. Relapses are very rarely met with. They may commence imme- diately or three or four days after the fe- ver of the first attack has declined. Generally coexisting with epidemics of other diseases, it is especially related to hooping-cough. The one disease appa- rently predisposes to the other. Thus often an epidemic of Measles precedes one of hooping-cough, or vice versa. In the latter case, the paroxysmal cough may continue, or temporarily disappear during the existence of the Measles. It is stated that persons with pulmonary disease, such as bronchitis, are especially apt to catch the disease. The period of incubation, in those cases in which the disease was produced by in- oculation, was seven days. Synonyms.— Measles ; Flecken ; Ma- seru ; Morbilh ; Rubeola ; Rougeole. Symptoms. — Measles is generally ab- rupt in its commencement, and is then ushered in by chilliness which may amount to rigors, or not uncommonly, in children, to convulsions ; or, on the contrary, the invasion is so insidious that it is impossi- ble to determine with accuracy the first day of attack. The disease, when estab- lished, is accompanied with a variable amount of prostration, but which is usu- ' For much of tlie information contained in this article, the author is indebted to Wil- lan's Miscellaneous Works, Dr. Armstrong's Practical Illnstrations of Scarlet Fever, Mea- sles, &c. ; Trousseau's Clinical Lectures, Graves's Clinical Lectures, Hebra, Eilliet et Barthez's Maladies des Enfants, .Journal fiir Kinderkrankheiten, Schmidt's .Jahrbucher, Ganstatt's .Jahresbericht, Aitken's Practice of Medicine, Parkes on the Urine. VARIETIES. 107 ally not extreme, and sometimes amounts only to a feeling of lassitude. The pa- tients take voluntarily to bed, and are in- disposed to either physical or mental exertion. They are fretful and irritable, in some cases only when disturbed ; in others they are constantly restless, whin- ing, and peevish — differences dependent on peculiarities inherited, or developed by bad education. The expression is va- cant, and the powers of perception and reflection are much impaired. Delirium is in some cases present, always slight and usually limited to the nigiit. " The skin is hot and dry; the lips are parched, and in severe cases covered with sordes ; the tongue, thickly coated, is mostly moist, and a few red papillae may be often ob- served to project through the thick coating of fur. The appetite is much impaired, and the thirst often extreme. Vomiting not infrequent at the commencement, may be repeated and persistent, and then indicates a severe attack of the disease. The bowels, in some cases confined throughout, are often relaxed, and are generally easily influenced by medicine. Diarrhaa not unfrequently first occurs at the period of the eruption. Usually from the very commencement the mucous mem- brane of eyes, nose, mouth, and respira- tory tract suffers changes. The conjunc- tivae are injected, and the eyes suffused with tears. There is generally some in- tolerance of light, and occasionally the patient complains of a sensation as of Band beneath the lids ; the eyelids are swollen and red at the edges ; there is often repeated sneezing, with at first a thin watery discharge from the nose ; epistaxis not infrequently accompanies the coryza at its commencement. The mucous membrane of the mouth and throat is mottled with redness, and a feel- ing of weight and tension over the frontal sinuses may be complained of There is generally some soreness of the throat, but without much swelling of that part. The cough is dry, hacking, and frequent, and there is a feeling of weight and oppression at the chest, at which part wheezing and rhonchal fremitus may often be felt. The voice is often hoarse ; the respirations are hurried and shallow : the pulse is in- creased in frequency, but loses in force. The urine is scanty, and deposits an abundance of lithates on cooling. In rare instances severe pain in the abdomen has been noticed, with or without diarrhoea ; pain and tenderness have been sufficient to lead to the idea of peritonitis, but they entirely disappear on the resolution of the rash. Usually on the fourth day from the commencement of the disease the charac- teristic rash appears. First noticed on the forehead close to the scalp and on the chin, it from thence spreads oxax the face. trunk, and extremities, in the accomplish- ment of which it occupies a period vary- ing from a few hours to two days. On tlie appearance of the rash the fever is stated to increase ; it certainly does not diminish. The lachrymation of the eyes and injection of the conjuuctivte become more marked. There is slight s^velling of the whole surface of the body (if the rash be abundant and general) ; this is especi- ally noticeable in the face, and causes a variable amount of alteration of the fea- tures, so that in some cases the patient can scarcely be recognized. The feet and hands at the same time feel full and tense ; deafness may be present, being due to the swelling of the mucous membrane of the Eustachian tube. The cough at this time generally in- creases in severity, and is occasionally rather paroxysmal. Examination of the lungs reveals so- norous, sibilant, and even a small amount of submucous rhouchus, the latter being most abundant at the bases of the lungs. After the second or third day of the eruption the fever disappears, the tempe- rature becomes normal, the pulse much less frequent, and the patient at once enters on the period of convalescence. The period elapsing before perfect health is restored varies greatly ; in some cases the recovery being rapid, in others prolonged to an indefinite period, this diversity being dependent on the previous state of healtli of the patient. Tlius, if the health has been impaired by excesses of any kind, or by bad hygienic conditions of life ; or if the patient be tlie subject of tuberculosis, sorofulosis, or S3'philis, the recovery is often very greatly retarded, and more or less serious sequels often result. Further, other conditions being the same, recovery is more speedy in the young than in the old. Varieties. — The severity of the dis- ease varies greatly, and has thus led to its division into Morbilli mitiores and Morbilh graviores. Occasionally the dis- ease is unaccompanied by any catarrhal symptoms, and is then termed Morbilli sine catarrho. This latter form is said not to protect the patient against another attack. Morbilli mitiores has already been described. Morbilli graviores. Malignant Measles, or Black Measles, appears to have been far more common formerly than at pres- ent ; still, cases do now and again present themselves. Due either to individual peculiarity, or more commonly to a previously depraved state of health, or to epidemic causes, it may begin mildly, or the symptoms may be at once violent and severe. Usually the rash is but imperfectly developed, and partial in its distribution, of a Uvid, pur- 108 MEASLES. plish, or even black color, apt to disappear and again appear. There are marked prostration, great treuiulousuess, twitch- ing of the muscles, dehrium low and muttering in character, stupor or partial coma. The lips and teeth are covered with sordes, the tongue becomes dry and brown, the pulse is rapid and feeble, the respirations are hurried, and often the symptoms of congestion of the lungs are present. The extremities are cold, and petechial spots appear on various parts of the body.' The urine may contain blood, and bloody effusions are found in the vari- ous cavities and organs of the body. Death usually occurs early ; should the patient rally, convalescence is much pro- longed, and death not infrequently results from diarrhoea, bronchitis, or other of the sequelae. Bash. — Usually appearing on the fourth day, in some instances it is noticed as early as the first, or may be postponed to the seventh or eighth day of the disease.^ 1 Dr. Veit (in Virchow's Archiv, Bd. xir. Heft. 142 ; reported in Canstatt, iv. p. 225, 1S5S) states tliat petechial eruption is in some cases dangerous, whilst in otliers the disease runs a favorable course. When serious, he says that the condition is brought about by previous excesses or irregularities of life, and that sucli cases are met with in all epidemics. He states that if the rash be at its commence- ment petechial, it is not an unfavorable sign ; but that if it subsequently become so, if the rash change from wine-red to black, in form of round spots, extensive patches, or in streaks, then it is of almost fatal significance. It is certain that not unfrequently small petechial spots may be met with on the uppc r part of the chest, and occasionally elsewhere, in cases which run a favorable course ; but extensive and numerous petechias, especially if seated on the legs, are to be looked upon as of very serious import ; though less so than if they occur in scarlet fever or small- pox, in which diseases their appearance war- rants us in expecting a fatal termination ; nevertheless, though this is the rule, cases of extensive petechial rash do occur, which run throughout a favorable course. [During the civil war in the United States of Ame- rica, quite a considerable number of cases of measles occurred amongst the soldiers, often assuming a typhous or malignant character ; the rash being ill developed, or petechial and dark purple in color, with a tendency to prostration throughout the attack. These cases corresponded very nearly with what was formerly called Black Measles. — H.] ' Of twenty-eight cases — In 1, the rash appeared in twelve hours. 2, on the 1st day of the disease. 6, " 2d " 6, " 3d " 10, " 4th " 2, " ."ith " 1, " 6th The commencement of the disease in these Earliest seen on the forehead, close to the scalp, it from thence rapidly spreads to the rest of the face, then to the trunk and lastly to the extremities, in the accom- pUshment of which it occupies, in some cases but a few hours, but more commonly three days. On the first day chiefly limited to the face, it increases greatly in quantity over the trunk on the second and is most abundant on the extremities on the third day of the eruption. The development of the rash is best observed on the trunk. There are earliest seen minute red, not elevated points, probably the papillre of the skin reddened, and but little, if at all, enlarged. These rapidly develop, increase in breadth, and become elevated and acuminate in form, the diameter measuring at this stage about a line. In their further growth they increase chiefly laterally, and thus become flattened. The ultimate size they attain varies, although sometimes not advancing beyond the size mentioned when they are acuminate ; they may become as large as a pea : in the former case they can be felt, and seem to be but slightly elevated ; in the latter they feel hard and even " shotty, " though this is always much less marked than in the rash of smallpox. The amount of the rash varies greatly. At first much scattered, fresh spots quickly appear on the previously unaf- fected skin. The spots are generally grouped, and often assume the form of crescentic or irregularly circular patches. Always at first discrete, they may become so numerous, that on enlarging laterally they coalesce and form patches of various size, sometimes sufficiently large to cover the chief part of the chest, or one or other of the extremities. These patches for the most part have their long axis across the trunk, they are always abruptly elevated, and the redness is sharply defined, though generally irregular in outline. Should the rash be very intense, the surface and red- ness of the patches are quite uniform ; but mostlj^ in the redness numerous small papilte' can be seen, and even in the for- mer case, on the decline of the rash, the papillfe become visible. Mostly abundant on the face, the quan- tity of rash developed becomes less the lower we descend, and the eruption is often only thinly scattered on the furthest extremities of the body. The individual parts of the rash have a very short duration. Each spot, usually at its height in twelve hours, has often in cases was dated from the very earliest symp- toms noticed or complained of. For some of these cases the author is in- debted to Mr. Butt, and also to Mr. J. Bartlett, of Netting Hill. ' These are much larger than the punoti- form elevations seen in scarlet fever. VARIETIES. 109 twenty-four hours again subsided ; so that no elevation remains judging by both sight and touch — a mere red mottling being left. The rash declines in the order of its invasion. In rare instances, if the eruption be intense, small, clear, acumi- nate vesicles may be developed at the sum- mit of the papillffi, or minute petechife may occur ; these latter, usually not nu- merous, are perhaps most frequently met with on the neck, upper part of the chest and the bend of the elbow. Though generally described as of a rose color, the rash appears to the author to be a mixture of red and yellow, the red greatly predominating at the beginning of the eruption ; but as the spots enlarge and become flat, the redness declines, and tlie yellow tint becomes much more appa- rent. It is of a brighter and more intensely red tint at those parts of the body which by exposure have become florid. It is thus well marked on the face and the hands. On the palms of the hands and the soles of the feet the papules generally look deeply situated, as if indeed they were placed beneath the cuticle. By pressure the redness disappears, and a slight yellow discoloration of the skin remains. After the rash has lost its elevation, a reddish coppery discoloration is left. The redness (which is most marked and re- mains longest on the face, where the vas- cularity of the skin is greatest) is always removable by pressure, quickly declines, and leaves a coppery discoloration. This coppery discoloration on the other hand is unaffected by pressure ; occurring in spots a few lines in diameter, it is ill-defined in outline ; sometimes of a uniform color, but more generally punctiform ; is propor- tionate to the previous intensity of the rash, and is consequently most marked on those parts of the body where the rash is most developed : hence it is well seen on j the face, upper part of the trunk, but { especially on the shoulders and over the scapular regions. It lasts a variable time, [ but has mostly disappeared by the tenth or twentieth day from the commencement of the disease. The rash occasionally departs from the above description, in respect both of its nature and its course. Thus it may ap- pear first on the trunk, and then spread, sometimes involving, at others leaving free, the face ; or the face may be the only part affected. In some cases it is very limited, the rest of the surface remaining free from rash. It is apt to appear earliest and to be the most marked in the neigh- borhood of sores or inflamed parts of the skin. Sometimes, owing to a serious internal inflammation, mostly of the lungs, the rash suddenly recedes and may entirely disappear. The desquamation is always slight, and is most marked on the face, or where the rash has been confluent : it is limited to the discolored patches of the skin, and sometimes is only seen when the skin is tightened and viewed sideways ; it begins usually on the sixth or eighth day of the disease, and continues eight or ten days. The scales tliat are separated are usu- ally very fine, often scarcely visible, un- less dropped on a black ground. It is very rare for continuous pieces of the cuticle to be thrown oft'. The elevation of the temperature, or fever, varies greatly in degree. The high- est temperature reached in ordinary cases is usually 103° Fahr. If the temperature rises above this, it indicates a severe, if it continues below this, a mild attack. The temperature corresponds, in respect to its daily or other variations, to that of most fevers ; thus it cannot assist us to make a correct diagnosis in doubtful cases. The fever is stated to increase till the eruption and catarrhal symptoms reach their height. As measured by the temperature, the disease has a ver}' variable duration ; in some cases declining on the fourth, or continuing to the eighth or tenth day of the disease.' At the end of the disease, the tempera- ture (i. e. fever) suddenly and greatly de- clines, but still usually rises slightly (to 100'^ or 101° Fahr.) on the one, and some- times two days following. After this, it becomes normal, and continues so through- out convalescence ; or it sinks for some few days below the point usual in health.^ The glands behind the javv', down the neck, and in the groin become enlarged. The degree of enlargement behind the jaw is regulated by the amount of throat affection ; that of the glands in the neck and groins, by the amount of rash present: hence the enlargement is greater in the neck than in the'groins. The glands usu- allj' resume their proper size from the sixth to the tenth day of the disease. The enlargement is rarely so great in an}' of these regions as it is in scarlet ' Of 14 cases — 2 ended on the 4th day. 4 " 5th " 4 " 6th " 2 " 7th " 1 " 8th " 1 " 9th " It is right to state that in many of these cases the rash appeared before the fourth day, in several even on the first or second day, cal- culating from the day on which the very earliest symptoms appeared. 2 Tlie temperature in convalescence from all diseases is often below par, is easily de- pressed by exposure, nnd moreover is very slow to rise again after it. 110 MEASLES. fever. In both diseases the enlargement is greater, the amount of irritation being the same in persons wliose previous health has been bad, and thus the degree of en- largement serves as an indication for the treatment of the patient. There may be no aiiection of the mu- cous membrane of the eyes, nose, throat, and lungs. Mostly, however, the whole of the tract suffers. On the conjunctiva, especially of the lids, is seen much fine capilliform and ramiform injection ; the former declines as the rash fades, but the latter remains a few days longer. The suffusion of the eyes usuallj' con- tinues some days after the injection has left, and in some cases may be noticed on the twentieth day of the disease. Discharge from the nose, at first clear and watery, is one of the earliest symp- toms observed. The mucous membrane of the alffi of the nose is red, and not un- frequently excoriated. On the decline of the rash, the inflammation also subsides ; the discharge may cease immediately, but more commonly it becomes muco-purulent, and continues for a few days longer. If, however, the child has been badly nour- ished previous to the fever, or is the sub- ject of the scrofulous diathesis, these symptoms are apt to be much more marked and of longer duration. The ate of the nose are rather swollen. The mu- C0U.S membrane, much excoriated, easily bleeds. The discharge is either thin and sanious, or thick and muco-purulent. This accumulates, dries, and blocks up the orifice. The upper lip may become much enlarged, hardened, and at first painful. The prolabium often cracks, bleeds, and scabs. These conditions may last from three weeks to as many months. Occasionally the discharge from the nose brings out an attack of eczema on the lip, which may spread over the rest of the face. These appearances, being due to the previously impaired health of the child, become important indications in respect of the treatment. The mucous membrane of the lips, gums, cheeks, soft and hard palate, usually red- dened, in rare cases remains normal. The intensity of the redness varies, and it is not equally distributed, being usually most marked on the gums' and lips. On the cheeks and palate the redness, some- times uniform, is mostly mottled. The gums are much reddened, rather swollen, and easily bleed. On the lips the redness, whilst imiform, is more intensely marked at places forming spots, mostly round, sharply defined, and especially noticeable in the neighborhood of the frajnum. Al- ' Especially that part corresponding to the incisor and canine teeth. most always on the gums, often on the lips, and occasionally on the cheeks and solt palate, are seen thin opaque white patches or films, looking as if the mucous membrane had been swept over with a solution of nitrate of silver ; these vary in size, are often sharply defined, can be easily removed, and leave the mucous membrane entire, but red and sometimes bleeding. On the decline of the rash and fever, the inflammation of these parts subsides. The redness for the most part disappears, leaving only a coarse rami- form injection, best seen on the lips. The swelling of the gums subsides, but the whole mucous membrane retains for some time a swollen, spongy, and not unfre- quently a glazed appearance. The white patches cease to enlarge, thin away, espe- cially at their edges, and finally disappear; often, however, remaining for ten or fifteen days. Occasionally ulceration is observed, usually slight — but sometimes severe- commencing close to the teeth (especially the incisors), appearing generally after the fever has subsided, tjut sometimes as late as the tenth or twelfth day of the dis- ease. If slight, this usually heals in three or four days. It is noticed mostly in sickly children. Aphthae, and superficial, sharply cut ulcerations — usually small, round, or oval, but occasionally as large as a shilling, and irregular in outline, covered in some cases with an ash-gray, easily removable exu- dation, at others by a tough, smooth, leathery adherent membrane — are some- times seen on the gums, lips, tongue, Ac. They especially occur in certain epi- demics. Of no danger, they heal in a week or ten days ; the membranous form being more obstinate, lasting sometimes three weeks. The tongue is rarely clean throughout ; mostly thickly coated, moist, and with a few red prominent papillse, it is sometimes dry and brown, the latter state indicating much depression, and being suggestive in respect to treatment. It begins to clear from the fourth to the eighth day of the disease. The fur is at first thrown off iu the form of patches — leaving clear spots, sharply defined, oval or round, and about two to three lines in diameter. The rest of the tongue becomes clean by the eighth to the twelfth day, but still the patchy appearance remains, and can often be seen till the twelfth or fifteenth day of the dis- ease. If any intercurrent disease super- venes, the tongue remains coated for a longer time. The tonsils and mucous membrane of the pharynx, generally red and rather swollen, may be severely aflfected, and the tonsils may be so enlarged that they nearly meet. The mucous membrane, red, and at first dry, on the subsidence of COMPLICATIONS AND SEQUEL.E. Ill the, inflammiition, becomes moist and cov- ered with much muco-purulent matter. This ceases in a few daj'S, leaving tlie mucous membrane spongy and sodden in appearance. Whilst the inflammation lasts, there is usually some pain, especi- ally on deglutition. This is usually not severe. The Eustachian tube may be in- volved, and there is then great pain, and difficulty of hearing. This is uncommon. Vomiting, not common except at the very onset of the disease, may be persist- ent and continuous, the blandest food being immediately expelled. Sometimes the vomited matters are of a grass-green color, usually at the same time there is diarrlioea with motions of a similar color. Such vomiting only occurs in serious cases, and calls for a grave prognosis. Diarrhoea, beginning usually at the time of the eruption, "is not infrequent. Often severe, and sometimes bloody, it may cause death in young children. The color of tlie motions varies ; they are light-colored, clayey, and sometimes green. The diarrhoea continues for a va- riable period, often after the fever has subsided, even to the tenth or twelfth day. The motions may continue clayey in color after the}' have become less fre- quent and of greater consistence. During the course of the disease, and for some time after, the bowels are very easily influenced by purgatives, a .fact that should be borne in mind in the treat- ment of the disease. The diarrhoea lasts longest in the weak aild sickly. The cough, at first hacking, frequent, and troublesome, in a few days becomes more annoying, violent, ringing, clang- ing, or often paroxysmal in" character ; sometimes so violent as to cause retching, and even vomiting: it usually greatly im- proves when the rash fades, and often disappears in a few days more. It may, however, continue for some time, retain- ing its paroxysmal character. The cough may become paroxysmal as late as the eleventh or fourteenth day. Expectoration, at first scantv, clear, and viscid, on the decline of the rash and the subsidence of the inflammation of the bronchial tubes, becomes muco-purulent, abundant, sometimes of a bright-green color, and nummulated, the mas'ses float- ing in a clear, thin watery fluid. It usu- ally quickly lessens in quantity, and mostly disappears by the tenth or twelfth day of the disease. Urine, scanty, and on cooling deposit- ing an abundance of lithates, has gener- ally, during the fever, a peculiar yellow color. Albumen in small quantities is frequently, blood less commonly, found during the fever days. Both the urine and breath have a peculiar odor. This, in the author's experience, is only met with in children, in whom it can be detected in all acute febrile diseases, especially when the mucous membrane of the mouth is afleeted. CoMrLicATiONS AND Sequelje are either tlie usual anatomical lesions, so in- creased in severity, or continued after the fever has declined, as to become of serious importauce ; or intercurrent diseases not usually attendant on Measles. Very va- rious in nature, and often of great seve- rity, they not unfrequently terminate in death. They vary in different epidemics, and are, to some extent, influenced by the season of the year. Pulmonary affections are more common in winter than summer. Some are moreover dependent on the pre- vious depraved health of the patient, such as the gangrenous inflammation. Convulsions, not uncommon in children at the very commencement of the attack, are usually without danger. They may however be repeated, and terminate fa- tally. Occurring by no means connnonly, at a later period of the disease, they are then usually repeated, and accompanied with some severe internal inflammation, mostly of the lungs. At this period they are generally fatal. Laryngitis, commencing with slight cough, soon followed by much oppression at the chest, hoarse cough, noisy and stridulous breathing, occurs before the eruption, or with a recession of the same. It may be croupous or diphtheritic. It mostly disappears on the evolution of the rash, and, if not then, on the decline of the fever. Chronic inflammation of the larynx is commonly met with, and generally proves obstinate. It disappears only to return again on slight exposure to cold. The voice and cough are hoarse, and some- times at the same tiine there is deafness in one or both ears. When the latter oc- curs, the tonsils are usually enlarged, and at the same time the patient snores much during sleep. This aflection may continue to recur for several years. Chronic inflammation of the bronchial tubes, with or without the last-mentioned sequelae, may follow Measles. The cough is hollow, ringing, hacking, or sometimes paroxysmal, and is easily aggravated by exposure to cold. Witli or without ex- pectoration, but accompanied usually by some oppression of breathing, it may con- tinue with remissions, or for a time dis- appear ; but may, for years, return on exposure to shght exciting causes. Capillary bronchitis may occur either during or subsequent to the decline of the fever. It is almost always fatal in young children under two years of age. Pneumonia, simple or lobular, occurs both as a complication or as one of the sequelas. 112 MEASLES. The symptoms of lobar pneumonia are mostly wl'U marked and characteristic ; they may, however, he masked or take on the character of those of typhoid fever. Lobular pneumonia, by no means un- common, is often difficult to diagnose. The fever is high, the respirations are much hurried, the nares act strongly vfith respiration. Dulness on percussion of the chest is absent always at the commence- ment, and sometimes throughout the dis- ease. There is heard, irregularly scat- tered over the whole of both lungs, fine crepitation — occurring with both inspira- tion and expiration — but in cliildren this crepitation is by no means easy to distin- guish from the subcrepitant rhonchus of bronchitis. In bronchitis the rhonchus is at first limited to, and always most marked at, the bases of the lung. It is usually larger and more evenly distributed than the crepitation of lobular pneumonia, which is generally limited to different parts of the lungs. In bronchitis the fever is mostly less severe, and there is greater lividity of the lips, with less disturbance of the respiration. But, though the above differences often hold good, yet cases oc- cur in which it is often impossible to make the diagnosis. Its influence on the rash is greater than that of bronchitis, the fever being higher. Broncho-pneumonia is by no means un- common eitlicr as a complication or one of the sequelffi of this disease. The disease begins as ordinary bronchitis ; this in- creases in severity ; alnmdance of loose, 8ubcrci)itant rhonchus is heard over the chief part of the lungs, at first limited to, and always most abundant at the bases. This is at tirst moist and distant ; but as the consolidation advances, it sounds very superficial, ringing, dry, and high-pitched. This change in the character of the rhon- chus is usually tlie only sign by which it can be told that the bronchitis has passed into broncho-])neumonia. For mostly all dulness is absent ; nay, there may be, and at first generally is, increased resonance, whilst the respiratory sound is merely harsh, or completely covered by the rhon- chus. If the consolidated portions coa- lesce, dulness may be developed, and tubular breathing caught, but this only happens in rare and very severe cases. In this affection the fever is very high, the nares dilate greatly during respiration, the face is livid, the respiration very greatly labored, the jugular vein often full, and the expectora.tion, where it oc- curs, is bronchitic in character.' The child very frequently, perhaps generally, sinks ; the surface becomes cool ; the pulse weak, feeble, and fluttering ; the respira- tion superficial : the expired air cool ; sordes collect on the teeth and gums ; delirium of a low muttering character is present. There is a muscular trembling, picking of the bed-clothes, and after a period varying from six to twelve days the child dies. It mostly occurs in children from two to six years of age, and is very frequently fatal. Its duration is said to be two to four weeks, but the child either dies be- fore, or the fever subsides on the eighth or tenth day. Ehonchus may continue to be heard some time longer. Beginning as simple bronchitis, the in- flammation spreads laterally from the fine bronchial tubes, producing minute red spots or streaks. Red and then gray hepatization soon follows, and little bodies varying in size from a millet seed to a pea are formed. Ulceration may begin in the mucous membrane of the bronchial tubes of the hepatized tissue and spread laterally, till small cavities, filled with a grayish tena- cious fluid, are formed. A bright red line in the hepatized portion, and bound- ing the cavity, may be seen. These hepatized portions of lung may be so numerous that as they enlarge laterally they coalesce, and thus much of the lung maj' become completely consolidated, and such portion is sometimes riddled with small cavities. When in the state of red hepatization, the little bodies mentioned look not unlike tubercle, but they are most abundant at the base, less sharply defined, stand out less prominently, are less dense, and are at the same time more granular-looking. Gangrenous inflammation of the mouth usually begins insidiously : it occurs some- times during, but mostly after, the fever. There is at first slight excoriation, the in^ flammaiion then quickly spreads, the parts become much swollen, and the eye may be closed. The tissues become hard, red, and painful. The surface is some- times at first covered with a dirty, fetid, gray exudation. The tissues slough, the cheek may be perforated, the gums de- stroyed, and the teeth drop out. Both cheeks may be affected. The affection is only met with in children, who almost always die. ' Similar inflammation occurs sometimes in the vulva. Acute tuberculosis or chronic phthisis may occur during the course of the dis- ease, but it usually first gives evidence of its existence after the fever has declined. Acute tuberculosis follows Measles more frequently than any other of the acute specific diseases, hooping - cough being perhaps excepted. Bleeding at the nose in rare cases may be so great as to endanger life. Inflannnation of the ear may at first ' Children under twelve rarely expectorate. See Cancrum Oris. Vol. II. DIAGNOSIS. 113 escape notice. The child cries greatly, and apparently witliout cause, and puts its hands to its ears. There may be some redness and swelling of the meatus. On the third or fourth day a muco-purulent discharge occurs. [Inflammation of the eyes (conjuncti- vitis) is far from uncommon ; sometimes leaving the eyes in an irritable state, in- capable of much use, for a considerable time. Examples of blindness from this cause, if they occur, must be rare ; but such are said to have occurred ; probably from neglect of the ophthalmia present during the attack and convalescence. — II.] Gangrene of the lung, diphthcritis of the labia, acute Bright's disease with anasarca, and some other complications, may occur. It may be added that the complications occurring during the eruptive period are usually without danger. DlAOKOSls. — This is made chiefly from the rash, and the co-existing coryza. As the rash in the different stages some- what simulates that of scarlet fever, ro- seola, smallpox, typhus fever, and syphi- litic roseola, the distinction between these rashes must be mentioned. ' Scarlet Fever. — The rash appears on the second day of the disease. It is very generally diffused. In Measles the pa- pillss are often widely scattered. The elevations always present in scarlet fever are very small (punctiform) ; those in Measles much larger (papilliform). Where the rash of the Measles forms patches, the elevations seen in the general redness are larger than those of scarlet fever ; the edges of these patches in Measles are sharply defined and abruptly elevated ; in scarlet fever, ill-defined and not at all elevated. Occasionally in scarlet fever there arc a few prominent elevations on the arms and legs ; these may be mistaken for the pa- pilliE of Measles, but the rash on the rest of the body is sufficient to establish its true nature.'' The tint of redness in most cases ' The rasli of Measles is often, at its com- mencement, compared to that of flea-bites, hut the differences between them are always well marked, and by the most superficial ex- aminations they can be distinguished. Flea- bites take on two different forms. In the simpler there is no elevation, but a central point of redness, not removable by pressure, surrounded by a small ring of a less intense color ; this latter redness disappears on pres- sure. In another form there is a round firm swelling, varying in size, often as large as a pea ; this itches greatly. It has all the cha- racters of the wheals found in urticaria. ' It is stated that tlie two fevers may co- exist, and that these rashes may be mixed. No such case has come under the author's notice. [See article on Riitheln. — H.] VOL. I.— 8 is different in the two eruptions. Coryza is not noticed in scarlet fever, though the conjunctivas are almost always injected. Jioscola JEstiva may have a rash not un- like that of Measles. This rash in appear- ance is intermediate between Measles and scarlet fever, but generally more closely resembles the latter. Tims, the rash is generally much diffused and ill-defined, the elevation is slight, coryza is absent, and the teyex is trifling. It frequently occurs many times in the same patient, and often at the same period of the year. Smallpox. — Tliis disease in some re- spects corresponds to Measles. In both there arc catarrhal symptoms. In both small red points beginning on the face and then spreading over the rest of the body, are met vrith. In smallpox the disease begins abruptly ; in Measles not infre- quently insidiously. In smallpox there is often severe pain in the back and head, with much vomiting. These symptoms are most generally absent in Measles. The rash of smallpox is from its com- mencement hard and "shotty," quickly becomes crowned with an umbilicated vesicle. Moreover, the fever greatly de- clines or even disappears temporarily, when the rash is fully out, in both respects diflering from Measles. In smallpox, if unmodified, a characteristic smell is pre- sent. Tlie rash appears on the third day in smallpox, usually on the fourtli day in Measles, but the departure from this rule in Measles is so frequent, that no groat stress can be laid on this distinction. Typhus Fever. — The mottling left after a severe attack of Measles is often ex- tremely like the petechioe of tj^phus fever, but the early appearance of the rash of Measles will in all cases be sufficient to ensure a correct diagnosis. The rash of typhus fever, nroreover, appears first on the wrists. The mottling left by the rash of Measles is in all respects like tlie mottling seen in syphilitic roseola, but the rashes are dif- ferent at their commencement, and the mottling left by Measles is most marked on the shoulders and over the scapute, the mottling of syphilitic roseola is gene- rally absent from these regions, and is most marked on the trunk. Moreover, the general symptoms are sufficiently dif- ferent to render a mistake impossible. ' Occasionally copaiba, morphia, and cer- tain fish, produce a rash which in some instances it is impossible to distinguish from that of Measles. The rash, how- ever, produced by these causes, is often very irregular in its distribution, and lasts a much longer time than that of Measles, ' The author believes that Dr. Hare was the first to point out tliis resemblance be- tween tlie rash of Measles and that of syphi- litic roseola. 114 MEASLES, if the medicine be continued. Occasion- ally there are, mixed with this rash, ■wheals of urticaria ; when such is the case, there is much itching. Prognosis.— Usually a mild disease, the prognosis is very favorable. The degree of danger is dependent on the previous health of the patient, on the time of year at which the disease occurs, and on the nature of the epidemic. If the health has been bad, the prog- nosis is more serious, but even in such cases the result is mostly favorable. If the patient be tubercular, the prog- nosis becomes grave. Cold and damp weather, favoring the development of pul- monary affections, increases the danger of the disease. The severity and the nature of the com- plications occurring during different epi- demics, vary greatly. Yet, in the worst epidemics, the majority of cases recover. Treatment. — Not possessing any medicine capable of shortening the dura- tion of the disease, it must be our object, in treatment, to conduct the fever to a favorable termination, and to ward off any intercurrent disease. ' The patient must be confined to bed. Too much light should be excluded, for strong light is annoying to all febrile pa- tients, and in Measles causes some jjain in the inflamed conjunctivae. The room should be well ventilated, and all excreta and dirty linen imme- diately removed. The patient must be most carefully protected from draughts. The sense of heat and dryness of the body, sometimes most distressing to the patient, can be much alleviated by washing the surface with soap and tepid water ; too great exposure being avoided by one part of the body being cleansed, dried, and covered, before tlie rest is exposed. The feeling of tension of the hands and feet can be relieved by rubbing these parts with some firm greasy matter, such as suet. All sources of annoyance or irx-itation, all noises should be avoided, and thus sleep is promoted, a condition which most materially affects the welfare of the pa- tient, — sleep lessening the fever and in- creasing the appetite. Food, light and nutritious, such as arrow-root, gruel, good beef-tea, milk, chicken or veal broth, jellies, &c., should be given at the usual meal hours. The quantity should be moderate, great care being taken that the digestion be not impaired by too large in- gestion of food. Should the patient be very weak, the food must be administered ' The remarks made respecting tlie treat- ment of Measles, of course apply for the most part to all febrile diseases, and especially to those of long duration. in small quantities and at short intervals. There is no stimulant so important as food. The prospect of recovery in all acute febrile diseases is very greatlj', if not mainly, dependent on the power possessed by the patient of digesting and assimilat- ing food. If there be often-repeated sickness,' food of the very blandest nature, pounded raw meat,^ Liebig's beef-tea,' uncooked white of egg diluted with water or barley water, should be given in small quanti- ties, and be very frequently repeated. Thirst must be assuaged, and thus the restlessness of the patient allayed by drinks regulated with respect both to quantity and quality. Large draughts should be prohibited, as they tend to im- pair the digestion, and cause diarrhosa : small quantities, swallowed slowly, or ice to suck, are sufficient to allay thirst, and they also prove grateful to the patient. The patient, however, must be allowed to take larger quantities of fluids than in health, as an increased quantity is required by the system during the existence of fever. Acid or acid and bitter drinks are gene- rally found to lessen thirst to a greater degree than mere water, and are more- over grateful to the patient. "Imperial drink," lemonade, with very little sugar, raspberry vinegar, or weak infusion of cascarilla, with a few drops of hydrochlo- ric or nitric acid, are all — especially the latter — useful. Stimulants are administered to support the strength of the patient. This they do in a great measure by promoting diges- tion, and by also directly increasing the force of the heart's action ; for in fever- patients the pulse, under the influence of alcohol, most certainly gains in force. ' A very unfavorable symptom, for sick- ness itself very greatly prostrates the patient, and by the vomiting the nutritious matters are returned : nay, more, the vomiting is due to a condition of the mucous membrane of the alimentary tract most unfavorable to digestion. 2 Before pounding the meat all fat and ten- don should he removed. ' Liebig's beef-tea is made by cutting one pound of beef very small, pouring on this one pint of water, to which have been added thirty minims of hydrochloric acid and two scruples of common salt, and allowing this to stand three hours. It should then be strained and strongly expressed ; it is then fit for use. [Better than Liebig's preparation, in the esti- mation of many, is beef-tea made by pouring a pint of cold water upon two pounds of lean beef, chopped small, letting it stand near the fire for two hours, then boiling for twenty minutes, skimming while hot, and poTiring off at once, without filtration. This contains all the nourishing qualities of the meat, in an easily assimilable state. It admirably exem- plifies the Hippocratlo aphorism (ii. ll)i TREATMENT. 115 The administrntion and quantity of stimulants given must thus he regulated hy the condition of the patient. Gruidauee in this respect can he derived from the previous history of the patient, the exist- ing state of the patient, aud the nature of the epidemic. If the patient previous to the fever, has been in an unhealthy state from any cause, such as overwork, excesses of any kind, or is the subject of scrofulosis or tuberculosis, in whom the fever always tends to become typhoid in character, and to leave one or more of its sequelse' be- hind, stimulants may with benefit be given early in moderate quantities : and at the same time the patient should be carefully watched, so that their quantity may be increased in anticipation of any great amount of prostration. Again, in some epidemics the disease is violent, and apt to become typhoid. Pa- tients met with in such epidemics may have stimulants given them early with benefit. But the chief information re- specting the administration of stimulants, and the quantity of these to be given, is derived from the then existing state of the patient. If the disease be progress- ing favorably (the previous health having been good), stimulants had better be alto- gether abstained from. But if the patient become at all prostrate, the tongue dry, the pulse small aud frequent, stimulants must be given freely and often. It should he the anxious endeavor of the physician to anticipate such a state, and prevent it hy the early use of alcohol. '^ In reference to the amount to be given, no exact rules can be laid down. Expe- rience at the bedside alone can teach this. It may, however, be stated that young children bear stimulants well in disease. It is a matter of but little importance in what form the stimulant is given, pro- vided it is sound in quality. The patient's taste should be consulted. Thus, brandy, gin, whiskey, port or sherry wine, bitter or draught beer, may be given. ^ Only one kind of stimulant should he administered at the same time, though it • The probability that the various anatomi- cal lesions met with in Measles will become chronic, is determined by two conditions — first, by idiosyncrasies, inherited or acquired — thus patients who have had many attacks of bronchitis, will be very liable to have some chronic bronchitis left behind ; and secondly, and chiefly, by the previously impaired health of the patient. * Whilst in such cases stimulants should he freely given, it must not be forgotten to give the patient food in small quantities, fre- quently [repeated ; for food is the best and most natural stimulant. ' The patients will sometimes take stimu- lants in this form when they refuse them in all others. may be frequently changed at the request of the patient. [There are certainly very many cases of Measles, indeed the large majority under ordinary circumstances, which require no alcoholic stimulation at any period of the attack. While young children in states of positive exhaustion bear stimulants very well, the doses in which they are given must, for beneficial action, be re- duced in greater proportion than is need- ful with any other remedies except opium and other narcotics. — 11.] At the commencement of the disease, if vomiting has not occurred, an emetic can be often given with benefit, and the bowels, if confined, should be opened by a mild purgative, it always being borne in mind that in Measles the intestines are usually very easily influenced by purga- tives. Acetate of potash, acetate of am- monia, and nitric ether may be given in suitable quantities every three or four hours ; and if the cough be troublesome, some ipecacuanha wine may be added. If the skin be hot, the pulse hard, and incompressible, aconite, given hourly, will be of much service. Opiates are but rarely required ; sleep should be obtained by removing, as far as possible, those conditions that are liable to render the patient restless. Bleeding at the nose, if severe, should at once be stopped. This can be accorn- plished by the injection of cold water, or the breathing up of astringents, in fine powder, into the nose ; should these fail, plugging becomes necessary. Por the convulsions that occur, often but little is required, and but little can be done — those occurring early quickly dis- appearing ; those occurring late almost always ending in death. In the treatment of laryngitis. Trous- seau warns against the application of leeches, and adopts Graves's recommen- dation of a sponge wrung out of boiling water, and applied over the larynx. [Some practitioners of large experience believe, nevertheless, that leeches may do a great deal of good, at least when the application of the hot wet sponge for a time does not afford entire relief. — H.] If suffocative catarrh supervene, or a serious internal inflammation cause the recession of the rash with much prostra- tion and possibly with coma, a warm bath, to which two tablespoonfuls of mustard have been added, may be used with bene- fit. The child should be kept in the bath till the arms of the nurse holding the child tingle and smart. Gangrenous inflammation is best treated locally, by the application of strong hydro- chloric or nitric acid, and generally by the free use of stimulants, with sesqui-car- bonate of ammonia and tonics. If there be much inflammation of the fauces (but this is not usual), hnseed 116 MEASLES. poultices to the throat, and the inhalation of steam or ice to suck will be found of benefit. On the subsidence of the intlani- mation, if the formation of muco-purulcnt matter continue, adults can use astringent gargles. It must be borne in mind that children under eight j-ears of age cannot gargle, and thus the fluid should be inject- ed into the throat with a syringe. There is no fear of choking, provided the stream of the injected fluid be not too great. Inflammation of the lungs, when occur- ring in children, requires active stimulant treatment. Bleeding in these cases can never be borne.' The chronic sequelffi being dependent on the impaired health of the patient, are best treated by those means and medicines that promote the general health of the patient, and also when possible, by local applications. The child should be warmly clothed, with flannel next the skin. Much of the day should be spent in the open air and in direct sunlight, unless the patient be too young, or the sun's heat too powerful. Hours of rest should be long, and sleep may be indulged in with advantage for a short time during the afternoon.* Simple healthy food, at regu- lar hours, with a very moderate allowance of stimulants, or even without any, should be given. Sea-bathing or cold-sponging will be found to be of the very greatest advantage for the cure of these sequete. The sea'bath should be taken about three hours after breakfast. If the patient be very weak, a very short stay in the water of one to two minutes at most should be allowed. The sea should be smooth, and ' [From this dictum it is necessary for the American editor to express absolute dissent. Wliile it is true that pneumonia complicating measles does not often require bleeding, it may, at least, in a certain number of cases, be well borne, even by children ; and the universal employment of active stimulation (by which the author means, no doubt, the free use of alcohol) to this complication must, it is be- lieved, while saving some cases, aggravate others to a fatal end. — H.] 2 Every care should be taken, during con- valescence, to insure sound sleep. The sup- per should be light, and be taken one or two hours before going to bed. No stimulants should be taken during the evening, unless the patient be very weak. If baths cause restlessness, they must be discontinued for a few days, or the patient should be directed to remain in the water for a shorter time. Dur- ing convalescence the patient is in much the same condition as a child. It is a period, if not of growth, of great repair — a condition analogous to growth. The appetite, digestion, and assimilation are greatly influenced by sleep. This influence is well seen in ulcers on the surface of the body. After a restless night these are painful, tlirobbing, inflamed, and swollen, and apt to spread ; whilst after a refreshing sleep they have a much healthier appearance. If the weather be wet or stormy or cold, a tepid sea -bath is preferable to open-!iir bathing. Children should be coaxed, not dragged into the water, as baths fail to act as a tonic, and produce much depres- sion in persons laboring under strong mental emotions. The cold sponge-bath may be used be- fore breakfast. If the patient be very weak, and the weather very cold, a little warm water should be added. The time the sponging should be continued depends on the condition of the patient ; the weaker the subject the shorter the time ; thus one to two minutes is in many cases as much as can be borne, for if continued too long, in such cases no tonic effect fol- lows, but depression, which generally lasts during the rest of the day. Very young children can be much benefited by cold- sponging, even during the winter months, if the bath be properly used. The spong- ing should not be continued longer than a minute, and if the weather and water be very cold, the child's feet should be placed in warm water, and the bath administered before a good fire ; by these means reac- tion is promoted. Salt may be added to the bath with benefit. Under such treatment all the sequelse greatly diminish, nor need there be any apprehension that the chronic bronchitis should be aggravated ; for if the baths be administered in the manner described above, this disease almost invariably greatly improves. Of medicines, iron, quinine, and especi- ally cod-liver oil, are always very benefi- cial. The latter should be administered after food, for at this time the bile is poured out in largest quantity into the intestinal canal, and it is found that animal membranes moistened with bile allow fats to pass through. The chronic discharge from the ears, nose, and vagina is usually easily arrested by local applications. The affected part should be washed frequently (in propor- tion to the amount of discharge) during the day with tepid water, and injections of lead lotion, or of solutions of alum (3.i- to 9j-)i or sulphate of zinc (gr. iv. to Ij.), will generally promote the cure.' The chronic inflammation of the larynx, or of the bronchial tubes, is most quickly mitigated and generally cured by inhala- tion of steam with ITLx. to Hlxx. of tr. iod. poured on the water, from which the steam is given off'. Creasote may be sometimes used, but does not give such good results as the iodine. The inhala- tion should be used night and morning for about ten minutes.* "The chronic diar- ' In the author's experience lead lotions are preferable to the others. s The cough is greatly influenced by charge of climate. If the cough be easy and the ex- pectoration scanty, a warm moist climate, but ROTHEIN: GERMAN MEASLES. 117 rhrea, which occasionally follows Measles, should be treated by a carefully regulated dirt, and the occasional use 'of hyd. c. creta. K the diarrhoea be exhausting, it can be generally temporarily stopiied by an injection of starch, of the consistence of cream, and about two ounces in quan- tity; to this some laudanum or one of the metallic astringents must be added. Raw pounded meat sometimes has a beneficial influence on the diarrhoea. [ROTHBLN"; GERMAIN MEASLES. By Henry Haktshorne, M.D. Definition. — An exanthematous dis- order, intermediate in character between, or composite of, Scarlet fever and Measles. Synonym. — Rubeola. This term is, by some writers, restricted to it: although by many others it is applied indiscrimi- nately to Measles. History. — Apparently more common on the continent of Europe, this affection has not been much noticed in Great Brit- ain, and has been scarcely described until within a few years in the United States. Yet there is reason to believe that it has long, if not always, been tolerably fre- quent ; its resemblance to both Measles and Scarlatina causing it to be usually as- signed in description to one or other of those diseases. Dr. Murchison and others have ex- pressed the opinion that it is a distinct disease, having nothing to do with either IMeasles or Scarlet fever, and not protect- ing its subjects from either of those affec- tions. Dr. J. Lewis Smith, of New York, ' observed and described an epidemic of it prevailing in that city in 1874. In 1875 more than a dozen cases of it occurred at Haverford College, near Philadelphia. More than one sucli an epidemic has been witnessed in rural localities, in Maryland and elsewhere ; the popular designation for the affection being French Measles. Symptoms. — In the cases observed at Haverford, Pa., the early general symp- toms were mild; malaise, headache, slight sore throat, loss of appetite, and debility. In two or three days, with some increase of fever, a rash appeared, having more the color of that of Scarlet fever than of Mea- sles, but dotted or miliary (sub-papular) in form. In some cases it became almost continuous, with a moderate amount of tumefaction of the limbs and general sur- if the expectoration be abundant, a warm dry dimate is beneficial. ' [Sanitarian, July, 1874.] face. In one instance the fauces exhibited a scarlet hue to the eye, although no feel- ing of soreness of the throat existed in that case. Catarrhal symptoms were not no- ticed in any of these patients. In some of them, the glands of the neck were swollen. None had a very high degree of fever. The duration of the attack was about a week ; and convalescence was rapid. No sequeliB were observed in any instance. Dr. ,1. Lewis Smith mentions that albumi- nuria and dropsy occasionally follow this disorder, as well as chronic bronchitis. Altogether, in several characters, liotheln most nearly approaches Scarlet fever ; while, in the absence of severity in any of its symptoms, it is more like Measles. Pathology. — Opinions may readily differ as to the nature of this affection, whether it is a specific disorder, or a hy- brid of Measles and Scarlet fever. The latter would seem to be at least possible, according to the analogy of some other diseases ; although hybrid maladies are certainly rare. Examples of such are met with in malarial regions bordering upon yellow fever districts, where malig- nant remittent combines the characters of two usually distinct fevers; in typho-ma- larial fever, seen in many cases in the U. S. Army during the civil war of 1801- 65; and in scorbutic dysentery, occurring among soldiers during that war as well as in 1854-56 in the Crimea. In the absence of any record of fatal cases, the morbid anatomy of the affection can only be con- jectured ; and its true pathology may be considered as yet undetermined. Diagnosis.— While a place in descrip- tion and classification seems to be practi- cally needed for a combination of symp- toms not included in the typical account of either of the commonly recognized ex- anthemata, reasons have already been given for obscurity in the diagnosis of its examples. In a case occurring some years ago in Philadelphia, two physicians of similar experience saw the patient within 118 PAROTITIS. an hour of each other ; one pronounced it Measles and the other Scarlet fever. When, however, after about three da3'S of indisposition, a rash breaks out v^fhich is miliary in form, but of a nearly scarlet hue, attended with slight sore throat, with or without a disposition to cough, and moderate fever, all of which symp- toms subside within a week, leaving no sequelae, and especially when a number of such cases occur in the same neighbor- hood, exhibiting the same absence of severe [ character, and all followed by rapid conva- lescence, we may conclude it to be an epi- demic of Rotheln or Eubeola. This is con- firmed if neither Scarlet fever nor Measles is prevalent at the same time and place. Treatment. — Nothing peculiar exists in the indications of this affection, apart from those of other exauthematous fevers. Almost no treatment is usually required. Confining the patient to his room as a mea- sure of precaution, oven if not ill enough to seem to need it, a single dose of citrate of magnesium or Rochelle salts may be given. If the fever should be considera- ble at night, solution of citrate of potas- sium or acetate of ammonium may be prescribed. Flaxseed lemonade will be suitable as a demulcent and diluent, if either sore throat or cough should call for any treatment. These mild measures, with care to avoid exposure during con- valescence, lest a bronchial attack, or pos- sibly suppression of perspiration, renal congestion, and anasarca might occur, are all that are likely to be appropriate. A second attack is not to be expected ; but it is not proven that Eotheln affords pro- tection against either Measles or Scarlet fever.] PAEOTITIS. By Sydney Ringer, M.D. Definition. — An acute febrile disease, characterized by an anatomical lesion situated in one or both parotid glands, which runs a short course, and almost in- variably terminates favorably. SYX0NY3IS. — Parotitis ; Cynanche pa- rotidea ; Ziegenpeter (Germ.); Parotide, Parotidite (Pr.) ; Mumps (Engl.). Sysiptoms. — Beginning abruptly — rare- ly with rigors, more commonly with a feeling of chilliness, with or without vom- iting, pain in the head, back and limbs — the disease in its course is accompanied by the symptoms common to all febrile diseases. The face is sometimes fiushed, the lips may be dry ; impairment of strength, variable in degree, is generally slight, and sometimes absent; tlie tongue is furred, but usually moist ; the appetite, in some cases natural throughout, is in most impaired, and may be nil. The pa- tient usually complains of thirst, and the bowels are often confined. The pulse and respiration are increased in frequency, the former often greatly so, especially in children ; it also sometimes gains in force ; the urine is scanty and high-colored ; the temperature of the body is raised, but this elevation varies much in degree.' Usually at the very com- ' In one case the highest temperature mencement of the disease, but occasion- ally postponed for twelve, twenty-four, or even thirty-six hours, the affection in one or other parotid gland, sometimes in both, manifests itself by pain, followed in a few hours by swelling of the glands and stiffness of the jaws. The pain and swelling first appear im- mediately beneath the ear, and posterior to the ramus of the jaw, and from this part spread in all directions, upwards to the face, downwards and backwards in the neck. On the face the swelling ap- pears earliest on that part immediately in front of the lobe of the ear, and then quickly extends upwards to the zygoma- tic arch, and forwards involving a varia- ble extent of the face. The swelling dis- appears in the inverse order of its invasion. It is at first fiat, but soon becomes more prominent, and is usually most marked anterior to the lobe of the "ear. Firm and elastic to the feel, it is generally tolerably well defined, but does not pit on pressure; and, whilst the skin over the enlargement is mostly natural in color, it is in some cases mottled with a slight red blush, and is in rare cases of a bright scarlet hue. The redness disappears on pressure, but quickly returns on the pressure being re- moved. The degree of enlargement va- reached was 101| ; hi another, however, it rose to lUoil. PATHOLOGY. 119 ries : whilst in some cases apparent only behind the ramus of the jaw, or even so slight that it easily escapes notice, it is more usually co-extensive with the parotid gland, and occasionally extends I'ar be- yond this, involving a large part of the face and neck, and, in some rare cases, reaching to the upper part of the chest, giving to the head and neck a pyramidal shape. The swelling increases from three to six days, then usually remains station- ary for twenty-four or forty-eight hours, after this rapidly declines, and often has entirely disappeared by the eighth or twelfth day from the commencement of the attack; the redness subsides much ear- lier, and is occasionally followed by a super- ficial desquamation of the cuticle. Not unfrequently one or both submaxillary glands are also involved, in which case the swelling extends along the body of the jaw, reaching nearly to the symphysis. The pain and tenderness, dull and aching in character, vary greatly in de- gree ; sometimes they are only complained of on movement of the jaw, and are then seated beneath the ear, and behind the ramus of the jaw — a fact easily accounted for when it is remembered that this part of the enlargement is most affected by the movement — in other cases, however, the pain is constant and severe, and occa- sionally extends beyond the limits of the apparently affected tissues, reaching even to the chest and shoulder. The pain more severe in adults than in children, usually lasts only during the time the swelling is increasing : on the other hand, tenderness on pressure, which is always present, continues for some days longer, and is longest observed in the part first affected. The jaw is generally fixed, and the mouth slightly open ; moreover, its movements are limited, or entirely prevented, the degree of impediment being proportionate to the amount of pain and swelling present. Consequent on the im- pediment in the movement of the jaw just mentioned, the speech is affected, and mastication can be but most imperfectly and painfully performed ; and when, as is sometimes the case, the tonsils are en- larged and inflamed, and the swelling ex- tends even to the cellular tissue of the pharynx, deglutition also becomes diffi- cult, and danger of suffocation, in very rare instances, is imminent. The mucous membrane of the mouth is unaffected, and the salivary secretion, in some cases dim- inished, in a very small number .increased, is usually natural in both quality and quantity. Occasionally only one parotid gland is affected ; in most cases, however, both suffer. The left side is most frequently the first involved, and the pain and swell- ing in it precede that in the right for a period varying from twelve to thirty-six or forty-eight hours. The side first at- tacked suffers the most severely. It is stated that, in rare instances, the gland has suppurated. Other organs besides the parotid and submaxillary may be affected. In many the testicles, one or both, may suffer ; whilst in the female the mammoe, the labia majora, and uterus are the parts oc- casionally attacked. The tonsils and pha- rynx may also be involved. When the testicle is diseased, the inflammation in- volves both the tunica vaginalis and the epididymis ; and if the disease be limited to one of these organs, this is situated on the same side with the parotid, solely or most severely, affected. These complica- tions, or metastases as they are termed, usually make their appearance whilst the parotid and the submaxillary glands are enlarged ; but, on the other "hand, the swellings may decline and disappear from the glands, and not make their reappear- ance elsewhere until a period, varying from a few hours to one or two days, has elapsed. In this last case, whilst the swellings are in abeyance, active general symptoms, sometimes of an alarming cha- racter, may occur ; there may be a feeling of great anxiety, pallor of the face, cold- ness of the extremities, smallness and great frequency of the pulse, and to these symptoms delirium, vomiting, and purg- ing are sometimes added. However, on the reappearance of the local mischief at any part of the body, these symptoms dis- appear. These metastases, rarely occur- ring in children, and by no means common in adults, are prone to occur in individuals of the same family; in other words, family idiosyncrasies tend to their development. The duration of the disease varies; thus, in mild cases it may run its course in four days, whilst in severe cases it may con- tinue for ten days. Its duration is usu- ally longer, and the fever higher, when metastases occur. Pathology. — As the disease rarely kills, the opportunities for investigation on this point are necessarily but few. It is generally, however, held that the organ affected, and the cellular tissue within and around it, are inflamed, and that there is an excess of serosity in these parts. The glands may'remain somewhat en- larged and hardened for a considerable time after all the acute symptoms have dis- appeared, and it is even stated that in rare eases the affected testicle has atrophied. In Mumps, have we primarily a genera/l disease of which the local effects are the- sequence ; or, on the other hand, is the' disease in the first instance local, and are the general symptoms dependent on such local mischief? In the present state of medical knowledge, this question cannot be answered. Suffice it to say that, whilst 120 PAKOTITIS. some diseases, such as typhoid fever and dysentery, were formerly thought to be primarily "general," further observation on these aftections has at least rendered it possible that both of them are in the first instance "local," and that the gene- ral symptoms are secondarily dependent on these local lesions. Should this be fully established, it will go far to render probable that most, if not all, diseases are at their commencement local, and, amongst others, the disease under consi- deration. In favor, however, of the older view, the author may mention the follow- ing case in which, after the temperature of the body had become normal (i. e., after all fever had disappeared), the right pa- rotid, which had previously remained healthy, began to enlarge, became pain- ful, and corresponded in all respects in its behavior to the left, this latter gland having been previously affected during the time that the temperature of the body was raised. As no subsequent elevation of the temperature occurred in this case at least, the local mischief in the right parotid was insufficient to elevate the temperature, and was certainly in point of time sequential to the general condition. Most common between the ages of five to fifteen, the liability to the disease i-apidly diminishes in those under or above these ages ; and whilst old age does not afford an entire protection from the disease, it is unknown in children under one year. It occurs with equal frequency in both sexes. Some authf>rs, however, assert that it is more commonly met with in boys than girls. It is a contagious disease, not usually re- curring a second time, subject to epidemic influence, said to be most common in spring and autumn. Its period of incuba- tion varies from eight to twenty-two days. Being a disease of short duration and of slight intensity, the patient usually re- covers quickly both strength and weight. As in convalescence from all acute affec- tions, so with Mumps, the rapidity of re- covery from the anfemia, loss of flesh, &c., is proportionate to the age, being quicker and more perfect in young than old people, and is, moreover, determined by the previous health of the patient : if this has been good, the recovery is accom- plished perfectly and with rapidity ; whilst, on the other hand, if the health has been impaired by excesses of any kind, or by bad hygienic conditions of life, or if the patient be the subject of chronic disease, or of the tubercular or scrofulous diathesis, the restoration to perfect health is much retarded. Diagnosis.— This is rarely difficult. An acute febrile disease, accompanied with a swelling in, and assuming the shape of, the parotid gland, is diagnostic of Mumps. Parotid bubo' may in some respects simulate this disease. It is, however, a rare aftection ; almost invariably follows in the course of one of the acute specific fevers. The swelling does not take on the shape of the parotid gland, and quickly gives evidence of the existence of pus in various parts of the swelling. The mam- ma, testicle, etc. , are never affected. Enlarged lymphatic glands situated in the neighborhood of the parotid perhaps ought to be mentioned, though a careful examination would at once establish the nature of the swelling. Thus there is often more than one enlargement, usually the size of a Barcelona nut, commonly situated immediately in front of the ear. There is no swelling behind the ramus of the jaw ; the tumors can be felt to be su- perficial to the parotid, over which they are mostly movable, and moreover these enlargements of the lymphatic glands are always due to some irritation in the neigh- borhood, which can generally be discov- ered. Treatment. — In common with the other acute specific fevers. Mumps has hitherto failed to be arrested in its course by any mode of treatment at present known. The utmost therefore that can be done is to mitigate the severity of the symptoms, and tlius conduct the disease to a favorable termination. Being mostly a disease of trifling importance, but little danger is to be apprehended and but little treatment is required. All active treatment, whether general or local, is in most cases to be avoided. At the very commencement, an emetic followed by a purgative will be generally useful. The bowels should be kept regu- larly open, but active purgation should be avoided. By this means the severity of the fever is lessened, for it is well known ' My friend Dr. H. Jeaffreson, late Resi- dent Physician to the London Fever Hospital, lias supplied me with the following notes concerning parotid bubo. It begins below the ear and behind the jaw, is hard and brawny to the feel, and ill defined. The skin over the swelling is almost inrariably of » dusky red color : is immovable over the swell- ing ; in three or four days becomes boggy, and in five or six bursts, and discharges pus. It is by far most common in persons of mid- dle or of old age. It is very rare in children, but may occur at the age of five or six. Of the acute specific fevers, it almost in- variably follows typhus. No case has oc- curred for some years past at the Fever Hos- pital after measles, scarlet fever, or typhoid fever. Not more than 3 per cent, resolve. Both parotids may be attacked, and the sub- maxillary glands may also be attacked in conjunction with, or independently of, en- largement of the parotid. The former condi- tion is by far more free[uent than the latter. TREATMENT. 121 that constipation has the effect of elevating the temperature in febrile patients. In Mumps, as in all fevers, we have an undue elevation of the temperature of tlie body, due in part at least to increased combustion of some of the tissues. The treatment must be directed so as to cou- trol this increase of waste, and supply the loss by appropriate food. This is espe- , cially needful with patients whose health previous to the disease was impaired : for in such, a great amount of bodily and mental weakness, lasting for a considera- ble time, may result. With this object in view, two chief points should be attended to, namely, rest and the appetite. Best and even confinement in bed should be enjoined ; for it is found that in all fe- brile diseases, exercise, both of mind and body, is capable of increasing the abnor- mal elevation of the temperature. The pain also, which may accompany febrile disease, is much allayed by perfect rest. The appetite must have strict regard paid to it ; for the increased waste of the tissues is compensated for iu proportion to the amount of food digested. Should no food be taken or assimilated, the pa- tient is placed in all respects in the posi- tion of a starving person, and to tliis must be added an active, increased con- sumption of the tissues. To secure or promote the appetite and proper digestion of the food, attention must specially be paid to pain, sleep, and the nature of the diet. Pain, if severe, destroys entirely the appetite and arrests the digestion of food; therefore, should the pain in the affected organ be great, appropriate treatment must be employed. For the most part, hot fomentations or poultices are sufH- cient for the purpose. Should, however, these fail, one or two leeches applied ia the neighborhood of the affected organs will generally quickly afford great or even entire relief This is especially the case when the testicle is affected. The pain is further mitigated by perfect rest of the part; thus the jaws should be moved as little as possible, and the testicle, when it is affected, should be carefully supported. In regard to the second point — sleep — this can in most cases be attained by easing the pain of the affected part in the manner just described, and by allaying any distressing symptoms that may be present, such as thirst, heat of skin, <&c. The thirst can be removed by sucking ice, or the patient may be directed to rinse out the mouth with cold water, or to swallow small draughts of cold water slowly, and at short i'ntervals. It may be much relieved by drinking acid drinks, especially if weak bitter infusions be added. Thus, " whey, or common water acidulated with currant jelly or raspberry vinegar," or a very light infusion of cas- carilla acidulated with hydrochloric acid (Graves), will generally succeed. Large draughts of water should be avoided, as they distend the stomach and give rise to annoying sensations to the patient, and because they retard digestion. Efferves- cing drinks, moreover, by distending the stomach, are apt to distress the patient. Acid fruits will allay thirst, but they must be used with moderation, as they may produce diarrhoea, flatulence, colic, and even nausea. The disagreeable sensation due to the hot, dry skin, may also increase the rest- lessness of the patient and thus prevent sleep; this can be allayed by sponging the body with cold or tepid water, one part of the body only being exposed at one time, to prevent the bad effects of cold. Soap may be added with advantage to the wa- ter, as it cleanses the skin more tho- roughly and removes any smell that may be connected with the cutaneous exci'e- tion ; this is advantageous, as it is well known that smells of any kind, and espe- cially when disagreeable, lessen the appe- tite, and may cause headache, nausea, and even vomiting and much depression. And lastly, strict attention should be paid to the diet, both in regard to its nature and the time and method of its adminis- tration. The food should be liquid, so that mastication is unnecessary; thus the inflammation in the parotid is not in- creased by the movement of the parts, but at the same time it should not be too dilute, otherwise digestion is impaired. Thus, good beef-tea, strong mutton or veal broth, gruel, or arrowroot, milk and eggs may be given, the latter with cau- tion, as eggs often disagree with febrile patients. Pounded meat, either cooked or raw, and without spices, are also ser- viceable. Liebig's beef-tea will in some instances be found especially beneficial ; this, indeed, can often be tolerated by the stomach when all other foods are rejected. In respect of time and manner of ad- ministration, it must be borne in mind that the digestion of febrile patients is mostly impaired, and therefore only small quantities of food should be given at one time, and these should be taken at the ordinary meal-times, and at no others. When prostration is great, and the quan- tity that can be given at one time is very small, the food must be administered at shorter intervals, and sometimes even every half hour. It is inadvisable that the patient should take to allay the thirst any nutritious food, such as milk, as the appetite for food at the proper time is thus much les- sened. During the grave general symptoms that sonietimes occur after the disappear- ance of the swelling in one organ, and be- 122 SUDAMINA AND MILIARIA. fore another is involved, more active trL-atment may be adopted, though mostly the disease passes ou to a favorable ter- mination. If the pulse be weak, the surface cool. and the features nipped, chloric ether, musk, wine, and brandy should be given, and warm baths with mustard to the ex- tremities may prove of service SUDAMINA AND MILIAEIA. By Sydney Ringee, M.D. ALTiiorGH Sudamina and Miliaria generally occur at the same time, they difter so much in respect of their appear- ance and the method of their develop- ment, that they require separate descrip- tion. It may be first stated that, while Suda- mina often occur without Miliaria, the latter, on the other hand, are generally accompanied by Sudamina. The prob- able reason of this will afterwards appear. Sudamina. — These vesicles are minute and highly transparent, spherical or oval in shape, and often appear deeply seated in the cuticle. They may sometimes be so small as easily to escape notice, or on the other hand, they may measure two lines in diameter at their base. Partly on account of their minuteness, but chiefly owing to their great transpa- rency, they are apt to escape notice. They are best seen when looked at ob- liquely, and may often be more easily de- tected by the touch than the sight. , These vesicles are sometimes widely, if not equally scattered, but at other times grouped and limited to particular portions of the surface of the l)ody. The skin at their base and in their neighborhood is usually unaltered, whereas, in rare cases, a narrow rim of redness is seen around them. They vary greatly in number ; being sometimes so few that they can be ea.sily counted, and at other times so numerous that the chief part of the trunk is covered with them. The base of the neck, the neighborhood of the navel, and the sides of the thorax, are the parts mostly affected. They reach their full development in a few hours, remain so for about one day, and then either burst or dry up. When of large size and at the height of their development, they look tense and full, and feel hard and " shotty. " As they decline they lose their tenseness, and the cuticle covering them becomes wrinkled and loose, at the same time they may extend laterally, and lose their regu- lar form. If they be numerous, they even coalesce, and hence in rare cases rather considerable patches of cuticle may he de- tached from the corium beneath, the cuti- cle itself retaining its continuity. On their disappearance, the cuticle forming them is detached from the surface of the body, leaving the skin entire beneath. If the conditions producing them continue, fresh crops appear, and run their entire course in three or four days. These vesicles are most commonly limited to the trunk ; they may, however, occur on the extremities, but are rarely seen on the face, hands, or feet. Occa- sionally they become slightly turbid, but they mostly remain transparent through- out. Their contents, watery, colorless, and transparent, are generally acid, oc- casionally neutral, and very rarely alka- line ; they contain chlorides. Ifo organic elements are seen on microscopic exami- nation, with the exception of a few epithe- lium cells probably derived from their cuticular covering. They are characteristic of no particular disease, but are produced by sweating;' ' Sweating is most commonly dme either to a fall in the temperature of febrile patients or to general weakness and exhaustion. It especially occurs towards the close of typhoid fever, during the early convalescence of scar- let fever, and in the conrse of phthisis, this last-named disease being often accompanied by great daily variations in the temperature. In scarlet fever, according to the author's ex- perience, profuse sweating is more common, and lasts longer during the early convales- cence of the patient than in other febrile dis- eases ; and hence Sudamina, in very large quantities, are often met with at that period of the malady. Profuse sweating at the com- mencement of febrile diseases (with the excep- tion of rheumatic fever), when the tempera- ture remains permanently high, indicates great weakness, and thus adds to the serious- ness of the prognosis. In non-febrile persons, if sweating be easily produced by excitement, exertion, or MILIARIA. 123 and hence they often occur on the decUne of fevers, and especially on those "critical days" when the sweating is most pro- fuse. Much difference of opinion exists re- garding the anatomy and the method of production of these vesicles, or Sudamina. According to some authorities they are due to accumulation of sweat in ob- structed and distended sweat ducts. Others, Bserensprung for instance, hold that they are produced by the exudation of the perspiratory fluid between two layers of the cuticle, the exudation being caused by obstruction of the ducts from accumulation of effete epithelium cells, As Sudamina produce no annoyance or symptoms, no treatment is required. They are best prevented by checking as t-dv as possible the sweating that produces them. This sweating as has been stated, is often produced or increased by weak- ness and impairment of the health, and may be reduced by relaxation from work, out-door exercise, sea-bathing, and tonics. Dr. Druitt states that the sweating of hectic fever can be controlled for some hours by the sponging of the body with water as hot as can be borne. In many cases of phthisis all treatment fails to les- sen the amount of perspiration, for in this disease the perspiration is caused both by the daily fall of the temperature and the exhaustion produced by the disease. MiLiAEiA. — The vesicles of Miliaria, in both their appearance and method of development, differ from tliose of Su- damina. They are like the latter, how- ever, in size, and are produced by perspi- ration. They are at first acuminate in form, and round or oval at their base ; but in the course of twenty-four hours they some- times extend and become irregular in out- line. They never present the tense ro- tund appearance of Sudamina. They are almost invariably surrounded at their base by a narrow rim of redness, and the sur- face on which they are seated is not in- frequently somewhat elevated. Their contents are from the first turbid, opaque, and white ; are acid in reaction, and by means of the microscope are seen to con- tain a large number of granular cells, often shrunken-looking, as if badly devel- oped. On the addition of acetic acid, the granules disappear, and there are seen one, two, or three nuclei. The vesicles of Miliaria, when freely exposed, quickly the health is generally impaired. It must, however, be recollected that great differences ill respect of the amount of sweating are met with in different individuals. Persons who hare returned from tropical climates often continue to sweat greatly on the slightest provocation. dry up, and a httle redness remains for a short time longer. The skin between these vesicles is often mottled with red- ness, and here and there small red papilte are seen, on the summit of which, by means of a lens, a small vesicle can often be detected. Vesicles, in all respects similar to those last described, are not infrequently seen during the eruptive stage of scarlet fever, and they are situated on the papillse of the skin, which are elevated in this disease. They are formed only when the rash is intense, and on those parts most affected ; and are therefore seen most frequently under the clavicles and around the navel. They may, however, occur on the'extremi- ties, and are then best developed on the thighs. They are often arranged in elon- gated groups, corresponding to the fur- rows of the skin. Miliary vesicles are often abundant on the surface of patients who sutler from rheumatic fever, when sweating is profuse, and especially when this has an oft'ensive smell. Hence, in this disease, they are most developed and abundant in young adults, and are rarer in children and old people. They are probably produced by inflammation. This is shown by the large quantity of cells they contain. To the author it appears probable that the vesicles of Miliaria are not formed during the act of sweating, Imt that they result from the irritation which the sweat causes. This view is supported by the following considerations: — The vesicles are especially apt to occur on those parts of the body from which the free evapora- tion of the sweat is prevented. Thus they are found under the band of the drawers when seen nowhere else ; and in cases of profuse sweating, if a piece of flannel be worn for some time, firmly tied round the neck (at which part of the body these vesi- cles are easily produced), they not infre- quently appear — ceasing, however, to be formecl when the flannel is removed. Moreover, in rheumatic patients these vesicles are very abundant over the back, at which part the perspiration is confined, and often allowed to accumulate, because of the pain caused in such movement of the patient as would be required for wash- ing this part of the body. They are also most numerous in those rheumatic pa- tients whose sweat is usually offensive and disagreeable. And further, according to the author's experience, they are most apt to occur in other patients when, from impairment of the health, either by over- work, want of sleep, excess of smoking, or other causes, the sweat smells offensively, and when probably it causes greater irri- tation of the skin. For the further settlement of this ques- tion the following experiments were made: Dry spongio-piline was placed on various 124 VARICELLA : DEFINITION. parts of the body, especially round the neck, and kept on the surface several days. By the action of this dry spongio-piline, Sudamlna, but in no case Miliaria, were produced. On the same patient, and to the same parts, linseed-meal poultices (which contain much acrid resin) were ajjplied, and vesicles of Miliaria were often produced, and especially on the ueck. Bread poultices, which are loss irritating, produced these vesicles, but in a much smaller number. In favor of this ] view may be further advanced the fact that the vesicles of Miliaria are often ac- ! companied by troublesome itching. This is most marked over the back, the part most dependent in rheumatic patients, and it may be very annoying, and prevent sleep. In the treatment of Miliaria but little is required. Frequent sponging of the sur- face of the body with soap and tepid water lessens their production, and re- moves the itching. YAEICELLA. By Samuel Jones Gee, M.D. DEFrsriTiON. — A contagious, febrile disease which is attended with an eruption of vesicles, does not last longer than a week, and does not recur in the same in- dividual. Just as smallpox and measles were not at tirst distinguished from each other, and mediaeval measles included scarlet fever, so were smallpox and chicken-pox con- fused together until the last century. In the year 1730, appeared what seems to be the earliest assertion of the doctrine of non-identity; we read that "the pesti- lence can never breed the smallpox, nor the smallpDX the measles, nor they the crystals or chicken-pox, any more than a hen can breed a duck, a wolf a sheep, or a thistle figs, and consequently one sort cannot be preservative against any other sort. " So far, Fuller. In the well-known paper read befijre the College of Physi- cians in 17C)7, Heberden enumerates what were to him sufficient reasons for disally- ing the two diseases. Yet since that day there have never been wanting those who have disputed the validity of the distinc- tion drawn ; indeed the doctrine of Fuller and Heberden has hardly taken fair root in any country except their own.' ' In the first edition of this volume there stood in this place a detailed criticism of the arguments, in favor of the identity of chick- en-pox and smallpox, adduced by Hebra, tlie living Coryphaeus of that doctrine. Since Hebra's book has been translated by Dr. Fagge for the New Sydenham Society, the reader who wishes to know what Hebra has to say may easily procure that information. I confess that I was annoyed at one or two of his assumptions, and amused at his logic ; I marvelled that a man with so great a repu- Let us review the arguments in favor of the non-identity of chicken-pox and smallpox. 1. Chicken-pox and smallpox are not interchangeable : — (i.) By infection, (a) There is not a single authentic instance on record where- in either of the diseases was the result of exposure to the infection of the other. (Trousseau.) (b) Chicken-pox may pre- vail as an epidemic isolated completely from cases of smallpox. (Mbhl.) Now, an epidemic of varioloid, free from con- current examples of non-modified small- pox, has never yet been seen. (ii.) By inoculation, (a) Chicken-pox is not inoculable. (Bryce, Trousseau.) (b) Smallpox, whether modified or not, inoculated, has never yet been proved to beget chicken-pox. 2. Chicken-pox and smallpox are not mutually prophylactic : — (i.) Smallpox did not prevent the oc- currence of chicken-pox. (Heberden: Halford, quoted by Gregory.) The read- er need not he reminded that undoubted smallpox very rarely recurs. (ii. ) Chicken-pox does not prevent the occurrence of smallpox. In the Cliil- dren's Hospital a girl sickened with chick- en-pox on January 17, and communicated tation shovild write so loosely. Was Heber- den a physician without experience, Gregory a mere apprentice to his art, and Trousseau's opinion unworthy of consideration ? If He- bra will confuse varicella and varioloid, he must even do so ; however, let it not be said that he does not deny the existence of vari- cella as a distinct disease. But ' ' quandoque bonus dormitat Homerus" shall cover all faults. CAUSES. 125 it to the child in the next bed ; in April, the girl first spoken of was attackud with modified smallpox (there were good vacci- nation marks on her arm), attended by severe invasion symptoms (vomiting, headache, backache), vfhich preceded the eruption several days ; she recovered ; soon afterwards her mother and sister were laid up with smallpox. 3. Chicken-pox and cow-pox are not mutually prophylactic. (i.) Oow-pox does not prevent the oc- currence of chicken-pox ; this we see every day. (ii.) Chicken-pox does not prevent the occurrence of cow-pox. (Abercrombie, Bryce. ) if the very existence of chicken-pox ad- mits of dispute, we cannot be surprised when we find that the published descrip- tions of the disease present ditferencL's and discrepancies without end. No doubt all physicians who have written upon small- pox, from the days of Rhazes downward, have left some notices of chicken-pox ; but these are, with a few exceptions, either vague or confused : because up to the beginning of the last century the two diseases in question were regarded as essentially identical ; confused, because hardly had a clear separation been made, before the introduction of vaccination, or rather the exaggerated expectations to which vaccination gave rise, led men to thrust into the realm of Varicella every example of varioloid. And even at the present day, the evanescence of the dis- ease and its lack of all gravity militate against better knowledge ; the induce- ments and the opportunities for study are small indeed. The epithet cAictoi-pox is derived from cicer (chick-pea) through the jFrench di.irlir. Varicella Inmnda) is a legitimate diminutive of rro-fi.s, a pimple. CAUSKS.—The efficient cause of Vari- cella is "contagion." The disease is readily comnmnicated through the air to a distance of several yards at least ; in de- gree of contagiousness chicken-pox "seems as infectious as smallpox." (Heberden.) Chicken-pox has never been transmitted by inoculation. Heberden (naturally enough) presumed that the disease was inoculable ; the only inference he drew from his failure to inoculate a person who had previously suffered from the disease was that it did not recur. About the end of the last century, the prevailing opinion in France was that chicken-pox could not be so transmitted. The instances of sup- posed inoculation narrated by Willan are most unsatisfactorj' ; the notion that such transmission might be impossible seems hardlv to have crossed his mind. Bcrard and I)e Lavit eftectivclj' inoculated Vari- cella, but Varicella v\'hich presented the same symptoms, progress, and form of pock, as variola. TIeim (quoted by Cross) was not less successful ; he took his Ij'mph from umbilicated vesicles v\'hich equalled in duration the pustules of 8mall[)ox. Xext came Bryce, who in 1818 published the result of his attempts to inoculate thirteen persons with the fluid of what, from his description, we may freely admit to have been undoubted Varicella ; the operation-wound healed up, and that was all. Lastly, Trousseau has failed in all his inoculation trials. Chicken-pox is not known to recur. It is a disease of childhood. The following table has been drawn up for me from the records of the Children's Hospital : — to ^ t. J3 usi I- J3 L. n t4 n h ti tl TK •a a 13 P! •TZ -3 a ^ f TS ^ -^ t -S ^ -^ 5 •7^ C^ r2 rt .0 « -d ^ ■a S pa pa a c Hj S pa at. «-^ 5^ s.^ ^^' ^^ S>: o '"' CO to Bovs 2 2 4 29 45 34 36 36 47 44 33 19 10 4 3 1 349 Girls 6 9 28 52 28 39 42 53 52 23 11 19 6 2 6 378 2 8 13 57 97 62 75 78 100 96 58 30 29 10 5 7 727 Judging from the same reports, there seems to have been an epidemic of chicken- pox in 1856. Adult females are occasionally attacked. (Gregory.) Description of the Disease. ■ — 1. Pre-cruptive Period. — ( i. ) Durcrtirin. — It does not exceed four days, and is cer- tainly less than a week (Gregory) : it lasts eight or nine days f?) (Heberden) : from fifteen to seveTitocn davs ( Trousseau) : my own observations would lead me to place the duration at about a fortnight, fih ) Symptoms. — There are no symptoms to be noticed before the eruption (Gregor}-) : they are absent or slight (Heberden, Mohl) : pooriiness, headache, and fever- ish ness precede the eruption by a few hours (Trousseau) : cough is sometimes observed. 2. Eruptive Period. — The eruption ap- pears within the first twenty-four hours of pooriiness in the form of small rose sjiots, slightly acuminated ; from ten to fifteen come out on the first day ; they appear on 126 VARICELLA. any part of the body. (Trousseau.) Heber- den and J. P. Frank also describe a red spot as the first appearance of the erup- tion of cliiclcen-pox. According to Bryeo i and Gregory, tlie first thing seen is an eruption of vesicles. For my own part, I have always noticed the vesicle to be pre- ceded by a red spot, and such a spot as I should not hesitate to call a papule, but a papule due to mere hyperemia of the cu- tis vera, and not to an exudation into it, for tension of the skin causes the varicel- lous papule to disappear. On the second day there may be a hun- dred or a hundred and fifty fresh spots ; those of the previous day have the epi- dermis raised in the form of a bleb, some- times perfectly round, containing serosity as clear as water ; there is no inflamma- tory areola. (Trousseau.) The vesicles from the first have the size of split pease (Bryce and Gregory) ; at any rate that size is soon attained or exceeded. The patient has the appearance of having been suljjected to a shower of scalding water. (Bryce.) The vesicle is unicellular, not umtailicated, has a very delicate cuticle, and when pricked collapses perfectly ; "after the vesicle is emptied, the finger passed over it does not detect any swelling of the cutis vera or the parts beneath." (Bryce, Mohl, Cross, Gregory.) The lat- ter statement seems to me to be much too exclusive ; a distinct elevation may often be detected, but is, like the swelling of the rose spot of typhoid fever, dispersible by pressure. The eruption occupies all parts of the body, the hairy scalp not excepted. The shape of the vesicles on the trunk is often oval, the long axis being athwart that of the body. Itchiness is common, and im- pels the children to rupture the vesicles. The next morning a hundred or a hun- dred and fifty new spots will have ap- peared during the night, the eruption of the preceding day having become vesicu- lar. (Trousseau.) The contents of vesi- cles which have lasted twenty-four hours become slightly milky ; the turbidity, how- ever, is uniforin. A slight inflammatory areola appears. This nocturnal outburst of spots (which become vesicular within ten hours) is re- peated for four or five succeeding nights from the beginning of the disease. (Trousseau.) Many vesicles, as soon as they have at- tained their full size, get broken, and so encrust at once. Those that remain un- broken present, on the third, fourth, or fifth day of their existence, a small cen- tral scab, which quickly attains to the size of the vesicle, and falls in a day or two. This scab is thin and granular ; it falls in fragments, and leaves no enduring red- ness and no cicatrix. If the vesicle have been subjected to unwonted irritation, the scab may be thick, coherent, and may leave, when it falls, a permanent pit. Gregory never saw a pit left. .3. Concurrent Si/inptorits. — These are of no importance ; the tongue is clean, the pulse unaflected, there is no appearance of fevcrishness. (Ileberden, Gregory.) There are outbursts of fever, sometimes violent, for four or five nights, ceasing by day, , (Trousseau.) Catarrh is common ; it may ! occasionally be serious, as in the case of a child who was under the care of Dr. West, on account of a chronic swelling of the glottidean mucous membrane ; her respi- ration was therefore somewhat labored at best ; by an attack of the chicken-pox she was brought to such straits that for forty- eight hours it seemed as if she could hardly escape tracheotomy ; with the ces- sation of the eruption the urgent dyspnoea ceased. It is with reluctance that no reference has been made to the name of Willan ; yet I think that the reader who consults his book will find it diflicult to believe that at least some of the cases which afforded materials for his descriptions were not cases of smallpox, especially those which were admissible into the variety of Vari- cella coniformis. 4. Sequelce.^An attack of chicken-pox sometimes leaves children in a poor state of health, such as may not be overlooked. Diagnosis. — Modified smallpox con- stantly resembles chicken-pox in (i.) the mildness of the symptoms, premonitory and concomitant ; (ii.) the scarcity of the eruption, and its character of coming out in successive crops ; (iii.) the shortness of the duration of the disease. (Cross.) Two or three days' high fever, with vomiting, headache, and light headedness, before the eruption, would exclude chick- en-pox. The absence of those symptoms would not exclude smallpox. Although the papule of chicken-pox has a certain elevation, it is something un- mistakably different from the peculiar shotty hardness of the papule of smallpox, modified or not. "Ah cases in which any of the pocks are observed to be indemed on the surface, whilst their, contents are clear, and before incrustation has com- menced, are at once to be distinguished from the water-pox. " (Cross.) The base of the varioloid vesicle is hard and raised to a degree never observed in chicken- pox. The pocks of varioloid are not ne- cessarily indented ; when not, we must trust to the "greater firmness and less rapid growth, although of equally short duration." "An elevation left after the scab separates determines the question. " (Cross.) The commencing scab of Vari- ceUa may be mistaken for umbilication. A perfect vaccination scar (it may not be unnecessary to add) often coincides with varioloid. SMALLPOX: DEFINITION — HISTORY. 127 The characters assigned by Gregory to his " variola varicelloides'' are : that it has at least forty-eight hours of premoni- tory fever ; that there are tubercular ele- vations of the skin ; that an uuibilication is always present ; and that the scabs dif- fer. The last character is comparatively unimportant, the first and third are put too absolutely. Prognosis. — "No physician has ever seen a child who has died of chicken-pox ; fatal complications are quite independent of the exanthematous fever." (Trous- seau.) Treatment. — " Curatur hie morbus quiete animi et corporis, et abstinentia a carne, vinoque." As much as possible, children should be prevented from picking the vesicles and scabs present on the face. Small doses of quinine ■will be useful dur- ing convalescence. Varieties and Synonyms.— (1) Va- ricella lentiformis. (AVillan.) On the first day of the eruption appear fiat red eleva- tions, in the centre of each of which a vesicle is soon formed; the vesicle never exceeds the tenth of an inch in diameter ; the scab falls without leaving a scar. (2) Varicella coniformis ( Willan) ; swine- pox. The vesicles rise suddenly, and have a hard inflamed border ; on the second day the surrounding inflammation is more extensive ; on the third the fluid is puru- lent ; a permanent scar results from each pock. (3) Varicella globularis (Willan) ; hives. The vesicles are larger than in varic. len- tif. and the cutaneous hardness less than in varic. conif. (4) Varicella sine varicelUs. (Wilson.) (5) Varicella solidesceus, verrucosa, pa- pularis, variola cornea (Van iSwieten), pemphigus variolodes solidescens (J. P. Frank), stonepox, horn-pox, or ivart-pox, is a form of true smallpox. (6) Varicella cellulosa (Cross), pustular umbilicated varicella (Wilson), variola va- ricelloides (Gregory), are names for that form of modified, smallpox which most re- sembles Varicella. Synonyma of true Ckicken-pox. — Crys- tal li (Ingrassias) ; variolas crystallina3, spurise, volaticse, beiugnte (Morton) ; lym- phaticse (Sauvages), pusillte (Heberden) ; pemphigus variolodes vesiculosus (Frank) ; varicella bullosa (Cross); water-pox, wa- ter-jags (provincial, to dag, daggle = to sprinkle). The following are some of the best ac- counts of the disease : — Wm. Heberden : 1st. Med. Trans. Coll. Phys. vol. i. 17G8. 2d. Conimentarii, 1802. Jno. Cross : Hist, of Variolous Epi- demic in Norwich, 1820. jSTicol C. Mohl : De Varioloidibus et "\"a- ricellis, 1827. Geo. Gregory : 1st. Cyclop. Pract. Med. vol. iv. 2d. Lectures on Eruptive Fevers, 1843. A. Trousseau : Cliuique Mcdicale, vol. i. 1861. SMALLPOX. By J. F. Marson. Definition. — Smallpox is a febrile, eruptive, and infectious disease, the pro- duct of a morbid poison ; which, after a period of latency, causes the development of an eruption on the surface of the body ; this passes through the stages of pimple, vesicle, pustule, and scab ; and, as a rule, exhausts or destroys the susceptibility to the disease, in the same person, for the remainder of life. Synonyms. — Jadari, Arabic ; EOT^oyia, Modern Greek ; Variola, Latin ; Small- pox, English ; the Pocks, Scotch ; Galra breac, Irish ; Petite Verole, French; Blat- tern, German ; Vaiuolo, Italian ; Vi rue- las, Spanish. History. — The origin of Smallpox is involved in much obscuritj-. A great deal of labor and learning have been bestoived in endeavoring to trace the beginning of the disease, but seemingly without any very decided success. The ancient Greeks and Romans do not appear by their writ- ings to have been acquainted with Small- pox, although De Ilaen, Dr. Willan, ilr. Moore, and Dr. Baron have endeavored to prove the contrary. Dr. Friend, Dr. Mead, and Dr. Mason Good were of opinion that the disease was not known to the Ancient Greeks ; and Dr. Adams, in the Appendix to the Commentary on Book Second of his trnnslation of Paulus jEgineta, agree.s entirely with the opinion 128 SMALLPOX. of Friend atid Mead, that the disease was not Ivnowu to tlie ancient Greeks. One of tlie earliest notices of a disease exhibiting the striiving cliaracteristics of Smallpox" is to be found in the historical writings of Procopius,' who lived in the middle of the sixth century. The disease^ " began A. D. 544, at Pelusium in Egypt, from whence it spread to Constantinople. " This corresponds closely with the era commonly assigned in medical books to the first appearance of Smallpox, viz., A. D. 509, the year of the birth of Maho- met. In that year an Abyssinian army, under Abrahah the viceroy, appeared be- fore Mecca, and was unexpectedly com- pelled to raise the siege. Several circum- stances concur to render it probable that the sudden retreat of the army was owing to the breaking out of Smallpox, and the dreadful mortality which it occasioned. Bruce,' in his travels, met with a manu- script account of the war, which confirms this story, and strengthens the opinion that Smallpox first ajipeared in Egypt and Arabia about the middle of the sixth cen- tury." Paulus JEgmeta lived at the end of the sixth or beginning of the seventh century. He professed to have treated, in his seven books, on all subjects connected with medicine and surgery, yet he says not one word to lead us to believe he was ac- quainted with Smallpox. Khazes, an Araljian physician, who flourished about 910, is generally referred to as one of the earliest and best writers on Smallpox. Xo doubt the disease had existed for some time before he undertook to describe it ; indeed, there is evidence in his work that it had, and he alludes to others who had written about it, especially to Ahron of Alexandria, and Messue of Bagdad. In the East, whence we receive the earliest accounts of Smallpox, there is a tradition — a mere tradition' — that the dis- ease in man had its origin from the camel. It is well known that this patient animal is extensively used in Arabia, Egypt, &:c. , as a beast of burden. If we may venture to reason on the subject from analogy, the tradition is not likely to be correct, inas- much as all other diseases that have been conveyed to man from the lower animals are not communicable by infection, only by inoculation. When once produced in man, they are still not infectious, in the usual acceptation of the term, as Smallpox is ; only producible again, from one to another, by inoculation, as in the instances ' De Bello Gotliico, lib. ii. 2 Gregory, Cyclop, of Pract. Med. vol. iii. p. 135. " Travels to Discover the Sourc3 of the Nile, vol. i. p. 514. * Moore's History of Smallpox. of cow-pox, glanders, hydrophobia, &c. When Smallpox appeared in this country in the sheep in 1847, ' we tried to commu- nicate it, by inoculation, to the human subject, and thought we had succeeded in doing so, and the virus was carried on from one to another for several weeks in succession. The pock produced was very like cow-pox, having only, as we thought, a bluer tinge, and was protective against Smallpox, as we ascertained by inoculat- ing the patient afterwards with the lymph ofhuman variola ; but we had unlbrtu- natcl}^ used for the original ovinution the same lancet, instead of having a new one, as we ought to have had, that we had previously used for vaccinating ; and al- though it was, as we believe, perfectly clean, and free from vaccine lymph, never- theless, as the disease could not be pro- duced again in the human subject, either by Mr. Ceely, of Aylesbury, who made repeated trials with the Ij'mph of sheep- pox, or by ourselves, the experiment was never brought before the medical profes- sion. Sacco writes of having frequently succeeded, in Lombardy, in transferring the virus of sheep-pox to man, and that it was as successful in protecting against Smallpox as cow-pox is. There has never been any reason to suppose that the Small- pox in sheep has produced by infection any disease in man. Those readers who are desirous of fur- ther information on the early history of Smallpox, will find a great deal of inte- resting reading on the subject in Moore's History of Smallpox ; Willan's Inquiry into the Antiquity of the Smallpox, Mea- sles, and Scarlet Eever ; Baron's Life of Jenner; Monro's Observations on the dif- ferent kinds of Smallpox ; and in Dr. Greenhill's translation of Khazes, forming one of the volumes of the Sydenham's So- ciety's publication. Description of Smallpox.— The dis- ease is divisible into varieties, which, for convenience, may be described separately. 1. Variola JJisrrcta; 2. Variola Semi- conjluens; 3. Variola C'oufluens; 4. Van- ola Corymhosa; 5. Variola Maligna; 6. Variola Benigna; 1. Variolce Anor)ialce, or irregular forms of the disease, embrac- ing those instances in which Smallpox is complicated with other diseases. It is called discrete, when the pustules stand separately, seniiconfluent, when they partially coalesce ; roiifliicnt, when they join and run into each" other; corymbose, when the disease appears in patches ; ma- lignant, when the eruption, besides being, generally, confluent, the initiatory and ' For an interesting; and able account of Variola Ovina, or Smallpox in Sheep, see a work by Professor Simonds, of the Eoyal Veterinary College, London, 1848. VARIETIES OF SMALLPOX. 129 succeeding symptoms are very severe, with hemorrliage from the mucous sur- faces, patches of purpura, and discolora- tions of the skin as if from having been bruised; benign, wlicu, althougli perhaps confluent, the eruption is superficial, and the accompanying symptoms are of a mild character; anomalous, when the disease is loraplicated with other diseases, eruptive or otherwise, as measles, scarlatina, urti- caria, &c. — ^or pneumonia, hooping-cough, bronchitis, disease of the brain, mania, &c. Smallpox is divisible Into four stages: — 1. The stage of incubation, which lasts twelve days, from the date of receiving the variolous germ. 2. The stage of initiatory or eruptive fever and invasion, lasting forty-eight hours. 3. The stage of maturation, continuing about nine days. 4. The stage of secondary fever, desiccation, and decline, lasting, of course, an imcertain time ; varying according to the severity of the disease. 1. (Stage of Innibation. — Smallpox ap- pears on the skin on the fourteenth day after the infection of the disease has been received into the constitution, the precise time being after thirteen times twenty- four hours have elapsed from the moment of taking the disease ; this time will of course occupy twelve wliole days, and part of two others. It is believed by the writer that the time from taking the dis- ease to its appearance on the skin is never longer than fourteen days, and his atten- tion has been constantly directed to the subject for upwards of twenty years. It is true but very few cases afford a decided opportunity forjudging of the precise time of incubation, not above one perhaps in fifty or more, but still these few cases are the very cases of value in deciding the point ; they have to be watched for care- fully to be "found. Three or four instances have occurred in which it seemed likely the disease had appeared between the tenth and eleventh days after receiving the infection ; they were cases occurring after vaccination, under which condition other stages of the disease are often inter- rupted, or cut short ; still these cases, seemingly decided cases, having been so few they can hardly be relied on : but the others, on the contrary, so many in the aggregate, they can hardly have failed to indicate the true time. i). Stage, of Primary Fever. — The ordi- nary course is this, — after twelve days' freedom from illness, there is severe in- disposition for forty-eight hours, and then the eruption of Smallpox begins to ap- pear. This is almost the invariable course. Still it is not invariable. In a few cases, but very few, there is more or less illness all through the period of incu- bation. The patient has not been so well as usual : experienced even at the time of taking the disease some unpleasant sen- VOL. I.— 9 sation, felt some nausea or giddiness, or sense of alarm, without knowing why it had happened. 3. Skuje of Mniuration. — In distinct and semicontluent Smallpox the early consti- tutional symptoms are much ameliorated on the third day, or about that time, when the eruption has been developed on the skin ; and the same remark applies with some reserve to confluent eases, but not so completely as to the distinct and semiconfluent forms of the disease ; the development of the eruption aftbrds only partial relief in confluent cases. The eruption appears first, usually, on the face, forehead, and wrists, and then on the rest of the body ; it is generally a couple of days later on the legs and feet than elsewhere. It is not thrown out at random, without order ; it may be ob- served to be in threes and fives, forming crescents, and in some instances, when it happens that two crescents come to- gether, they form a complete circle. The eruption is at first papular, then vesicular, then pustular, and takes about eight days to arrive at its full development, before the pustules begin to discharge their con- tents. [A marked characteristic at this stage is the wnhilication, or depression in the middle of the mature pustule ; giving it somewhat the shape of a hat whose crown has been pushed down at the mid- dle. — II.] During the stage of matura- tion, or concoction as the older authors termed it, there is often considerable swelling of the face and eyelids, so that the patient is popularly said to be blind with Smallpox for a certain time : and there is ptyalism in many cases, and in some a very tender state of the skin, so tender that the patient complains of the pain from the act of merely feeling the pulse ; all these may be looked upon as favorable signs of the disease ; patients who have the face a good deal swelled for four days, who have pretty free salivation, and a very tender skin, nearly always do well. 4. Stage of Srmndar;/ Fever, JJesiccatimi, and Decline. — AVhen Smallpox is not of such severity as to destroy life by the eighth or ninth day of eruption, there is a great increase of fever again, called the secondary fever, which is of vast import- ance, and gives rise to a train of severe and complicated symptoms, which will be described under the heading of Secondary Fever. Concurrently with it the pustules discharge their contents, and form dry, scaly scabs, and in favorable cases the dis- ease begins to dechne ; especially in those cases which will be described under the term Variola Bem'gna, and in modified Smallpox, as it is now frequently seen after vaccination. Varieties of Smallpox. — 1. Variola Discreta, or distinct Smallpox, is a term 130 SMALLPOX. applied to that form of the disease in which the pustules stand separately, or apart from each other, and might be readily counted. It is the simplest form of the disease, and is hardly ever attended with danger to hfe, except in children who may" be cutting teeth at the tinip, and may have convulsions or some aft'ec- tion of the brain, produced, it may be, by the combined influence of Smallpox and teething. 2. VarMa Scmiconfluens is that form of the disease in which the pustules partially coalesce, cannot be said to be distinct from each other, nor yet to run generally into each other. It is readily distin- guished in practice. Patients with this form of the disease usually do well ; when it proves fatal, the cause is from the com- bination of circumstances above alluded to in children with the distinct form of the disease ; or else from some complica- tion, as erysipelas, gangrene, &c., or, as happens now and then, from the petechial or malignant form of the disease being associated with only a semiconttuent form of eruption. The amount of eruption docs not alone destroy life in semiconttuent as in conttuent Smallpox. 3. Variola Conftuens. — This is the form of the disease which destroys the greatest number of persons ; the danger in fact arising principally from the amount of pustulation. It is found to prove fatal at the Smallpox Hospital, when large num- bers are taken into account, at the rate of 50 per cent. From the first the papulfe are very numerous, countless, and as the disease advances the pustules run into each other, and in the worst cases form one mass of disease. Even the confluent form of the disease may be fairly said to have its varieties. When the disease is but just confluent, and the patient has been previousl}' in good health, with an unimpaired constitution, he will probably recover. Patients do so in fact, as previ- ously stated, at the rate of 50 per cent. ; but when the disease is severely confluent, when it is almost impossible to put the end of a pencil between the pustules in many parts of the body, especially on the face, — and such cases are often met with, — a quarter of the amount of pustulation would be enough to destroy life. In cases where the eruption is observed at first to be generally confluent from head to foot, there may be said to be but very little chance for the patient's recovery. The danger is always rendered greater, cceteris paribus, when the eruption is very full about the head, face, and neck. The marked difference, from the first onset of the disease, between the distinct and confluent varieties of Smallpox, can- not fail to strike all observers. In the confluent form the initiatory fever is more intense, there is often delirium, sometimes of a very violent and uncontrollable kind, especially in persons accustomed to live freely, and in those more especially in the habit of indulging in taking ardent spirits. Such persons often require to be put under restraint to prevent their injuring them- selves or others. They are impressed oiten with the belief that they are about to be murdered, and endeavor, accord- ingly, to escape from control, — and have a tendency to commit suicide ; therefore it is desirable to put knives, razors, &c., out of their way. The nervous system is im- plicated ; there are tremors of the hands and lips— a state, in fact, often bordering on delirium tremens, produced partly by the Smallpox and partly by the previous habits of living. Draymen, barmen, pot- men, tailors, and women on the town, are very unfavorable subjects to be attacked with Smallpox, owing to their habits of indulging freely, and almost daily, in strong drinks. A very large proportion of the patients die who suffer in the early stage of confluent Smallpox from delirium ; it should be looked upon in every instance in which it occurs as a very unfavorable symptom. Fortunately, all cases of confluent Smallpox are not of this dangerous kind. There is the confluent superficial eruption, which often goes througli its course with- out an untoward symptom, especially in persons lately from the country, whose health is unimpaired by the injurious habits and bad air of a town life. Sometimes the pustules in confluent cases are very large and flat, they do not accumulate well, the edge of them is not well defined, and after they have been out some days they have a tendency to spread out, to become larger. These are danger- ous cases, and usually end in death. On the top of each pustule, or on many of them, a dark spot is formed during the stage of maturation in some cases of con- fluent Smallpox, and it will be observed, when this occurs, the pustules do not acu- minate well, they are rather flat ; when- ever these signs are noticed, the case should be looked upon as one of great danger, and the patient will most likely die. Persons of a weakly constitution, those especially with fair hair, have sometimes, about the eighth day of eruption, large bullae, filled with serum, intermixed with the Smallpox eruption. This is an un- favorable sign ; such patients require wine, beef-tea, jellies, &c., early, almost as soon as this symptom is observed. In some cases of confluent Smallpox there is an absence of the damask rose-red areola described, and very correctly, by the old authors, as surrounding, for a short distance, each pustule of the dis- ease ; and, instead of this, the skin be- tween the pustules is generally inflamed VARIETIES OF SMALLPOX. 131 from head to foot. These cases always do badly. The watery-pock is another dangerous variety of confluent Smallpox. These are, usually, very offensive eases : are accom- panied with a good deal of secondary fever : and end fatally for the most part, or else there is a very tedious convales- cence. The eruption of Smallpox is formed on some of the mucous surfaces as well as on the skin generally, — in the mouth, on the tongue, in the nares and fauces, on the membrane lining the larynx, trachea, and bronchi. When the vari are numerous on the larynx and trachea, the danger of the patient is thereby very much increased ; they produce a viscid secretion, cough, and a peculiar hoarse, metallic sound in coughing, indicative of their presence in these parts. A constant subject of com- plaint in most cases of confluent Smallpox is the soreness of the throat. To nearly every patient it is necessary to explain that this inconvenience is caused by the eruption being formed on the roof of the mouth, soft palate, fauces, &c., and that it is impossible to interrupt its course there any more than on the surface of the skin generally. Still the inconvenience goes off considerably in a few days ; the vari on the mucous surfaces have a shorter duration than on the skin generally ; do not maturate and scab as on the outer skin, from being constantly kept moist by the natural secretion of the mucous sur- faces ; they never reach beyond the stage of vesicles. 4. Variola Corymhosa. — This is a very singular and very fatal form of the dis- ease. It is rather rare. It is called co- rymbose, from carymbus, a bunch or clus- ter of ivy-berries, &c. Corymhose is also a botanical term, applied to a class of plants, the flowers of which are formed in clusters, like those of the carrot. We have gone over the register of the Small- pox Hospital for thirty years, for the pur- pose of investigating minutely the danger to life in this form of the disease, and find that, in this time, 104 cases of corymbose Smahpox have been admitted — 29 in un- vaccinated persons, 74 in the vaccinated, and one after inoculation. Of the 29 unvaccinated persons, 13 died, or 44 per cent. ; of the 74 vaccinated, 32 died ; and, deducting 2 who died of superadded disease, there remains a mortality of 41 per cent. The single case of corymbose Smallpox after inoculation died. It will thus be seen that corjmibose Smallpox is, in all cases, a very fatal form of the dis- ease, and brings life into danger nearly as much in vaccinated as in unvaccinated persons, varying only about 3 per cent. The danger in this form of Smallpox often seems to be out of all proportion to the amount of pustulation, which rules so powerfully in other forms of the disease : why it is so, it is impossible with our pre- sent knowledge to say, and it is probably one of those things which will for ever remain inexplicable. The disease, as stated, appears in clusters, or, it may be, that only a single cluster is formed, and yet the fatal character before alluded to is given to the disease. In other parts of the body the eruption is perhaps but sparsely scattered, and we might expect the disease to rank in danger with a com- mon semiconfluent case ; such, however, is not the fact in practice. It generally happens there are two or three patches, about the size of the palm of the hand, in different parts of the body, in which the pimples are as closely set as could be ; and in the immediate neighborhood of each patch the skin is for some distance free from eruption, or nearly so, a few spots only of the disease being formed. There is a great tendency to symmetry in this form of the complaint ; when a patch is formed on one arm, or leg, it often hap- pens that a similar patcla is formed on the same part of the corresponding limb on the opposite side. In some instances there are numerous corymbose patches in different parts of the body, about the size of a half-crown or five-shilling piece. When these corymbose cases seem to be recovering, very frequently some danger- ous complications arise to mar our fair hopes of a successful termination of the malady, and generally, under more favor- able circumstances, there is a long and tedious convalescence. 5. Variola Maligna. — This truly fright- ful variety of Smallpox was called by the early writers on the disease Black Pock, or Variolm NUjra. The symptoms are very formidable at the onset. The blood appears to be poisoned from the first by the disease ; it is rendered very fluid and watery. If a portion be drawn from a vein, a large part of it will be found to be serum, and what ought to be crassamen- tum remains almost fluid ; it is principally coloring matter — the fibrin seems to have disappeared. Tlie countenance of the patient is sunken, the breathing anxious, and in some instances deatli takes place before the eruption has been developed, leaving some doubt about the real charac- ter of the disease in the minds of those persons not by practice familiarly ac- quainted with its varied appearances ; — a doubt whether it was Smallpox, scarlet fever, or some other form of idiopathic malignant fever. The eruption in mahgnant Smallpox is rather slowly developed. There is hem- orrhage from some, occasionally from all, or nearly all, of the mucous surfaces ; from the nose, from the mouth, from the air-passages, from the bowels ; the urine is high-colored from blood mixed with it. 132 SMALLPOX. In the female there is invariably hemor- rhage from the uterus, and abortion in cases of pregnancy. The fojtus is visually horn dead. Early in the attack there is a patch of cflfused blood under the conjunc- tiva, which should always be looked upon as a most dangerous symptom. We have seen blood, in some very rare instances, ooze from the ears and eyes. Livid patches from effused blood are formed on the surface of the body, and blood is mixed with the fluid formed in the Small- pox vesicles, which can scarcely be said to become pustules. There is great depres- sion, but not often delirium — indeed, but rarely ; the intellect usually remains clear to the last. A confluent eruption nearly always accompanies the malignant form of Smallpox, and death commonly takes place on the fifth day of the eruption. Petechial Smallpox partakes very much of the same characters as malignant Small- pox. Numerous little dark spots, resem- iDling flea-bites, especially about the armpits and groins, are observable, and the skin in these parts has a greenish-yellow hue, very like what we see during recovery from a bruise. The condition of the fluids is no doubt very much the same in these two varieties of the disease ; malignant and petechial Smallpox are very nearly akin. 0. Variola Henirjna. — Van Swieten and others have described a form of natural Smallpox under the title of Variola Verru- cosa, or cornea, stone-pock, horn-pock, and wort-pock, which we sometimes see in these days, and in which the disease is of a mild, modified character. It is ushered in with symptoms as severe as in the dangerous confluent form, but on the third or fourth day of eruption all the severe symptoms begin to subside ; the eruption assumes a modified form, such as wo constantly see in post-vaccinal cases. We have often had an opportunity of observing this form of the disease in children whose mothers were at the hospital with them, and who knew perfectly weU no attempt had been made at vaccination. The pustles are of unequal size, some shrivelling and dying off', while others are maturing : there is no secondary fever, and no pitting. These are examples of mild natural Smallpox, such as have occurred no doubt at all periods to a few favored individuals, and in which, fortunately for the ol)jects at- tacked, the disease leaves no trace behind. 7. Variolw ^noniate.— Smallpox is ren- dered irregular by being complicated with other diseases. We have seen it in con- junction with scarlatina,' measles, urti- caria, syphilis, bronchitis, pneumonia, phthisis, dysentery, &c. Pregnancy may ' See Med.-Chir. Trans., vol. xxx. Mar- son, on the Co-existence of the Eruptive Fevers. be mentioned as one of the anomalies; and another, the existence of Smallpox on the foetus at birth; which must have gone through the stage of incubation, the pri- mary fever, and early days of eruption, before it was born. We have several times seen children who were born with the eruption of Smallpox out on the body, but modified as it is on the mucous sur- faces. Mead" imagined that persons wlio were insusceptible of Smallpox had possi- bly gone through the disease before birth. First Symptoms of Smallpox, or Primm-y Fever. — This disease begins with rigors, fever, thirst, headache, sickness at the stomach, sometimes accompanied with vomiting, pain in the back, and general indisposition ; followed, after forty-eight hours of illness, by an eruption on the skin of pimples, which are generally ob- served at first on the forehead, face, and wrists. Among the early symptoms of the disease should be enumerated, as now and then occurring in children, one or two convulsive fits. This occasionally happens in adults also, but not so often as in children. On passing the fingers over the points of eruption some hardness is felt in the skin, as if a grain of mustard- seed, or a small shot-corn, were imbedded in it ; but the skin is not tender to tlie touch at these points, nor does pressure seem to produce any pain. In cases of Smallpox after vaccination, which are so frequently met with in these days, the true or distinctive eruption of Smallpox is very often preceded by roseola, which lasts two or three days — the roseola ea:a«- thematica — which may lead observers, not intimately acquainted with the early symptoms of Smallpox, to suppose the patient has an attack of scarlatina ; but this eruption may be known from that of scarlatina by not being so completely dif- fused over the skin as the rash of scarla- tina usually is ; it is also of a lighter, brighter, roseolar scarlet tint, than the eruption of scarlatina, which has a rather dingy hue ; and, above all, it has a mot- tled appearance. Secondary J'erer.— Besides the initia- tory fever, the fever of invasion in Small- pox, there is what is called the secondary fever, which begins, in confluent cases, about the eighth or ninth day. In the milder cases of Smallpox, secondary fever is hardly perceptible ; in the malignant and severely confluent cases death takes place before the secondary fever has barely commenced. But, in most in- stances of confluent Smallpox, patients suffer more or less from secondary fever, which seems to bo the cause or forerunner of a very important chain of events. The ' De Variolis et Morbillis, cap. iv. edit. 1747. FIRST SYMPTOMS OF SMALLPOX. 133 pulse is increased iu frequency, there is tliirst, dry tongue, and hot skin ; in many cases, particularly in the plethoric, some local inflammation arises, often occurring at the elbow, seemingly from leaning on it when taking food. But cellular intlani- mation takes place, in different patients, in nearly all parts of the bodj'-, sometimes it is deeply seated between the large mus- cles ; twice we have known abscesses formed between the gastrocnemius and soleus muscles, causing intense pain dur- ing the formation of the matter. These deep-seated abscesses in Smallpox are sometimes the result of injury received months before. In one of the examples just mentioned, a seaman, in jumping from his ship to the wharf, missed his balance, and fell back on the ship, strik- ing the calf of his leg against the side of the ship; no harm would most likely have followed had he not taken Smallpox or some other severe febrile disease. Numerous small boils take place in many cases of confluent Smallpox; phleg- monous inflammation in others, involving often the greater portion of a limb. Pa- tients who, from their previous good state of health, just escape dying from the se- verity of the eruption, at the usual time, viz., from the ninth to the thirteenth day, are very apt to suffbr severely from sec- ondary fever, and its consequences; such as pleurisy, pneumonia, ulceration of the cornea, &c. : these are amongst the very serious evils that may be expected. It is difDoult to account for this peculiar form of fever in Smallpox; some have imagined it is owing to the absorption into the cir- culation of the pus formed on the surface of the body. If this were true, we should see, more frequently than we do, the re- sults we recognize as belonging to py- Eemia. These results we do see in some instances, but they may be said to be ex- ceptional; whereas secondary fever is the usual consequence of confluent Smallpox. The absorption of some fluid forming part of the eruption, and more readily taken into the circulation than pus is, we strongly suspect, to be the cause of sec- ondary fever, but our knowledge of ani- mal chemistry at the present day is not sufficiently precise to enable any one to say what this fluid is ; it is one of the problems for the industrious and inge- nious to solve. Secondary fever com- mences after, just after, the pustules have begun to discharge their contents; it may be that the absorbed fluid is not part of the original secretion, but the product of de- composition, or of some chemical change that takes place after the matter of Small- pox has been exposed to the air. In the horn-poek, as it is called from its hard- ness, in which there is some modification of the eruption in the advanced stage of the disease, such as we observe frequently after vaccination, the matter is dried up suddenly without bt-iug ilischarged at all: these cases arc entirely free from second- ary fever; therefore it would seem that the discharged matter has something to do with secondary fever. Pleurisy is one of the most painful and fatal sequete of the secondary fever of confluent Smallpox. Patients are attacked with it very suddenly, and hardly ever re- cover ; it runs a very rapid course, and terminates fatally in three or four days, sometimes sooner. The symptoms are generally at the first of a very decided character ; violent pain in the side, wiry pulse, shortness of breathing, great diffi- culty iu drawing the breath, and a very anxious expression of countenance. Such cases are all but hopeless ; but we have, in some very rare instances, seen patients recover ; tlicy should, therefore, not be entirely given up as past hope ; we had a very severe case lately in a j'oung Scotch- man, who, after a long convalescence, ultimately got well. Pneumonia occasionall}' follows severe secondary fever. It comes on much more insidiously than pleurisy, and assumes the congestive character so well described by Mr. Erichsen, under the term of "Con- gestive Pneumonia, "in ]\[cd.-Ohir. Trans. vol. xxvi. p. 29. It is slower in its pro- gress than pleurisy, and is very likely to have existed two or three daj-s before it is discovered. It is more rarely, perhaps, seen than pleurisy, and is not so uniformly fatal ; but it should be viewed as one of the very serious complications occurring in the advanced stage of Smallpox, and very likely to prove fatal. Bronchitis is another serious complica- tion of advanced Smallpox ; dangerous at all times, doubly so when the body is weakened by other exhausting disease. Glossitis sometimes arises during the secondary fever of Smallpox ; the tongue becomes very much swollen and dry, so that the patient is unable to articulate or close the mouth ; it is a very distressing and perilous symptom ; those attacked with it nearly always die. Otitis, followed by abscess in the ear, not unusually results from Smallpox. The pain produced during the formation of the matter is ver}' great, but it is immediately relieved on the breaking of the abscess. It is probable that, in some instances, per- manent injury may remain in the ear from this occurrence. The abdomen escapes singularly free from complications in Smallpox. ^ We do now and then meet with peritonitis, but very rarely ; diarrhcea more frequently ; and sometimes with mucous enteritis in children. Erysipelas, pytemia, gangrene, &c., are frequently met with, at'times, in hospital practice. They form the most serious 134 SMALLPOX. drawbacks to all hospitals, and are, as is well known, fatal in their tendency. These diseases are amongst the complications of Smallpox, and are not confined wholly to hospitals ; they are met with in private practice, occurring after severe confluent Smallpox when the disease has lasted a fortnight or more. They are very dan- gerous. Erysipelas, more particularly of the head and face, occurs more frequently than any other form of superadded mis- chief. Patients with it, for the most part, get well ; but erysipelas occasionally gives rise to pytemia, which is followed by large abscesses, perhaps bed-sores, hectic fever, and death. The scrotum is apt to be- come gangrenous after Smallpox, especi- ally in those who have the ill luck at the time to be suftering from gonorrhrea. It is a fatal complication ; patients generally die who are attacked with it, but not al- ways. "\Ve have several times seen the whole scrotum slough awaj', and the pa- tient entirely recover ; and it is interest- ing and surprising to see what a good covering is formed afterwards to the tes- ticles, almost as good as before the scro- tum was injured. The women of the town are bad subjects for Smallpox. ^Vhen they ha^•e gonor- rhoea, they are very likely to have gan- grene of the genitals ; and, from their pre- vious irregular habits and spirit drinking, their illness commonly ends fatally. We had a patient two years since with gan- grene of the genitals, owing to leucorrhoea ; it might, however, have been gonorrhoea ; she was barmaid at a large hotel. Variolous Ophthalmia and Corneal Ulceration. — Conjunctival inflammation often begins on the fifth or sixth day in Smallpox, and continues for a few days, and then subsides under the use of simple remedies. But there is another form of mischief — ulceration of the cornea — which often leads to the loss of an eye ; both eyes, fortunately, being but rarely affected, although this does sometimes happen. Formerly a large number of the inmates of the asylums for the blind had lost their eyes from Smallpox. The injury to the eye, by which the organ is destroyed, is not from the pustules of Smallpox forming on the eye, as used to be supposed, but from a destructive form of ulceration be- ginning almost invariably at the edge of the cornea. After having been in constant attend- ance at the Smallpox Hospital for up- wards of three years, and having witnessed the great epidemic of 1838, and having seen upwards of 1500 cases of Smallpox, the author was induced to write a paper on Variolous Ophthalmia, which was read before the Westminster Medical Society in 1830.' Out of 1500 cases, no instance ' Medical Gazette, No. 32, May 4, 1839. had then, or for some time affcenvards, come under his notice in which the pustule of Smallpox was formed on the eye. It does, however, happen now and then. In nearly thirty year* the number of cases of Smallpox admitted into the hospital has exceeded 15,000. Out of this number 26 instances have been noticed in which the primary pustule of Smallpox has formed on the eye. It has not. however, in any one of these instances, injured the eye in any way ; the cases have all done well. in these very rare instances in which the pustule does form on the conjunctiva, it has nearly always been observed to have its seat half-way between the cornea and the inner canthus of the eye, where the conjunctiva is thicker than elsewhere. It has never been seen on the coraea. Now and then it has been observed half- way between the cornea and the outer canthus ; the conjunctiva is thicker in this part also than over the eye generally. So that in these very exceptional instances, once in perhaps 500 cases, the pustule of Smallpox does form on the conjunctiva, but does not destroy or injure the eye in the least, so far as has been observed. The ulceration of the cornea that leads to the destruction of the eye in Smallpox begins after the secondary fever has com- menced. It has been observed to begin as early as the tenth day after the com- mencement of the general eruption, and as late as the thirtieth ; the fourteenth day is a common time for it to be first seen. It comes on with redness and slight pain in the part affected, and very soon an ulcer is formed having its seat almost invariably at the margin of the cornea : this continues to spread with more or less rapidity, according to the degree of secondary fever present ; in the more violent cases an ulcer being formed on each side of the cornea at the same time, showing the disease to be advancing with great severity, and presenting a tolerably certain indication that the eye will be entirely lost. The ulceration passes through the different layers of the cornea until the aqueous humor escapes ; and if the part of the cornea destroyed be large, the iris protrudes through the open- ing. In the worst cases there is usually hypopyon, and when the matter is dis- charged the crystalline lens and vitreous humor escape ; or the humors may escape from deep and extensive sloughing in the first instance, without the formation of matter ; this being succeeded, of course, by the total annihilation of the form of the eye as well as the sight. In some instances the ulceration proceeds very rapidly, the entire cornea being swept away within forty-eight hours from the apparent commencement of the ulcera- tion ; and, what is singular, now and then the mischief goes on without the least DIAGNOSIS. 135 pain to the patient, or his being aware tlmt anything is amiss with his eye. This destructive ulceration never goes on rap- idly, but when there is a high degree of secondary fever present. That is a point which should be particularly remarked. It is likely to occur when there is a hot and dry state of skin, rapid pulse, thirst, loaded tongue ; these having been pre- ceded by a very confluent state of the disease, and the patient has just escaped dying at the usual time, namely, the nintii, tenth, or eleventh day of eruption. Then it is that some serious consequence may be apprehended, such as the loss of an eye, formation of large and deep ab- scesses, sloughing of the cellular mem- brane, or, may be, formation of matter in one side of the chest ; some of th(>se serious results may be expected when the second- ary fever runs high in confluent Smallpox, combined with the circumstances above detailed. It happens occasionally, unfortunately, that persons have had something amiss with their eyes before Smallpox conies on — some scrofulous tendency, or sensitive state of the conjunctival membrane caused by their occupation. For instance, a chimney-sweep was admitted into the hospital, and his eyes were in such a sen- sitive state from soot getting into tliem in the course of his work previously, that he had been several days in the hospital, keeping his head constantly under the bed-clothes, before he would allow his eyelids to be opened. When this was at last accomplished, both ey-es were found to be entirely lost from ulceration of the cornea. Conjunctivitis, rather slow in its pro- gress, begins in some cases during a tedious convalescence as late as the third or fourth week of Smallpox : after it has existed a few days, there will generally be found, on close examination, a small ulcer on the cornea ; and, in this advanced stage of the complaint, the ulcer is com- monly not at the margin of the cornea, but nearer the centre of it. Diagnosis.— It is often of great conse- quence to be enabled to decide as soon as possible on the nature of a febrile erup- tive disease, as, in the cases of persons employed in large establishments, ser- vants, etc., in order to their removal for the safety of others ; and, on the other hand, it is unjust to the patients them- selves to send them amongst Smallpox or fever patients, if they are not sutt'eriug from these respective diseases, where they may contract, and even die of, a disease of a far more dangerous nature than the one they may happen already to be sufter- ing from : on this account, early and cor- rect diagnosis is of great consequence to all persons concerned, as well for the credit of the medical practitioner as for the safety of the patient. Upwards of twenty diseases have been mistaken, within the last few years, in the early stage of illness, for Smallpox, and the patients have been sent as having Smallpox to the Smallpox Hospital. It has been observed, however, that three or four diseases mis- lead much more frequently than others ; with the symptoms of these diseases, therefore, it will be desirable to contrast Smallpox. The four diseases are — Measles, febrile lichen, varicella, and some forms of continued fever. Some of the early symptoms of Smallpox are common to the other diseases above enumerated, such as fever, thirst, headache, sickness, and vomiting ; but there is in Smallpox what there but rarely is in the other diseases — and when it exists it is accidental, not part of the disease itself — acute pain in the back, evidently not muscular pain. 1. Diagnosis of Smallpox from Measles. — Measles is far more frequently mistaken for Smallpox than any other disease is mistaken for it. In Smallpox the eruption follows on the third day, or after forty- eight hours'' illness. In measles the erup- tion generally appears on the fourth day, or after seventy-two hours'' illness ; there is, besides, usually some cough, and lachry- mal discharge and flery redness of the eyes. The eruption, too, of measles, al- though a little elevated above the surface of the skin, is not so distinctly felt as in Smallpox : it appears more superficial. The lapse of forty-eight hours after the commencement of illness before the ap- pearance of eruption, the pain in the back, and the shotty feel of the eruption on the skin in Smallpox, contrasted with the lapse of seventy-two hours of illness before eruption in measles, the cough, red- ness of the eyes, and less marked feeling of hardness and prominence on the skin, should be enough, compared with the general appearance of the jiatient, to dis- tinguish the two diseases. 2. Diagnosis of Smallpox from Fehrile Lichen. — Febrile lichen is more lilce Small- pox especially, than any other form of disease is, not variolous. At first it must be confessed there is great difficulty in distinguishing between febrile lichen and modified Smallpox ; still, however, by attending minutely to some leading cha- racteristics, they may be distinguished : and here again tune comes materially to our aid ; lichen appears on the second day of illness, or after tuxntyfour hours' ill- ness, and the eruption is without the or- der we observe in Smallpox ; it appears scattered at random over the surface of the skin, and begins to appear at first generally on the trunk, as well as on the head and face, which is not the case in Smaflpox. Two or three days will always, of course, put an end to any doubts there 136 SMALLPOX. may be on the subject, as no fluid, or next to none, is ever found in the eruption produced in lichen. 3. Diagnosis of Smallpoxfrom Varicella Vera. — Varicella vera leads to doubt in the minds of many practitioners. The distinction, however, between the two diseases is tolerably easy, and hardly ought to admit of mistakes. The initia- tory fever of varicella is but very slight, scarcely perceptible ; wherw as it is genaral- ly rather severe in Smallpox, even where the resulting disease is mild. Twenty- four hours only elapse in varicella after the commencement of indisposition before the eruption begins to appear ; there is no hardness, as in Smallpox, on passing the fingers over the points of eruption, and no areola at the base of each vesicle, or if any, very slight indeed ; in most cases none. The erufition in varicella has its seat just under the cuticle, between the external and deeper layers of the epi- dermis ; is vesicular, as if raised by a shower of boiling water ; scattered over the skin without the order of threes and fives together, forming crescents and cir- cles as in Smallpox ; there is besides al- ways, or nearly so, what is a very good guide, one or two large vesicles on the shoulders, generally between the shoulder- blades, much larger, and more spread out than the rest of the eruption, wanting the defined edge and hardness of the eruption of Smallpox. In the advanced stage the contents of the vesicles become purulent ; but still, those who have watched the course of the disease carefully, cannot well be in doubt as to its real nature, and want of identity with Smallpox. [The vesicle of chicken-pox scarcely pustulates, as a rule, and never fully itm- bilicates like that of Smallpox. In a very few cases one or two vesicles upon a ten- der part (as the face) may involve the true skin sufficiently to leave a small mark or pit ; but this is quite exceptional. — H.] Even near the present day,' the doubt has not been altogether removed that varicella and variola may be of kindred origin. Heberden first pointed out clearly the distinction between the two diseases. "We have no doubt whatever that they are quite independent of each other. Patients admitted with varicella into the Smallpox Hospital have often taken Smallpox dur- ing their stay there ; and the converse happened a few years since ; a child who had been in the hospital with variola was discharged cured and a short time after- wards was readmitted with varicella vera. 4. Diagnosis of Smallpoxfrom continued Fever. — The slow insidious commence- ment of continued fever, with none of the suddenness and violence of attack observed 1 See Thomson ou tlie Varioloid Epidemic of Scotland, 1S2U. in Smallpox, and the languid and general aspect of the patient in fever, ought al- ways to be enough to mark the distinction between the two diseases. Smallpox and continued fever. PiiOGNOSiS. — In foretelhng what will probably be the result of any particular case of Smallpox, the judgment should be guided by the most striking points already described. 1. The quantity of eruption ; 2. The age of the patient ; 3. Whether or not the mucous membrane of the larynx and trachea seems to be much implicated ; 4. The state of the fluids giving rise to the malignant or petechial form of the dis- ease ; 5. The state of the nervous system, and previous habits of living ; 6. Whether the patient has been vaccinated, and, if so, the number and quality of the cica- trices (to be alluded to particularly here- after) ; 7. Whether the disease is compli- cated with pregnancy ; 8. The favorable or unfavorable circumstances in which the patient is placed. TABLE I. Showing the rate per cent, of mortality from different forms of eruption in 2654 unvao- cinated cases of Smallpox, admitted into tile Smallpox and Vaccination Hospital, London, from 1836 to 1851, inclusive. Unvaccinated Smallpox. Cases. Deaths. Rate per cent, of Mortality. Confluent . . Semiconfluent . Distinct . . . 1838 614 202 937 51 8 50 8 4 2654 996 37 Note. — Eighty-one of the above patients who died were affected with antecedent, or superadded disease, as well as with Smallpox, viz., Confluent, 58; Semiconfluent, 15; Dis- tinct, 8. 1. Confluent Smallpox is always more or less dangerous. Whenever the disease is confluent, the prognosis should always be very guarded in the early stage of the illness. Unvaccinated patients with this form of the disease die, as shown in Table I. at the rate of 50 per cent. Great con- fluence about the head and face is always to be dreaded, as patients often die with it when the eruption is but thinly scat- tered on the rest of the body. AVhen the pustules are flat, do not acuminate well, and when the areola} around them on the extremities arc of a clarety hue, and the eruption on the face is white and of a pasty appearance, the patient has but lit- tle chance of recovery. Distinct Smallpox is a disease of but little danger per se when imcomplicated with other'symptonis of a fatal tendency ; as shown in" Table I. PROGNOSIS. 137 it producef? a mortality of only 4 per cent. ; it liardly ever alone endangers life in the adult. Semiconfluent Smallpox produces, or is implicated in producing twice the mor- tality of the distinct form of the disease; it is sometimes, in rare instances, accom- panied with symptoms of malignancy, viz., hemorrhage from the mucous sur- faces, etc., and may become dangerous from the previous bad habits or shattered health of the patient. Under these cir- cumstances a few deaths take place from somiconlluent Smallpox, amounting to 8 per cent. TABLE II. Ages of the unvaccinated patients admitted with Smallpox, at the Smallpox and Vaccination Hospital, London, from 1836 to 1851 inclusive, with the rate yier cent, of mortality, calcu- lated at different periods of life. Date 1836 to 1851. AoKiN Years. Total. 0-5 5-10 10-15 15-20 20-25 25-30 30-40 '4O-.OO I 50-60; 60-70 70-80 SO-90 Patients Deaths 356 181 50 334 91 27 270 62 23 571 154 26 669 274 40 270 124 45 154 89 57 18 13 8 5 1 1 1 1 1 2654 996 Percentage of deaths . 69 75 37 JJote. — About 2 per cent, of the unvaccinated patients died from Smallpox complicated with antecedent or superadded diseases. 2. Age should occupy an important place in the prognosis of Smallpox. Its influence is the greatest in early and in advanced life. See Table II. 50 per cent. die under 5 years of age, and upwards of 50 per cent, beyond 30 years. The least mortality talies place from 10 to 15 years of life. 3. The state of the mucous membrane of the air-passages should be duly esti- mated; this can be pretty well known by the tone of the voice. When the larynx is much implicated there will be a good deal of cough, and the sound from cough- ing, and the voice in speaking, will have a hoarse metallic resonance. Laryngeal and tracheal complications render the dis- ease very dangerous. 4. A knowledge of the condition of the fluids is very important in estimating the danger in Smallpox. All symptoms indi- cating malignancy, and a putrescenf state of the blood, should be looked upon as very unfavorable signs. Hemorrhage from any of the mucous surfaces, pur- pura, blood effused under the conjunc- tiva, or into the Smallpox vesicles, should all be regarded as very dangerous symp- toms. 5. The state of the nervous system is amongst the most important points to be taken into consideration. Cases accom- panied in the early stage with delirium generally end fatally. Persons of pletho- ric habit and free livers are very apt to have delirium, with a nervous, tremulous manner, and sleepless nights, and are very difficult to manage. The irritable temperament is unfavorable in Smallpox. Such persons often worry themselves about the merest trifles, and when they would otherwise do well, but for this irri- tability, the case ends in death. Delirium coming on for the first time about the tenth day is a very bad sign; such patients nearly always die. Cliildren who grind their teeth hardly ever recover. The prognosis in the above cases should be un- favorable. On the other hand, a quiet state of the brain and nervous system, a tranquil cheerful manner, with hope of re- covery, are tolerably certain indications of a favorable result. 6. The patient liaving been vaccinated will make a most important difference in estimating the danger from Smallpox. If the -^-accination has been performed in four or more places, and corresponding cicatrices remain of good quality, readily seen, the case will, in all likelihood, end well. The early symptoms of Smallpox may be very severe, often are so, in well- vaccinated cases, but they subside as soon as the eruption is thrown out, which is usually highly modified, and all goes on well. But" there are, unfortunately, many persons who have not had vaccination well performed, and they will suffer from Smallpox, probably, accordingly. When one or two cicatrices can but just be seen, doubtfully seen, the case may be as se- vere as if there had been no vaccination at all, tlie eruption pass through its seve- ral stages quite unmodified, and the dis- ease proceed, and terminate, uninfluenced in any way by the previous vaccination. 7. Pregnancy is a most unfortunate and dangerous complication in Smallpox. Abortion is very apt to take place. In fatal cases the child is usually thrown oft' 138 SMALLPOX. the day before death. It is generally born dead, but not invariably so. Al- though the danger in Smallpox is very much increased by pregnancy, and should always be taken seriously into account in forming a prognosis, pregnant patients occasionally do well, especially after vac- cination. They sometimes abort, and sometimes do not; sometimes both mother and child do well. 8. The circumstances under which a person is placed in Smallpox may influ- ence very much the result ; as, for in- stance, on board ship; in a small, confined ill-ventilated house ; hospitals are espe- cially dangerous to the pregnant woman, witness the mortality in the lying-in hos- pitals;' the prejudices of friends in over- heating the patient, and giving cordials and strong drinks at unseasonable times; all these things may interfere with the chance of recovery. Susceptibility to Sjiallpox. — Each individual of the human species is born, it would seem, with a susceptibility to contract Smallpox, measles, scarlatina, and perhaps some other diseases, belong- ing to what is called the zymotic class — those diseases produced by a morbid ani- mal poison. There is in the organism, most likely in the blood, some inborn principle or ingredient, clearly not essen- tial to life and well-being, by which we are rendered liable to undergo these dis- eases. It is no doulit ordained by an overruling Providence that we should pass through these ordeals, from which hardly any are altogether proof, if they live but long enough, and from which large numbers annually die. After re- covery from these diseases, the body is generally in no way better or worse for having passed through the change pro- duced by the diseases, except in those in- stances in which the person is disfigured by the marks of Smallpox, or the seeds, perhaps, of scrofulous disease are brought into action ; or, in the case of the measles, some pneumonic mischief may be left be- hind ; or, in scarlatina, injury to the ears. All the functions essential to life usually go on as well as before, after passing through these diseases ; therefore it would seem to be some innate principle in no way necessary to the well-being of the in- dividual which is destroyed, or got rid of, during the attack ; a principle or ingre- dient by which we are rendered liable to undergo these respective diseases. Some persons on exposure escape the infection of Smallpox over and over again, but take it at last. In 1844, a woman, 83 years of age, was admitted into the Smallpox Hos- pital with severe confluent natural Small- ' See Lectures by Dr. Barnes, in the Lan- cet, 1865, vol. i. p. 141. pox, of which she died, who had nursed her own children and her grandchildren with the disease, and had otherwise often been exposed to variolous infection, but never took it before. A similar instance is mentioned by Sir Thomas Watson, in his Lectures, of an old woman who had for years acted as a village nurse, and had nursed a great many persons with Small- pox, but at last, at 84 years of age, took the disease, of which she died. Some persons have been known to pass through a long life, frequently exposed to Smallpox, but have never taken it; others, late in life, have taken it from inoculation, who had resisted taking the disease in the natural way, as it is called, namely, by breathing an infected atmosphere. Some few resisted, in inoculation days, both in- oculation and the natural mode of taking the disease ; but these were very rare cases. All periods of life seem to be about equally susceptible to the influence of the contagion. In many parts of this country, before the invention of railways, Small- pox was absent for twenty years together. This happened more esisecially before the introduction of inoculation. Then, on the disease breaking out among the inhabit- ants of these but little frequented dis- tricts, the infection being conveyed to them by tramps, or dealers in small wares, the disease spread with fearful rapidity, and nearly all who came within the sphere of infection, whether young, or those more advanced in life, since the last invasion, took it, and it caused dreadful mortality, as it does in the present day to the unvac- cinated. All ages being taken together, it is found that about one-third, or rather more, of those who take Smallpox in the unprotected state — that is, who have never been vaccinated, or had Smallpox before — die of the disease. It is particu- larly destructive to the dark-skinned races ; the blacks who come to the Small- pox Hospital sufter more from the disease than the native inhabitants of Great Britain. The same thing has been found to take place abroad. Dr. Bulkley, in the American edition of Dr. Gregory's "Lec- tures on the Eruptive Fevers, '"'mentions an instance in which a tribe of American Indians took Smallpox, and they all died of it. Every individual of the tribe was swept away. IsTFECTiors Katxjre of Smallpox.— Boerhaave was the first to point out the infectious nature of the disease. Before his time it was thought to depend on some peculiar influence of the atmosphere, and it is a remarkable circumstance that Sydenham, who paid so much attention to this disease, should have overlooked so obvious a property of it. Most likely it ' Page 34. INFECTIOUS NATURE OF SMALLPOX. 139 (s communicable from the moment when the initiatory fever begins. It may be given by the breath of the patient before the eruption has appeared on the surface of the body. It continues infectious so long as any of the dry scabs resulting from the original eruption remain adhe- rent to the body ; a single breathing of the air where it is, is enough to give the dis- ease. The dead body, for several days after death, has been known to communi- cate the disease (see Hawkins, in London Med. Gaz., vol. iii.); and in all probability it would produce the disease for some months afterwards. A few years since a lady was walking at Islington, and met a person with Smallpox ; twelve days after- wards she was taken ill, and for a few hours was delirious. The illness passed off without eruption. Her married sister, who had not been out of the house for three months, on account of pregnancy, was seized with illness exactly twelve days again after her sister's attack, which ill- ness proved to be severely confluent but modified Smallpox. The case is singular and very interesting, as showing that the disease may be communicated by a person who had the early symptoms of the dis- ease, precisely at the usual time after be- ing exposed to Smallpox infection, but whose illness passed off without the char- acteristic eruption ; a case in fact of Va- riola sine eritptione as first described by Sydenham. ' The infecting source bears no relation generally to the resulting disease ; a mild case may, and often does, give rise to a severe one ; and, on the contrary, a severe case may produce a mild one. The dry scab of Smallpox would most likely set the disease going months, perhaps years, afterwards by inoculation, just as the dry scab of cow-pox has been fovmd to be ef- fectual for the purposes of vaccination after being kept a considerable time. Clothes that have been worn by a per- son when suffering from Smallpox may retain the infection for a long time, as may the furniture, especially woollen fur- niture, of beds, and bedding, unless washed and thoroughly purified by exposure to the air, &c. Becurrent Smallpox. — Smallpox but sel- dom occurs the second time. Instances of second attacks have, however, been recorded from the time of Khazes to the present day. Thirty years ago we began to collect minute statistical information of all oases of Smallpox admitted into the Smallpox Hospital. At that time there were probably as many persons in this country who owed their protection to having been inoculated, or having had Smallpox, as to vaccination. "VVe have communicated to the Eoyal Med.-Chir. ' Sydenham, vol. 1. ch. 3, sec. 2. Soc' the particulars of this inquiry for sixteen years— 1836 to 1851. Of 5797 cases of Smallpox, 2654, or 45 per cent. were unvaccinated •, 47 cases, or less than 1 per cent, were after a previous attack of Smallpox or Smallpox inoculation ; 3094 cases, or 53 per cent., were after vaccina- tion. It will, therefore, be seen tliac the cases of reputed Smallpox after Smallpox have been but comparatively few, and even some of these would perhaps admit of doubt ; lichen, varicella, and some forms of pustular syphilis are difficult to distinguish from Variola, and might easily be mistaken for it, except by those inti- mately acquainted with the minute cha- racteristics of eruptive diseases. The Smallpox Hospital has been founded 119 years, but there is no record of a patient having been admitted there twice, each time suffering from Smallpox. We have, however, no doubt of the disease occur- ring a second time, as measles and scarla- tina do, but we think the instances are far more rare. An Irishman, the son of a medical offi- cer in the army, who had been vaccinated in infancy by his father, and had a large cicatrix remaining from the vaccination, and who was attended by his father for Smallpox in early life, and bore decided pits of the disease, in 1844, at twenty- three years of age, was admitted into the Smallpox Hospital with severe confluent Smallpox, of which he died. We liave repeatedly seen the disease modified, when it takes place after natural Smallpox, or after inoculation, just as it is modified by vaccination. Among the circumstances that seem to predispose the constitution to receive a second attack of Smallpox is, as after vaccination, exposure for a time to great change of climate, either hot or cold. Women who have had Smallpox, or have been inoculated for it, often have, when suckling children with Smallpox, a few irregular spots formed on the breast about the nipples ; these spots are produced on the breasts by contact with the matter of Smallpox from the child's lips and face. There hardly ever is any accompanying indisposition ; the effect is purely local,"and cannot properly be considered to be a second attack of Smallpox. Variola sine Eruptione.—Sydenhiim was the first to notice a form of fever without eruption, which prevailed at times when Smallpox was epidemic, and which he calls ''Variohits Fever."'' "This Fever originated in that particular epidemic constitution of the atmosphere, which, at the time in question, produced the Small- pox. Hence, with the exception only of 1 Med.-Chir. Trans, vol. xxxvi. 2 Sydenham, vol. i. ch. 3, sec. 2. Syden- ham Soc. Edit. 140 SMALLPOX. those symptoms which Tvere the necessary effects and consequences of the eruptions, it was, if not identical, at least closely akin to the Smallpox. Each disease set in similarly. In each there was the same pain upon pressure over the pit of the stomach. The color of the tongue and the color of the urine were alike in the two complaints. The profuseness and spon- taneity of the sweats occurred equally at the commencement of both maladies. The common tendency to salivation was also equal. It occurred during the fever, when its heat and violence reached beyond a certain intensity. It occurred during the Smallpox, when the pustules became con- fluent. Finally, as the fever was most rife at that particular time when the ravages of Smallpox were greater in these parts than at any other time within the limits of my own observation, there can he but little doubt as to the identity of character between the two diseases. Of this I am certain — all those practical phe- nomena which determine treatment were the same for the two diseases, with the single exception of the eruption of Small- pox, and of its effects." De Haen has noticed a similar occur- rence as having come under his observa- tion. We have seen a few such cases that confirm the supposition. They occurred after vaccination, and are likely to be more numerous in these days than in the days of Sydenham, as we believe vaccina- tion modifies Smallpox, in difl'erent per- sons, at every stage of its progress. Such cases are not likely to be sent in any large numbers to the hospital, as the eruption is the only decided evidence of the disease being Smallpox. Some like cases occur- ring in a school, were reported to the Epidemiological Society, in 18.52, in an- swer to a series of questions on Smallpox and vaccination extensively circulated among the medical profession. M. iledlund, giving an account of the Swedish epidemic of 1824, states (Magen- die. Journal de Physiologic, tome vi. ; and Gregory, Library of Medicine, vol. i. p. .303) " that three different forms of disease were then observed, all, as he believes, pathologically allied, viz., true Smallpox, the varioloid, and the fever without erup- tion. This fever, he adds, began and ended at the same time with the epidemic. The early symptoms were identical with those which preceded the variolous erup- tion. He considered it as a mild unde- veloped Smallpox." Treatment.— There is no specific for the cure of Smallpox. "It is a melan- choly reflection," says Dr. Gregory, " but too true, that for many hundred years the efforts of physicians were rather exerted to thwart nature, and to add to the malig- nancy of the disease, than to aid her in her efforts. Blisters, heating alexiphar- niicH, large bleedings, opiates, ointments, masks, and lotions to prevent pitting were the great measures formerly pursued, not one of which can be recommended. What think you of a prince of the blood royal of England (John, the son of Edward the Second) being treated for Smallpox by be- ing put into a bed surrounded with red hangings, covered with red blankets, and a red counterpane, gargling his throat with red mulberry wine, and sucking the red juice of pomegranates ? Yet this was the boasted prescription of John of Gad- desden, who took no small credit to him- self for bringing his royal patient safely through the disease. We may smile at this ; but if either he, or Gordonius, or Gilbertus, were to rise from their graves and inquire whether this is one whit worse than Mesmerism, or at all more absurd than homoeopathy, or hydropathy, we should, I fear, look a little foolish. Let us, then, avoid the errors of our ancestors, without reproaching them." ' One of the first things to arrange on undertaking to treat a case of Smallpox should be, if possible, to place the patient in a large airy apartment ; bed-hangings, carpets, &c., had better be removed. The room should be kept cool in summer, and agreeably warm in winter, and the air of the room should be changed two or three times a day. In hospitals, the space allowed for Smallpox patients should not be less than two thousand cubical feet for each patient. For a long time the custom was to keep patients with Smallpox as warm as possi- ble ; to heap bedclothes on them, to shut out every breath of air, forbid any ablu- tion, or even change of body or bed hnen. All this proceeding must have produced a horrible state of things. To Sydenham we are indebted — and a very great debt we may be sure we owe him — for having revolutionized all this. Like many other reformers of abuses, he was not able to accomplish the change he sought from these abuses without a good deal of oblo- quy. Thanks to his perseverance, he suc- ceeded. We now use light bed-coverings, frequent change of linen, fresh air, ablu- tions, and cooling drinks, with the greatest benefit to our patients. To Sydenham we are also indebted for having first drawn the distinction between Smallpox and measles ; no very great effort to accom- plish, we should perhaps think, for any pathologist of the present day, the dis- tinction seems so clear between the two ; yet it was a step in pathology of great im- portance at the time, as Smallpox and measles had been for centuries looked up- on as only modifications of the same dis- ' Lectures on Eruptive Fevers, p. 93. American Edition. Lect. V. TREATMENT. 141 ease ; just as we until quite lately — thanks to the sagacity of Steward and Jenner — looked upon typhus and typhoid fevers as only modifications of the same fever. Like most other things, it seeans easy enough to understand when once it has been clearly explained ; but honor and praise are none the less due to the original observers. Easy as it seems, we might not have seen it ; most likely we should not. In the majority of instances it cannot be known for the first two or three days of Smallpox what febrile ailment is approach- ing ; and, even if it were known, the mode of treatment would not materially differ. It will be right to give a dose of opening medicine to relieve the bowels, to keep the patient on simple diet, and to give saline medicine ; nothing, generally, is better or more agreeable than citrate of potash; or tartrate of soda, in a state of effervescence. In confluent cases of Small- pox it is necessary to cut the hair close ; in the un vaccinated, especially in children, the sooner it is done the better. But in the vaccinated exceptions should be made : to females, especially, it is a great morti- fication to lose a fine head of hair, which will perhaps take two or more years to restore thoroughly ; therefore it will be proper to wait until the fifth or sixth day of eruption to see if the course of the dis- ease is modified, because if it is, it will not be necessary to cut off the hair. The diet of tlie patient should consist of tea and toast, witliout butter, bread and milk, sop, and oatmeal gruel, grapes, the juifx of oranges, strawberries, and what patients are very fond of, and can have at all seasons of the year, roasted apples. For drink, toast-water, plain water, — which many prefer to anything else, — lemonade, imperial drink, milk and water, apple water, tamarind water, raspberry vinegar and water, and, what makes a very agreeable drink, some boiling water poured on black or red currant ielly. Sydenham says : " The moment that un- doubted signs of Smallpox have shown themselves, I forbid the patient wine, meat, and the open air. His ordinary drink is weak small beer with a toast put in to take the chill off. His food is oat- meal porridge, barley broth, roasted ap- ples, and the like ; articles which are neither hot nor cold, and which give no trouble to the digestion. I have no objec- tion to a form of diet that is common in the country, and which consists of a roasted apple mashed with milk, only it must be taken at intervals, moderately, and with the chill off the milk. Hot reiji- men I forbid altogether. I forbid also all such cordials as are used by some under the rash notion of propelling the pustules towards the skin." Eifty years ago, and later, it was not unusual to take away blood at the com- mencement of .Smallpox ; we never think of bleeding patients now at the Smallpox Hospital. Sydenham, Iluxham, and others used to recommend bleeding in Smallpox, but, notwitlistanding the sanc- tion of their great names, it must always have been a very doubtful proceeding. Delirium occurs in confluent Smallpox in persons of very different constitutions — most commonly, as previously stated, in persons of full habit, and free livers ; but it also occurs in persons of weakly consti- tutions, and who may have lived temper- ately : the pulse is small and weak, and the features shrunken. Such persons re- quire stimulants early — indeed it is about the only chance, doubtful as it is, of afford- ing any assistance towards recovery. This form of delirium should, of course, be clearly distinguished, before giving stimulants, from the delirivnn of plethora. Most wi'iters on Smallpox allude to sup- pression and retention of urine as occur- ring in this disease ; occasionally, perhaps not above once a year, we are told, at the Smallpox Hospital, a patient has not passed urine for several hours ; but on examining the bladder there is not any distension of it. At the next visit, on inquiry, we always find urine has been passed. "VYe have not had occasion to pass a catheter, in a case of Smallpox, for flve-and-twenty years, therefore we con- clude retention of urine must happen but verj' rarely in this disease. An invariable complaint in Smallpox is soreness of the throat, more or less ; this arises from the eruption being formed there as well as on the skin, which has to be explained to each patient, and it is necessary also to explain that we cannot stop the progress of the eruption there any more than on the skin, that it will go through a certain course in defiance of any means wo may use to interrupt it. The spots necessarily cause more incon- venience in the throat, from the confor- mation of these parts, than on the surface of the body. All we can do for the relief of it is to recommend some mild gargle, or a small quantity of fluid to be talJen frequently, or a little red or black currant ielly to keep the parts moist. The bowels should be at once well cleared, at the commencement of the dis- ease, by a dose, in the plethoric, of three or four grains of calomel, and eight grains of compound extract of colocynth, with or without sulphate of magnesia, and infu- sion of senna, and for the first few days they should be kept open two or three times a day. In the less robust, and in females, a salts and senna, draught alone will, perhaps, do. Afterwards, in the course of the disease, if the bowels act daily without aperient medicine, all the better; if not, they should be relieved 142 SMALLPOX. every two or three days by a salts and senna draught. So long as the tongue continue loaded with a brownish yellow fur, the salts and senna draught answers better than anything else ; when the tongue is clean a dessertspoonful of cas- tor oil, or a rhubarb and magnesia draught, is more suitable; but so long as the tongue is clean, there is but little need for opening medicine at all ; still the bowels should be relieved every few days. Not unfrequently it happens in Smallpox that the bowels are too much relaxed ; for this we keep a mixture always in the ward of the hospital, and find it very ser- viceable : — :^. — Cretffi preparatse, Pulveris acacife, Sacoliari albi, aa giss. Aqu!e |iv. Tincturse opii 5J. Spiritus ammoniffi aromaticae, Tincturre oatecliu, aa^ss. Aquffi mentha; piperitje ,^lij. Misce. Two or three tablespoonfuls' a dose, to be repeated in three hours, whether the first dose seems to have answered the purpose or not ; as without the second dose the diarrh(£a will often return. If after three or four doses of the above chalk and laud- anum mixture the diarrhoea still continue unchecked, having waited a suitable time, say three or four hours, it will be right to give three tablespoonfuls every four hours, of the compound infusion of roses ; the sulphuric acid often answers the purpose of stopping the diarrhoea when the chalk mixture has failed, but the chalk mixture so generally affords relief that we always try it first. Should the two forms, above given, fail to stop the diarrhoea, ten grains of pulv. kino comp. may be given every six hours, or a scruple to half a drachm of the pulv. cretse comp. cum opio. Eice and milk should be given as diet. If the above means all prove to be unsuccessful in stopping the diarrhoea, it will perhaps be found there is some tenderness, on pressure, of the abdomen; then a powder, or a pill, may be given every six hours, composed of three grains of hydr. cum creta, and two grains of pulv. ipecac, co. In the early stage of Smallpox many patients are restless and unable to sleep at night ; anodynes fail to procure rest. It may be worth while to try them once to see the effect, and repeat the dose or not as may be judged right. But there is in some patients the same wakefulness in the advanced stage of the disease, in pa- tients who are otherwise doing well; then an anodyne given once or twice, just to get them into the habit of sleeping, an- ' [If the stomach be at all irritable, a ta- bk'spoonful every three hours may suffice. — H.] swers admirably, and nothing does so well as the hydrochlorate of morphia; we have given it constantly for five-and- twenty years; it procures a comfortable sleep without causing thirst, or stupor, or confining the bowels, as tincture of opium does. It is convenient to keep a solution of it ready, four grains to the ounce : from twenty to thirty minims of the solution is a suitable dose; we generally find twenty- five minims to answer well. One warning we are desirous of givinw about the use of anodyne draughts: they should not be given when there is copious salivation and mucous expectoration. Pa- tients at such times are very sleepless, because they require to be kept vigilant to discharge the saliva and viscid mucus frequently, almost constantly ; if an ano- dyne be given under these circumstances, the patient goes to sleep, and the saliva and mucus, which ought to be frequently got rid of, go on accumulating during sleep in the air-passages, and thus the pa- tient dies, gradually asphyxiated by the secretion accumulated in these parts. Although the antiphlogistic treatment should be continued for perhaps the first few days after secondary fever has set in, patients shortly after its commencement require some additional support; beef-tea or calves'-feet jelly is very suitable to add to their diet, and a glass or two of the lighter wines may be allowed. The next stop will be, supposing the patient to be going on pretty well, some soup, with a few shreds of thoroughly done meat in it. So long as the tongue continues furred, a meat dinner does not do well. Perhaps great weakness is complained of, and the appetite is bad ; under these circum- stances, a grain and a half of disulphate of quinine, with two or three minims of dilute sulphuric acid, and half a drachm of tincture of ginger in an ounce and a half of water, twice a day, will be service- able. Game, poultry, or lightly boiled eggs might be allowed; and in cases of great prostration, some brandy in gruel at night. When the tongue has become clean, meat may be recommended, and some ale or porter, with or without wine, port or sherry ; care being taken not to try to get on too fast. Things, unfortunately, do not always go on so smoothly as this ; some large col- lections of matter may form, with slough- ing of the cellular membrane, requiring to be opened, or numerous boils harass the patient. It often happens that mat- ter is formed under the scalp, small in amount at first, but it goes on collecting and spreading, and there' is no disposition to point and break in this part as in other parts of the body. These collections should be opened early to prevent their spreading ; the operation is rather pain- TREATMENT. 143 ful, from the thickness of the scalp. A simple incision does not answer well ; the matter collects over and over again, and the cavity of the abscess keeps getting larger ; it is better done by a crucial inci- sion, and the cavity should be filled with lint ; these cavities are generally very tedious and troublesome in healing ; ni- trate of silver or a solution of it, freely applied to the interior, helps on the pro- cess. Instead of opening these abscesses by a crucial incision, a better plan, per- haps, to adopt is, to pass a seton through them, so that the matter may keep con- stantly draining away ; we often resort to this proceeding with good effect, particu- larly when the abscess has been allowed to become rather large before anything is said about it. Some form of steel, with or without qui- nine, is a useful medicine often, especially to females, during convalescence. Qui- nine and tinctura ferri sesquichloridi, or mist, ferri comp. should be tried. Cod- liver oil may sometimes be advantageously given, under such circumstances, as it is otherwise found useful, in scrofulous sub- jects, or those inclined to phthisis. The discharge from the pustules in some confluent cases is considerable and acrid ; the itching, and discomfort pro- duced by it on the skin, are I'elieved by the application of some absorbent powder freely used ; flour applied with a common dredging box answers very well, or hair powder, starch, or calamine, dusted on the face, hands, inside of the shirt and sheets, will be found serviceable. Many patients have numerous boils re- sulting from Smallpox ; they leave ulcers which are tedious in healing ; for some time no process of repair seems to be go- ing on, and the discharge from the ulcers further exhausts the patient. Some de- coction of bark, or quinine, with a few drops of dilute sulphuric acid, should be taken two or three times a day ; and, in some instances, where the tongue is rather furred, two grains of blue pill, and three of compound extract of colocynth, may be usefully recommended every second or third night for a few times. The ulcers improve dressed with ung. elemi, or cera- tum calaminse ; bits of lint, dipped in black wash, and applied to the wounds, and left on a couple of days, seem some- times to do good. The majority of pa- tients only require the wounds to be cov- ered with bits of strapping. Some patients like cold, others warm, applications in erysipelas ; some prefer flour dredged over the inflamed part ; collodion may be tried. If one plan does not make the patient tolerably comfort- able, another should be tried. A liberal supply of wine should be allowed ; the same in gangrene : both erysipelas and gangrene are generally preceded by bilious vomitings and very often by diarrhcea. During the sloughing of gangrene, at its commencement, nitric acid lotion, a drachm to a pint, may be used with bene- fit ; later, sonic antiseptic should be ap- plied to the part : one-third liquor calcis chloratfe to two-thirds water ; or Condy's fluid properly diluted. Charcoal may be thickly applied, and covered with a lin- seed-meal poultice. A poultice made of beer grounds some recommend, others h:ive a preference for carrot poultice ; we generally trust to the solution of chloride of lime, or Condy's fluid. When there is any gonorrhceal discharge from the genitals, either in the male or fe- male, the bidet should be used, if possilile, twice a day at the least, or some other means should be resorted to to keep the parts affected cleansed ; if this be neglect- ed, gangrene of the genitals is very likely to occur. The patient, unfortunately, is not well able at these times to use the bidet himself or herself, and the cleansing of these parts is a very unpleasant office for another to perform for them, and hence it is very likely to be neglected un- less the medical attendant is very strict in enforcing his injunctions on the subject of cleanliness, and makesapoint of inquiring daily if the bidet has been used. Pleurisy is one of the most dangerous complications that can arise in the ad- vanced stage of Smallpox. It soon, gene- rally, carries oflT the patient. Bleeding is useless, if tried, and is, in fact, practically found to do more harm than good, and should be considered as inadmissible. The best plan to adopt — we believe, in- deed, the only one we have seen to do good, and we have seen many tried — is at once to put a large blister on the side, and give a full opiate, forty minims of the solution of hydrochlorate of morphia, pre- viously alluded to, or a like dose of tinc- ture of opium ; the dose to be repeated in twelve hours unless the pain has very much subsided. Wine, if the patient has been taking any, had better, perhaps, be withdrawn. Pneumonia, like pleurisy, arising in the advanced stage of Smallpox in a person previously debilitated by an exhausting disease, does not admit of, and certainly will not be benefited by, any active treat- ment. Very likely, on carefully examin- ing the chest, some consolidation of the lungs will be discovered. A blister should be applied, and five grains of blue pill given every night, or night and morning, for a few days ; acetate of ammonia at intervals ; an opiate at night, if very rest- less, and Iseef-tea as diet. Bronchitis is another of the dangerous inflammations occasionally met with in the advanced stage of Smallpox, hardly ever admitting of anything but palliative treatment, yet likely to be fatal. Counter- 144 SMALLPOX. irritation promises to be useful, and should be tried ; and the inhalation of the steam of water, through a proper inhaler, always gives some relief. The lowering S3Stem, with repeated doses of calomel, &c., re- commended by some writers, does not do well, and should be avoided. Variolous ophthalmia, and ulceration of the cornea, arc amongst the most serious results of confluent Smallpox. Bleeding, here again, used to be recommended, but the practice was bad : wc soon saw it did a deal of harm, and was inadmissible. Quite the opposite mode of treatment, in our opinion, is indicated. The patient should be put on as generous a diet as can be borne, and allowed port wine, two or three glasses a day, and take quinine or liquor cinchonfe twice or thrice daily. To the eye, the following application may be made: R — Fot. papav. lb. j., pulv. aluminis 5 j. pro fotu. Ung. cetacei to be applied each night between the eye- lids. We sometimes touch the ulcer with nitrate of silver, scraped to a point. The eye should be fixed with a speculum — the one shown in Hey's Surgery answers well — and an assistant should be ready with some olive oil, in a grooved director, to drop into the eye, immediately after the caustic has been aisplied. Or the ulcer may be touched, bj' means of a camel's- hair pencil, with a solution of nitrate of silver, a scruple to the ounce. The conjunctiva, in the advanced stage of Smallpox, often as late as the third week, becomes inflamed, and after a few days a small ulcer may very likely be observed on the cornea. In such cases, as soon as observed, a blister to the temple is nearly always of decided benefit. Perhaps a second may be re- quired — it often is. Should the conjunc- tival inflammation continue and the ulcer remain stationary, a solution of nitrate of silver, two grains to the ounce, may be dropped into the eye every second day, two or three times, with a large camel's- hair pencil. Should the eye seem irrita- ble, perhaps some vinum opii sine aromat. (to be had at Savory and Moore's) dropped within the lids, once or twice a day, may be serviceable. In nearly all cases, when lotions are not being applied to the eye, a green shade should be recommended to be worn. Scrofulous inflammation occurs after Smallpox, but it will be readily rec- ognized by the great intolerance of light, and by its occurring chiefly in children. From the earliest periods in the history of Smallpox strenuous efforts have been made to prevent the "pitting" that takes place from this disease. It must be con- fessed that it disfigures the countenance often terribly, and gives a very common expression to the handsomest face. We need not wonder then at the anxiety of friends, as well as of the patients them- selves, that something should be done to prevent, as far as possible, future disfig- urement. Some good can be effected, but when the disease is very severe the mis- chief arising from this cause cannot be wholly avoided. Velpeau recommended some years since that each vesicle should be opened and cauterized with a stick of nitrate of silver scraped to a point ; to do good the operation should be performed on the third or fourth day of eruption. In the most confluent cases, those likely to produce the greatest disfigurement, the proceeding is scarcely practicable : it may be in semiconfluent cases. Mr. Higgln- bottom reconunends the whole face to be washed with a strong solution of nitrate of silver, eight scruples to the ounce of water. We think this is much too strong, and that it will blister the whole surfaes ; if used, half the strength will be enough. A mercurial plaster is used at the Chil- dren's Hospital in Paris, the form for which is given by Dr. Aitken ;' it is a modification and simplification of the em- plastrum vigo cum mercuric^ It consists of twenty-five parts of mercurial ointment, ten parts of yellow wax, six parts of black pitch. This application has good effect, but is most suitable for use in semiconflu- ent cases, or those barely confluent, where the patient can be prevailed on to use a little care in the management herself; in severely confluent cases the application would soon be rubbed off by the patient's restless movements. The application recommended by Dr. Graves, a few years since, of a solution of gutta-percha in chloroform, did no good, and by confining the discharge under the coating of gutta-percha, produced a most offensive condition of the patient. What we do generallj' is this — wait until the pustules have been discharged, and the discharge has begun to dry, then put on some of the best olive oil, or a mixture of one-third glycerine and two-thirds of rose- water ; some of this may be applied once or twice a day, for a few days, until the scabs begin to loosen. Cold cream and oxide of zinc, or olive oil and lime water, form good applications ; or if the discharge is thin and excoriating, calamine mixed with olive oil. The patient should be warned not to allow the scabs to dry and remain some time on the nose, and other parts of the face, particularly on the fore- head and near the end of the nose ; when this takes place, the dry scabs themselves leave deep marks in the skin, worse than the eruption of Smallpox itself. The pain of removing the dry scabs is some- times considerable, and the patient can ' Science and Practice of Medicine, vol. i. p. 263. Third Edition. 2 Swe form in "Diseases of the Skin," by Erasmus Wilson, F.R.S. 4th Edit. p. 496. iMORTALtTY FROM SMALLPOX. 145 hardly be prevailed on to take them off, or allow others to do so. lu commou the pits from the eruption arc not deep at lirst, just after the patient has got well, and we may deoeive ourselves by think- ing our efforts to prevent disfiguration have been attended with considerable success. The disease leaves a peculiar brown stain on the skin at first, which soon wears off, but the pitting is more perceptible a twelvemonth or so after the patient has got well. One or two warm baths towards the end of the treatment should be enjoined in all cases of Smallpox. Mortality from Smallpox. — Two circumstances, wholly different in kind, influence very much the mortality from Smallpox, as will be seen on referring to Tables I. and II. These circumstances are, the age of the patients, and the con- fluent form of the disease. Infancy and advanced age are unfavorable periods for undergoing Smallpox. Children under 5 years of age die at the rale of 50 per cent. ; and adults above 30 years die in still larger proportions. See Table II. Pa- tients estimated at all ages, as they come to the Smallpox Hospital, die at the rate of 50 per cent, from conllucnt Smallpox ; 8 per cent, from semiconfluent, and 4 per cent, from the distinct forms of the dis- ease. See Table I. The most favorable time for taking Smallpox is from lU to 15 years of age : beyond 60 years of age hardly any who take it escape dying. Sydenham was fully aware of the dan- gerous day in Smallpox ; the eleventh he says, which is the nhith day of eruption, as shown in the accompanying Table, No. III. The notion of the old authors of the critical days in Smallpox being tlie 7th, llth, and 21st, is wholly wrong. The critical days, in fact, are really from the 8th to the 13th day, every one of these days being critical ; but death may take place at any period, as seen in Table III. : the extremes being the 2d day in one in- stance, and the 168th in another. Pa- tients may even die of the severity of the blood-poison from Smallpox before any eruption has appeared on the skin. The following Table, No. III., formed from the Register of the Smallpox Hos- pital for 10 years — 1855 to 1864 — shows the days of eruption on which 987 cases proved fatal : by adding two days to any given number the period of illness may be known. Two-thirds of the fatal cases, it will be observed, took place during the second week of eruption : — TABLE III. Showing the days of eruption on which 528 iinvaccinated, and 459 vaccinated oases proved fatal, from Smallpox, at the Smallpox Hospital, London, for the ten years 1855 to 18G4 in- clusive, and occurring amongst 1537 uiivaccinatccl, and 5C22 vaccinated cases. All patients having antecedent or superadded diseases of a fatal character have been excluded from the list, so as to represent the deaths from Smallpox alone, as accurately as possible. Unvacoinated Cases. Died on the r 2d day of erujition 3d. . . 2 1st week ■ 4th . . 5th . . 9 15 6th . . 18 7th . . 27 f 8th . . 53 9th . . 67 10th . . 52 2d week I 11th . . 60 12th . . 52 13th . . 3-9 14th . . 27 f 15th . . 21 16th . . 17 17th . . 8 3d week i 18th . . 10 19th . . 5 20th . . 6 21st . . r 22d . . . 2 23d . . . 2 24th . . 4th week i 25th . . 3 26th . . 4 27th . . 3 2Sth . . 7 Upwards of four weeks TOL. I.—" 10 71 350 Vaccinated Cases. Died on the 2d day of eruption 1 3d 2 4th .... 5th .... Uth .... 7th ... . C7 21 19 f 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st r 22d . 23d . 24th 25th 26th 27th 7 7 17 23 32 50 57 64 39 28 36 13 12 57 • 308 58 . 28th 1 Upwards ti four weeks 528 21 17 459 14G SMALLPOX. Morbid Appearaxces.— In all casus ] of death from Smallpox, tUc skill will l-x- hibit, of course, olitl'en'ut diseased appear- ances, according to the stage of illness at \ which the person has died. The most ■ striking morbid results of internal parts are those displayed on opening the larynx and trachea, with its brandies. These phenomena are peculiar to Smallpox. When the air-passages have been much affected by the disease, and -when death has followed on the eighth or ninth day, the mucous membrane is found to be very much congested and inflamed, the epithe- hum in some instances separated, caused probably, Dr. Petzholdt thinks, by fluid effused between it and the mucous mem- brane, so as to produce vesication. It is also covered with a very viscid mucous secretion of a brown color. After this is removed, the membrane appears thick- ened, pulpy, and in some instances ulcer- ated. The next most remarkable morbid con- dition found in the dead from Smallpox, is the state of the chest after pleurisy. This can hardly be said to be peculiar to the disease, because! a very similar state occurs after common inflammation. One side of the chest only is affected with va- riolous pleurisy ; except, perhaps, in some very rare instances. The cavity of the chest is found filled with sero-purulent fluid ; flakes of coagulable lymph floating in it ; adhesions here and there between the pleura costalis and pleura pulmonalis, and the lung on that side of the chest rendered unusable from the pressure of the effused fluid. Considerable difference of opinion has existed as to whether the pustules of Smallpox are ever to be found on the lining membrane of the alimentary canal. We do not believe that they are ; at all events we have never found them there. If they ever exist, it is in some such rare cases as that reported by Dr. Patterson,' in which he believes he observed pustules on the mucous membrane of the colon. Sir Gilbert Blane, Eostan, and others have reported cases to a similar effect. The majority of writers on Smallpox be- lieve that ulcerated spots on the mucous membrane of the intestines are due to other causes. Sir Thomas Watson says :^ "It is affirmed by some writers that the pustules of Smallpox occur in various in- ternal parts of the body, and especially upon the mucous membrane of the intes- tinal canal. I believe this to be a mis- take. The enlarged solitary follicles often put on very much the appearance of pus- tules." 1 Edinburgh Monthly Journal of Med. Sci- ence, Feb. 1849, p. 549. » Principles and Practice of Physic, 4th Edition, p. 862. "Many pathologists," writes Dr. Gre- gory,' "nave expressed their belief that true variolous pustules have been found in the gastro-enteric mucous membrane. Others, again, among whom may be men- tioned Cotunnius, Wrisberg, and Reil (who have paid great attention to the subject), are of opinion that this structure is incapable of developing variolous pus- tules, and that the appearances so de- scribed are in reality inflamed, enlarged, or ulcerated follicles, with petechial patch- es, similar in all respects to what are found in the common forms of idiopathic or typhoid fever. This pathological prin- ciple is fully borne out by the experience of the Smallpox Hospital. We may add, however, that even these appearances are very rare, and that the freedom of the abdominal viscera from urgent symptoms during life, and from all trace of disorgani- zation after death, is a remarkable feature in the disorder. Inflammation may, in- deed, originate from accidental causes in any internal organ during the progress of Smallpox, and its effects will be seen after death ; but these are not to be confounded with the specific and acknowledged effects of the variolous poison upon the skin and mucous membranes of the throat and chest." If vesicles of Smallpox are found on the ' gastro-intestinal mucous membrane, their course must be very similar to that de- scriljed in the folhiwing quotation from Petzholdt, in the Brit, and For. Med. Rev. vol. V. p. 473: "There appear on the lips and inner sides of the cheeks, small white spots, of a round or oval form, the centre of which is very frequently somewhat darker in color. The epithe- lium is at these places much softened, and at length rises so as to form a small white vesicle, which is at no period transparent, the softened epithelium re- maining always opaque and white ; it is incapable of any great expansion by the fluid collecting beneath it, and soon bursts. The subjacent mucous mem- brane is to be seen at some points eroded on its surface. The course of such a pock is, consequently, very brief; the constantly moist state of the mouth ren- dering its actual filling with pus and desic- cation, with the formation of a scab, alto- gether impossible. " When the lungs have become inflamed during or after the secondary fever of Smallpox, the morbid consequences will be found to be such as are observed after congestive pneumonia. Bronchitis occurring during the pro- gress of Smallpox leaves results similiir tf) those seen after bronchitis generally. But we believe we have repeatedly ob- served, both during life and after death, ' Library of Medicine, vol. i. p. 308. ANATOMICAL CHARACTERS OF THE VARIOLOUS POCK. 147 the air-passages, laiTnx, trachea, and laronchi, all or some parts of them, — the larynx and trachea especially, — affected with erysipelas, leaving such morbid traces as might be expected after this low form of inflammation. ANATOjncAL Characters of the Yakiolous Pock. — The variolous pock has been carefully examined with a view of describing its structure, by John Hun- ter, Dr. Adams, Petzholdt, Erasmus Wil- son, Dr. Gustav Simon, and others. It is not so easy as might be supposed to fix on the exact spot where the variolous pock first begins to be formed. On ex- amining a piece of skin of a person who has died on the third day of the eruption, there will be found to be patches of a whitish opaque substance between the epidermis and the true skin. These patches adhere flrmty to the true skin, but, as Petzholdt says, they may be re- moved by syringing the part carefully with water, leavhig the true skin nearly free from the new substance. If the epi- dermis, which includes the cuticle, proper- ly so called, and the rete mucosum' " be examined when the eruption of Smallpox first breaks out, its undermost layers are found to be softened, almost spongy, and as if filled with a fluid. If a circular in- cision be made into the skin round the circumference of a papula, this, being loosened by the cut from its lateral con- nection with the skin, can be removed pretty easily with the pincers, in the form of a little knot. This experiment shows that, at the period of the disease in ques- tion, the connection of the cuticle with the cutis is nearly destroyed at those parts of the skin which are affected, whilst a perpendicular section affords us a ready opportunity of satisfying ourselves that there is no cavity beneath the cuticle. During the growth of the pustules, the spongy softening of the cuticle is in- creased ; a still greater quantity of fluid collects between the substance of its low- est layers ; there at length arises a small cavity filled with fluid, and, by the in- creased accumulation of this fluid the cu- ticle is gradually pushed upwards." "When the thin covering of a part of the skill occupied by a pock is removed, the cutis does not come immediately into view, but it is covered by a substance, varying in color and consistence accord- ing to the degree of ripening of the pus- tule. At the time at which the formation of the cavity or hole described in the pre- ceding paragraph commences, the fluid that covers the cutis is clear ; at a later period it is turbid, more tenacious, and at length it becomes pure pus. If all these ' British and Foreign Med. Review, vol. v. p. 470, matters be removed, which is best done by a pretty strung stream of water from a small syringe, so as not to injure any of the subjacent parts, the following appear- ances can be seen with the aid of a micro- scope : In all the pocks where pus has formed, there remains some of it behind, which cannot be washed off; and if we employ for these investigations portions of skin that have had their vessels filled with red coloring matter, it can be seen with the naked eye that the pus is, as it were, wedged in between the bundles of vessels, and is retained bj' them and be- tween them." The depression in the pocks Dr. Petz- holdt thinks is caused by the ducts of the cutaneous glands, which are ruptured as the pustules fill with pus and maturate, but which, in the early period of the erup- tion, bind down the cuticle to the cuta- neous glands, and thus produce the pit or umbiUcus. Sir Thomas Watson says:' "Without going minutely into the anatomy of the pustules, you may distinctly see if you closely examine them when they are five or six days old — you may see, at least, in many of them — two colors, viz., a central whitisli disk of lymph, set in, or surround- ed by, a circle of yellow puriform matter. In truth, there is, in the centre, a vcsifle, which is distinct from the pus. You may puncture the vesicle, and empty it of its contents, without letting out any of the pus : or you maj' puncture the part con- taining the pus, and let that out, without evacuating the contents of the vesicle. The vesicles have even, by careful dissec- tion, been taken out entire ; and they are said to consist of several little cells. It is most probable that the lymph contained in this separate vesicle is the purest part of the variolous poison." Mr. Erasmus Wilson writes :^ " When a well-formed and mature pustule is ex- amined by dissection, it is found to be di- vided in its interior by a transverse sep- tum into two chambers, both containing pus. The upper chamber is the larger of the two, and they communicate with each other, to a greater or less extent, by the rupture of the transverse septum around its marginal border. The epidermis form- ing the superficial boundary of the pus- tule is the segment of a sphere, and con- tinuous by its circumference with the cuticle covering the adjoining skin. The transverse septum is a layer of false mem- brane, of a whitish color, which was de- posited on the derma at an early stage of the pustule. Subsequently this layer be- comes separated from the derma, and I Principles and Practice of Physic, 4th Edition, p. 865. ' On Diseases of the Skin, 4th Edition, p. 4S9. 148 SMALLPOX. raised by the formation of pus beneath it, and at the same time it is brolien around its edges, and permits the pus of the deeper cavity to communicate with that already contained in the superficial cham- ber. In consequence of the peculiarity in the mode of its production, this layer of false membrane generally retains perma- nently the umbilicated form of the primi- tive pustule, and is thinner at the centre than towards its circumference. When the septum is removed, the deep chamber is brought into view, and the depressed and sometimes ulcerated base of the pock exposed. The surface of the base is of a bright or purplish-red color, and highly vascular. "Some difference of opinion subsists with regard to the cause of the umbili- cated appearance of the pustule of Variola during its early stages. Dr. Heming many years since attributed it to the per- foration of the pustule by the efferent duct of a sebiparous gland. Velpeau, who be- lieves that the principal seat of Smallpox is the follicles of the derma, would, I sup- pose, entertain the same opinion. Other writers believe it to be produced by the pores of the skin, and Kayer refers it to the attachment of the false membrane. I agree with Velpeau that the follicles of the skin are the primary seat of the vas- cular congestion, that this congestion gives rise to the production of the papules or vari, and consequently that the epi- dermal sheath of the follicle is the proba- ble cause of the umbilication of the Small- pox vesicle. When the vesicle is examined at its height of development, it is found to be multilocular in structure, and, when divided by a transverse section, exhibits an appearance which Gendrin has com- pared to a spice-box, while Bosquet likens it to a severed orange." Dr. Gustav Simon' takes a different view of the subject : "I have found that variolous pustules are not always consti- tuted entirely alike. In many cases where a central depression clearly existed, the epidermis was entirely raised from the subjacent cutis ; and only at the spot cor- responding with the umbilicus were both membranes united by a thin, whitish cord, -which, as the microscope evidently showed, was a hair-sac. Upon the under surface of the epidermis, and for the most part also upon the upper surface of the cutis, was found a thin layer of a whitish mass, which, when looked at with the naked eye, possessed the characters indi- cated by Eayer;" which are, that "there exists in the Smallpox pustule, between the cutis and the cuticle, a false mem- brane, which in shape resembles a trun- cated cone, and has a thickness of half a ' British and Foreign Med. Rev., vol. iii. 1849, p. 350. line." " The layer fixed to the epidermis was not connected with that lying upon the cutis ; nor when the latter layer was absent, with the cutis itself; but the hair- sacs, ascending from the cutis to the epi- dermis, alone connected the two mem- branes." "Other vesicles manifested a structure somewhat different from the above. In these also there appeared beneath the epi- dermis a white substance; but this, at the spot where externally the umbilicus was visible, adhered to the surface of the eo- rium, so that the epidermis seemed fixed to the cutis by this white mass alone. Now as regards the white mass beneath the epidermic covering of the vesicles, and often also apparent upon the surface of the cutis, which most modern writers take for a false membrane, it consists, for the most part, of the deeper softened layers of the cuticle," &c. "As we are accustomed to give the name of false membranes to layers of coagulated fibrine, we cannot include the above-described white mass under this appellation; for, as I have before shown, the epidermic ele- ments always form its major part." "The fact that the described white mass, at certain spots of the vesicle, is prolonged uninterruptedly from the under surface of the epidermis to the cutis, while at other points this connection is interrupted by the dissociation of the un- der layers of the epidermis, or by the complete separation of the cuticle from the cutis — this fact, I repeat, is the occa- sion of the little divisions, or compart- ments, mentioned by most authors. These are usually of unequal magnitude and ir- regularly arranged; but sometimes I have seen them arranged with tolerable regu- larity. In cases of the latter kind, the white mass extended itself from the mid- dle of the vesicle in the shape of little septa, like the rays of a circle, to the peri- phery, so that six or eight chambers of tolerably equal size were formed. In the middle of the vesicle, from which the ir- regularly arranged septa proceeded, a hair-sac was sometimes found. Fre- quently no separate compartments at all existed. In vesicles of this sort the epi- dermis was connected to the cutis in the middle by a thin white cord, or over a larger space; and around this centre ran a canal, into which the white mass ex- tended, in the form of little clusters or lamellae ; but the canal was at no point interrupted by a complete partition. Rayer appears to have observed the same thing." The reviewer says:' " That the produc- tion of an umbilicus is not dependent on the presence of a hair-sac or sebaceous ' British and Foreign Med.-Chir. Kev., vol iii. p. 352. SMALLPOX AFTER VACCINATION. 149 follicle, is easily proved; for it is well known that neither exists in the hollow of the hand and foot: yet in children, in whom the thin epidermis permits it to appear, the central depression is fre- quently excellently marked. A remark- able peculiarity, tirst noticed by Eayer, characterizes the variolous vesicle, formed beneath the horny cuticle, which, in the adult, invests the palm of the hand and the sole of the foot. On removing the epidermic cap of the vesicle and wiping off the fluid collected beneath, he observed that in the centre of the denuded corium a little elevation existed, while the cir- cumference was visibly depressed below the level of the neighboring healthy cutis. Dr. Simon has examined these points mi- croscopically, and he finds that the central elevation consists of a file of papillse of normal or nearly normal size and condi- tion, while the depressed margin is paved, with papillae, bent down or flattened. The explanation is simple. At the centre of the vesicle, an organic connection (from some yet unexplained cause) exists be- tween the cutis and cuticle, and at this point no fluid is effused; but around this centre, exudation of fluid occurs without impediment, and tends to force the cutis and cuticle asunder. In other localities the cuticle yields, and rises everywhere, except at the umbilicus of the vesicle; but there the texture of the cuticle is so dense, and presents such great resistance to the distending power, that the cutis itself yields first, and sinks below the ordinary level. " "Of the anatomy of pustules. Dr. Simon remarks, that the pus frequently exists between tlie cutis and cuticle, the process of suppuration commencing upon the surface of the cutis ; but that fre- quently, also, the suppuration begins in the tissues of the cutis, extending thence beneath the epidermis." The following is Wedl's view of the sub- ject :' "External integuments. — Exuda- tions in this situation are particularly fit- ted for study, being accessible to observa- tion even during liife. The most frequent are those which take place in the cuta- neous papillce, in which they are either confined to small limited districts, within which the exudation takes place around isolated groups of papilke, or are more extensive. An instance of the former kind, or of a limited exudation, is afforded in Smallpox, in which the spots are at first filled with a limpid fluid, containing nothing hut molecules, and do not become pustules till afterwards, when pus-corpus- cles are developed in the hyaline exuda- tion. The transudation takes place from the capillary system of the papillce, the ' Rudiments of Pathological Histology, by Carl Wedl, M.D. Translated by George Busk, F.R.S., Sydenham Society, p. 206. exudation as it is poured out gradually accumulating between the under sm-face of the epidermis and the upper surface of the corium. But since the process is con- fined to limited groups oi papillce, the epii- dermis covering the latter is raised in the form of a transparent vesicle, whilst the spot at which the hair escapes from its slieath, together with the excretory duct of the sebaceous follicle, remains depress- ed, and constitutes the central pit of the vesicle. In those parts of the skin where no hairs nor sebaceous follicles exist, as in the palm of the hand and sole of the foot, the exudation deposited around a point where several of the deeper grooves in the cm-ium meet, may cause a similar pit, since in a situation of this kind the ejn- clermis constitutes a stronger layer, and is of closer texture. When the puriform fluid in the pustules begins to dry up, the pit becomes shallower and wider, owing to the subsidence of the swelling. In the integuments of a subject dead of Small- pox, it is easy to perceive that the vessels of the papiUcn are more or less injected, when the skin has been macerated long enough to allow of the removal of the epi- dermis, beneath which the isolated patches of vascular injection are immediately ap- parent. Perpendicular sections show that the piapillce are the constant and principal seat of the injection; and it is from their vessels also that the hemorrhage takes place, in cases of petechial Smallpox." Smallpox after VACcusrATiON". — ■ Varicelloid, and Modified Small- pox. Yaccination was announced to the pub- lic by Jenner, in 1798. The then preva- lent practice of inoculation for Smallpox gave origin, no doubt, to the idea in the mind of Jenner, of performing a similar operation with vaccine lymph ; coupled with the popular belief among the peas- antry of Gloucestershire, that once having taken the disease from the cow, in milk- ing these animals, such persons remained ever afterwards proof against the infection of Smallpox. Great hopes were enter- tained at first, and for some years, that all who availed themselves of vaccination would remain secure against Smallpox for the remainder of their lives. Indepen- dently of the popular belief that cowpox afforded protection against Smallpox, it was thought by Jenner and the medical profession generally, that as there was great similarity, if not identity, between vaccinia and Variola, and as Variola was believed to occur but seldom a second time, the same law it W3,s imagined would govern the two diseases — that those who had had the vaccine disease would remain ever after, or nearly so, secure against 150 SMALLPOX. Smallpox; that they would enjoy the same immunity as those who had already had Smallpox, or at least as those who had been inoculated for this disease. Unfortunately this doctrine has not been altogether realized in practice. It has before been shown, p. 139, that at a time when there were probably about as many persons in England who had had Smallpox, or had been inoculated for Smallpox, as had been vaccinated, the numbers of those admitted into the Small- pox Hospital with Smallpox for a series of years, were but as 1 per cent, after Smallpox or inoculation, to 53 per cent, after vaccination. Notwithstanding this apparent drawback of vaccination from the first statements made about it, it was the greatest discovery in relation to dis- ease ever made by man for the preserva- tion of human life. The misfortune was that too much had been promised for it at first. Another great misfortune was, greater perhaps practically than the first, the public were taught to believe that the operation was so simple, and required so little knowledge and care, that anybody might perform it ; and thus it has been in a great measure left to chance in England. It has never been taught by appointed teachers until five or six years ago, and even now it has not been taken up in a proper spirit, and treated by those in authority at the examining boards as it ought to be, and from its intrinsic import- ance really deserves to be. Nearly all that has been done in England, in regard to the more effectual performance of vac- cination, and teaching of students, has been done at the suggestion and earnest entreaty of Mr. Simon, the able and zealous Medical Officer of the Privy Coun- cil ; not, as we might reasonably have ex- pected, by the Councils of our medical and surgical Corporations, who have the supervision and direction of medical edu- cation. Groat care is given to teaching and learning the capital operations, as they are called, which not one practitioner in twenty through the whole country ever performs ; no care, or next to none, to teaching and learning the other, which nearly all, when in practice, will have to perform frequently. Had certificates, fortunately, of having received instruction in vaccination been required of students at the examining boards, as they ought to have been, forty or fifty years since, hun- dreds of persons who have died, and thousands still living who have been badly vaccinated, and will still die of Smallpox after vaccination, might have been saved. As medical and surgical practitioners, our object should be to save all the lives we can by our art, no matter by what means ; and if a little operation — little apparently in practice, but very important in its results — well performed can save many lives, as most certainly it can, and prevent much suffering and sor- row, it should surely always be done with the greatest care, and in the best known way. The success of all operations de- pends on nice care and management. Operations for hernia and for stone, for instance, if roughly, carelessly, and badly done, end badly ; so it is with vaccina- tion : and so far as the public are con- cerned, it is quite as objectionable to them, no doubt, to die of Smallpox be- cause they have been carelessly and badly vaccinated, as it would be to them to die of hernia or stone because the operations for these complaints, respectively, had been badly performed. In the latter cases, the day of retribution would come Immediately ; in the former, unfortunately for its correction, it is delayed for perhaps twenty years, or more ; otherwise, it would soon be set right. The operation, as an operation, has not been properly estimated from the first introduction of it in England, and it should be looked upon as a blot on our polity that vaccination has been worse performed, generally, in Eng- land, its birthplace, than in any country in Europe.' Some cases of Smallpox after vaccina- tion were brought forward a few years after its first introduction into practice; and, in 1818, a work appeared by Dr. Monro, of Edinburgh,'' treating particu- larly on the subject. In 1819, nineteen cases of Smallpox after vaccination were admitted into the Smallpox Hospital, London, according to the Keport of Dr. Ashburner, then physician to the hospital, to the Court of Governors of the hospital held at the end of that year. In 1820 the work of Dr. John Thomson" was pub- lished, describing the disease which had lately prevailed in Scotland, and naming it a ''Varioloid Epidemic." In 1821 Smallpox after vaccination prevailed to a great extent in Sweden. In 1825 Small- pox was epidemic in Loudon, and at- tacked several persons who had been vac- cinated, 147 of whom were admitted in that year into the Smallpox Hospital. In 1828 there was a severe epidemic of Smallpox in Marseilles, when about 2000 were attacked who had been vaccinated. Between July 1831 and June 1836, as re- ported by Dr. Helm, 9.55 persons were attacked with Smallpox after vaccination in the kingdom of Wirtemberg, of whom 75 died, or 7 -8 per cent. From this period ' See Med.-Chir. Trans., vol. xxxvi. p. 381. " Observations on the different kinds of Smallpox, and especially on that which sometimes follows Vaccination. Edinburgh, 1818. ^ An Account of the "Varioloid Epidemic, wliich has lately prevailed in Edinburgh and other parts of Scotland, 1820. SMALLPOX AFTER VACCINATION. 151 cases of Smallpox after vaccination have kept gradually increasing in numbers, until they now amount to four-lifths of the admissions into the Smallpox Hos- pital. The introduction of vaccination has rendered the diagnosis and course of Smallpox, and consequently the study of the disease, far more intricate than it used to be in former days, and now is in the unvaccinated. The phases of the dis- ease have been made by vaccination far more numerous than they were before. A large majority of the cases of Smallpox occur at the present time (1865) after vac- cination. Thirty years since, from 1835 to 1845, the admissions of patients into the Smallpox Hospital were 44 per cent. of Smallpox after vaccination; from 1845 to 1855, 64 per cent. ; from 1855 to 1865, 78 per cent. ; and during the last two years (1863-4), 83 and 84 per cent, respectively. It will therefore be seen that they are gradually increasing in numbers ; and, now that vaccination has been made by law compulsory in England, the percent- age of cases of Smallpox after vaccination win no doubt go on increasing, until it will be rather a rare circumstance to see Smallpox in the unvaccinated, at least in the adult. Unfortunately, the number of admissions into the hospital keeps also increasing, owing principally, doubtless, to the rapid increase of the population of the metropolis, thus : — Admissions into the Smallpox Hospital, 1835 to 1845—3494. 1845 " 1855 — 4546. " 1855 " 1865—7320. Now there can be no doubt that what has been observed for the last thirty years at the Smallpox Hospital, London, in re- lation to the occurrence of Smallpox after vaccination, has been going on, in much the same way, all over the country, wher- ever Smallpox has prevailed.' The disease, as modified by vaccination, receivea the name of "varioloid," first suggested for it by Dr. John Thomson, of Edinburgh, who wrote a work on the sub- ject in 1820.^ This word "varioloid" has been adopted generally throughout Europe by writers on Smallpox — in France, Ger- many, Denmark, &c. &c. — in treating of Smallpox as modified by vaccination. It appears to us not to have been well chosen, ' See Report of the Smallpox and Vaccina- tion Committee of the Epidemiological Soci- ety, ably drawn up by Edward Cator Seaton, M.D., Hon. Sec. to the Committee, 1853. Also a valuable contribution by the same aiithor, "On the Protective and Modifying Powers of Vaccination," — a pamphlet, reprinted from the Journal of Public Health and Sanitary Review, 1857. ' An Account of the Varioloid Epidemic of Scotland. inasmuch as the disease is not simply " like" Smallpox, as the name implies ; it w Smallpox : it will give the disease in the most severe form, in the natural way, by infection, to the unvaccinated, and will produce Smallpox by inoculation just as a case of Smallpox uninfluenced by vaccination will do. There is not a good name, perhaps, for it at present. When the disease is highly influenced, and altered in its course, rendered mild, by vaccination, we call it, at the Smallpox Hospital, Variola Varicelloides^ — Variola like Varicella, which is a better term than "varioloid," the meaning of which is simply, "like Variola ;" not a very satis- factory way of explaining what is meant. Perhaps the best term for it is, " Smallpox modified by vaccination, " when it is modi- fied ; but it is not always modified in per- sons who have been vaccinated. Besides, there are various degrees of modification, when it is modified ; it is not always even like Varicella unfortunately, but often hardly modified at all, and such patients frequently die. Smallpox after vaccina- tion has, in fact, various degrees of sever- ity and modification, li:om the slightest form in which there is none, or hardly any eru^Dtion at all, to the most severe con- fluent cases, closely, often exactly, resem- bling the disease in the unvaccinated ; and it also assumes the petechial and malignant types after vaci;ination just as in the unvaccinated state. All this de- pends in a great measure on the way in which patients have been vaccinated. Those who have been fortunate enough to have been vaccinated in four or more places with lymph that leaves good, easily perceptible cicatrices, have almost invari- ably a slight form of Smallpox when it occurs ; but those who have only one or two marks from vaccination, such as are hardly visible, will probably have a severe form of the disease ; and those who have no marks at all are in still worse circum- stances. JSTow, although this rule holds good generally, almost invariably, still it is not an invariable rule ; and perhaps more exceptions wiU be found — we may say will certainly be found — in those who have been indifterently vaccinated, than in those who have been well vaccinated. Persons seemingly indifferently vaccinated will oftener afterwards have a light form of Smallpox than well-vaccinated persons will have a severe form of the disease. So far it is fortunate. But what we con- tend for, and always have contended for, is that, if possible, all should be vaccinated in the lest way ; at least the attempt should be made to vaccinate all in the best way, that there should be as little as possible of hap-hazard vaccination, done with a view • [Varioloid is the term commonly used in America. — H.] 152 SMALLPOX. that if the operation takes effect badly it can be done again. By such a proceeding persons often take vaccination badly, and cannot be made to take it properly after- wards ; the imperfect success prevents its taking fully again, and yet some day they ma}- take Smallpox severely, and perhaps die of it. Every effort should therefore be made that there may be as few imperfect vaccinations as possible. It is, however, undeniable that a few cases occur even to the best vaccinators that do not take the vaccination well. Children sometimes fall ill from other causes just after being vaccinated. There cannot always be good subjects at hand to vaccinate from ; the weather and other circumstances interfere with the regular I attendance of those who have been vacci- nated to afford supplies of lymph for the vaccination of others ; but careless and bad vaccinators avail themselves of these untoward circumstances as an excuse for having frequent failures. Great care and great nicety of management are requisite for uniform or almost uniform success in vaccinatinir, and without the observaneu of this nice care and management many cases of vaccination do badly, or do not take at all : after two or three failures the friends of a child are led to think it can- not be got to take the vaccination, and they neglect to have further trials made, and ultimately the child takes Smallpox, perhaps severely ; such results are of fre- quent occurrence. TABLE IV. Analysis of all the cases of Smallpox after Vaccination, admitted at the Smallpox and Vacci- nation Hospital, London, for a period of 20 years, viz., from 1836 to 1855, inclusive, show- ing, from a careful examination of the cicatrices, the relative amount of security given by the number of vesicles produced at vaccination ; and, judging from the character of the cicatrices, the probable state of activity and efficacy of the lymph used for Vaccination. ? g U O O u 11 Kesults. Patients admitted Tvitli Smallpox. 1 t 5 3 p 54 134 32 57 7 9 2 3 101 3 ■2 Eate per cent, of Mortality from Smallpox, after deducting entirely the cases affected by superadded disease. 1. Having one vaccine cicatrix . . 2. Having two vaccine cicatrices . 3. Having three vaccine cicatrices 4. Having four or more vaccine ) cicatrices ) 5. Stated to have been vaccina- ) ted, but having no cicatrix ) 6. Stated to have been vaccina- f ted, but particulars of cica- / trix not recorded ) 2001 j 1446 j 518 1 544 1 370 17 good indifferent good indifferent good indifferent good indifferent 1032 969 873 573 307 211 358 186 370 17 978 835 841 516 300 202 356 183 269 14 15 21 12 10 4 2 2 18 3-83 ).„3 11-91 r^'' 2-32 ),.„(, 8-34 P'" 23-57 6-66 4896 4896 4494 402 86 6-56 Xotes.^-A good vaccine cicatrix may be described as distinct, foveated, dotted, or indented, in some instances radiated, and having a well, or tolerably well, defined ed^e. An indifferent cicatrix — as indistinct, smooth, without indentation, and with an irregular and ill-defined edge. Aggregate mortality with good vaccine cicatrices, from Smallpox alone, uninfluenced by other diseases, 2'52 per cent. Aggregate mortality with indifferent vaccine cicatrices, from Smallpox alone, uninfluenced by other diseases, 8-82 per cent. There is found to be a mortality of about 2 per cent, in vaccinated as well as unvaccinated patients, from Smallpox being complicated with antecedent or superadded diseases. From the foregoing Table, No. IV., it i recorded at the time in the hospital regis- will be seen that nearly Ave thousand , ter, and the whole subsequently arranged cases of Smallpox after vaccination are re- ' under different headinss, so as to show ported on, each case having been carefully i the value of the different modes of vacci- SMALLPOX AFTER VACCINATION. 153 Bating, in persons who have had Small- pox after having Deen vaccinated several years previously. Three-fourths of the cases had taken the vaccination in but one or two places, and among these, by far the largest pro- portionate mortality from Smallpox has fallen ; and what should also be strongly impressed upon the memory is, that by far the largest amount of suffering and dis- figurement have been produced in those in this category who recovered. It is not simply those who died in the one class of cases that suffered more than others to which we are desirous of drawing the attention, but to those belonging to this class who escaped dying that also suffered and were distigurcd, a great deal more than those in another class in whom the vaccination had taken effect in four or more, places and recovered. This is very important to keep in mind. By vaccinat- ing so as to take effect in four or more places, we not only save life, but prevent a great deal of suffering and subsequent damage to the appearance of the person, which in females, at least, is of great con- sequence, and not always quite a matter of indifference to males. It will be observed that of 544 eases having four or more vaccine cicatrices, only half of 1 per cent, died of Smallpox, or 1 in 200 ; whereas of 9G9 cases; with 'only one indifferent vaccine cicatrix, just upon 12 per cent, died ; in each instance antecedent or superadded disease has been deducted, so as to leave the death, as far as could be known, purely the result of Smallpox. Here, then, is a very import- ant practical point to bear in mind when vaccinating : if only one indifferent cica- trix remains from tlie operation, such persons, taking Smallpox in after life, die at the rate of 12 per cent. ; on the other hand, if four or more cicatrices remain, only half of 1 per cent, will die of Small- pox. It should be further observed, that of 370 persons who believed themselves vac- cinated, but who had no cicatrix to show for having been vaccinated, but who trusted to it for their protection, they died of Smallpox at the rate of 23|- per cent. This again is a very important practical point to bear in mind ; persons having no cicatrix remaining from vacci- nation should by all means be urged to be re-vaccinated, else they may very likely some day fall a prey to Smallpox ; such persons are in a very unsafe position. Now, what has been going on in Lon- don for years past, as seen in patients who have been admitted with Smallpox at the hospital, has been going on also, there can be no doubt, all over the coun- try, in persons who have gone through the disease elsewhere — a very large majority of the patients admitted at the hospital are not Londoners, but persons who have come to London from the coun- try, to serve in the capacity of servants, or are employed in dillerent wuys of business. They were vaccinated in the counti'v. The security of vaccinated persons will be seen by Table IV. gradually to rise, not only from the number of cicatrit<'8 produced at vaccination, but also accord- ing to the quality of the cicatrices, agree- ing with the description given, in the notes of the Table, of the characteristics of good and indifferent cicatrices. Active vaccine lymph, such as leaves clear per- manent cicatrices, is evidently indicated as the most desirable to select for use in vaccinating. Another recommendation is, that it takes etlect more readily at the time of using it. Long humanized lymph requires a more dexterous hand to pro- duce anything like uniform and peri'ect success. In the notes of Table IV. it will be seen that the aggregate mortality in per- sons who have Smallpox is much less in those with good, than in those with indif- ferent vaccine cicatrices : thus taking all the cases together, regardless of the num- ber of cicatrices, those with good cicatrices died at the rate of 24 per cent, only ; whereas those with indifferent cicatrices died at the rate of 8| per cent.: this is also a very important subject to remem- ber, carrying with it, as it does, the in- creased amount of danger and suffering when Smallpox arises. One really good, circular, radiated, and indented cicatrix, is worth two or three indifferent cicatrices generally, such as can hardly be seen. With good, active, eighth-day lymph, an expert vaccinator will hardly ever fail ; cer- tainly not above once in 150 times. We may, indeed, confidently state, from those on whom we can rely, and from our own experience in vaccinating, that the failures will not be nearly so often as once in 150 times ; they should be very rare occur- rences indeed, in good hands. In the course of years, vaccine lymph becomes humanized, by passing many times through the subject, and can only be kept in a good state of efficiency by having many subjects constantly to select from for its continuance, and even then the cicatrices it leaves, after many years' use, are not so good as they were for- merly ; this is a point on which we can bear witness from our own experience, and it is shown by the above Table how very important it is to have lymph that leaves good permanent cicatrices. Out of large numbers of cases of Small- pox after vaccination, viz. 1958, admitted into the Smallpox Hospital during the years 1863 and 1864— Smallpox having been epidemic in London throughout these entire years — the moi-tality after vaccination shows a considerable increabc. 15i SMALLPOX viz. from 6'56 per cent, as given in Table IV., for tweutj' years — 1830 to 1855 — to a mortality of 9'2 per cent, out of l'J58 cases for the years 1863-4 ; all patients mani- festing antecedent or superadded diseases having been deducted from the calcula- tion as in the former instance, in making Table IV. It is a question that may be fairly and properly entertained, and deserves very mature deliberation, whether v^e ought not to resort more frequently than has hitherto been done to supplies of lymph from the cow. A good stock should not be carelessly given up ; with many sub- jects constantly to operate on, and choose from, it can be kept for many years in a good active state of efficiency ; and, how- ever many may be vaccinated, the lymph can only make the circuit of the human body fifty-two times every year, yet this multiplied by twent}- or thirty, as the case may be, according to the number of years, makes the total number considerable. The able and interesting researches of Mr. Ceely of Aylesbury,' by which he established the practicability of obtaining lymph from the cow, by inoculating these animals with the virus of human Small- pox, has secured to us the means of pro- curing fresh supplies of vaccine lymph should it be difficult to meet with the dis- liisu in its natural state in these animals. Mr. Badcock, formerly of Brighton, now of Camberwell Grove, informs me that he has succeeded thirty-seven times during the last twenty-five years, in in- oculating the cow with the virus of human Smallpox. The subject of deterioration of vaccine lymph will Ijo of course a disputed point. It will, perhaps, be argued that diseases of this class do not alter ; that they re- main perpetually the same ; that Small- pox, measles, scarlatina, &c., are the same now as the}' were originally, and ever will be. This argument may be regarded as true generally, but it should be remem- bered that vaccinia is not genuine Variola, even when we know the disease has been produced in the cow by inoculation with the virus of human Variola. In passing the disease through the cow it thereby undergoes alteration, and is not after- wards communicable to man by infection as true Variola is ; nor is vaccinia one of the diseases natural to man, but is only taken by him through the agency of in- oculation : therefore, on this account, it is likely from a variety of circumstances to undergo degeneration, as it is a disease produced at will — artificially— not taken ■ Observations on the Variolfe Vacciiife, and Variolation of Cows, by Robert Ceely, Esq., Surgeon to the Buckinghamshire In- firmary. In Transactions of the Provincial Medical and Surgical Association, 1840. when the body is most prone to receive it, as we may suppose the body is Mhen dis- ease is taken in the natural waj'. AYe feel bound, however, to state we have fre- quently produced, lately, with lymph brought into use by Jenner more than fifty years since, vaccine vesicles which, on comparison, exactly correspond with the vesicles sketched in Jenner's original work, explaining and illustrating the vac- cine disease ; but we also feel bound to state for consideration, reflection, aud practical deduction, the facts with regard to Smallpox after vaccination which have come before us at the Smallpox Hospital for the last thirty years. According to a statement of Dr. San- derson,' as reported to him by the local medical practitioners, the cows still suf- fer from the true cow-pox every spring, or nearly so, in the neighborhood of Berkeley, Gloucestershire, the birthplace of Jenner. Every now and then a patient is ad- mitted into the Smallpox Hospital who has been vaccinated after the symptoms of Smallpox have appeared, the disease being known to be Smallpox when the vaccination was performed. Several pa- tients were thus admitted a few years since from one of our largest west-end London parishes These vaccinations must have been done under a total misap-, prehension of the powers of vaccination to control Smallpox. It does no good whatever when so performed, and should not be repeated, as it only tends to bring vaccination into discredit with the public. The facts of the case are these : — Vacci- nation to be efi'ective should have gone on to the stage of areola before there is any illness from Smallpox. It has before been stated that when Smallpox has been taken into the system there is twelve days' free- dom from illness generally, forty-eight hours' illness, and then the disease begins to appear on the skin. The areola of vac- cination is not fully formed until the ninth or tenth day of the progress of the vaccine vesicles, on those who have never been vaccinated before ; so that unless there has been time for the areola to be formed after the vaccination, before the illness produced by Smallpox begins, the vacci- nation will not be of the least benefit. The progress of vaccination is generally— not always— interrupted as soon as the illness from Smallpox commences, but as it never can be exactly known when Smallpox is taken, so long as persons are well in a house where it exists it will be right to vaccinate or re-vaccinate, as the case may be, as soon as possible, all likely to contract the disease ; but this is a very different thing from vaccinating after tlie ' Sixth Report of the Medical Officer of the Privy Council, with Appendix, 1863, p. 213. SMALLPOX AFTER VACCINATION. 155 symptoms of Smallpox have actually com- menced. Example ; — Suppose an un- vaccinated person to inhale the germ of Variola on a Monday : if he bo vaccinated as late as on the following Wednesday, the vaccination will be in time to prevent Smallpox being developed ; if it be put otr until Thursday, the Smallpox will ap- pear, but will be modified ; if the vaccina- tion be delayed until Friday, it will be of no use, it will not have had time to reach the stage of areola, the index of safety, before the illness of Smallpox begins : this we have seen over and over again, and know it to be the exact state of the ques- tion. Ke-vaccination will have effect two days later than will vaccination that is performed for the first time, because re- vaccinated cases reach the stage of areola two or three days sooner than in those persons vaccinated for the first time. Four or five years since. Smallpox occurred in a family at Richmond, consisting of a man and his wife, and their niece. We received the account of the occurrence from the man, the only one of the three admitted into the hospital. The niece was the first attacked with the disease, and died. About a fortnight afterwards the woman was attacked, and died ; both at Rich- mond. During the woman's illness the man was vaccinated, and he had five large vaccine vesicles on his arm, without any areola, on his admission, in the early stage of Smallpox, at the hospital. The pro- gress of the vaccine vesicles was arrested by the Smallpox ; the man went through confluent Smallpox, wholly unmodified, and died. Now had the vaccination been performed one day sooner, the Smallpox would have been modified — two days sooner, and the man would have been saved from it altogether : this shows the necessity of performing the vaccination as promptly as possible in houses where Smallpox exists. Three weeks or a month had been lost after the first outbreak of Smallpox in the house before the vaccina- tion was performed on this man. Be-vaccinatimi. — It is found on examin- ing large numbers of persons attacked with Smallpox after vaccination, that the majority of those attacked are from eigh- teen to twenty-five years old, and that they had been almost invariably vacci- nated in infancy.' This may be partly accounted for, no doubt, by persons of this age coming to London from the country to act as servants, in shops, &c. But it would seem that all persons at this age become more liable to take the disease then than earlier, or later in life ; tliey become, in fact, more susceptible to it at this age than sooner after vaccination. It would, therefore, seem to be a wise course ' See Med.-Chir. Trans., vol. xxxvi. pp. 377, 380. to pursue to recommend all persons on reaching adult age, especially if about to change their place of residence, to be ex- amined as to their probable security against Smallpox. If they have four or more good cicatrices from vaccination they are tolerably safe; if, on the other hand, they have but one cicatrix, and that such as can hardly be seen, or no cicatrix at all, such persons had better be re-vacci- nated as a matter of precaution. These remarks apply especially to persons on passing from one part of the world to an- other, more particularly if the climate be very different from the one where they have been living. Any change from either a hot to a cold, or colder climate, renders persons liable to contract Smallpox. Per- sons coming from India to England should be re-vaccinated. Vaccination, judging from the cicatrices, does not appear to take effect so well in India as in England. At certain seasons of the year there, dur- ing the hot season, the vaccine lymph is said to suffer deterioration. However this may be, on examining persons who have been vaccinated in India, the cica- trices left by vaccination will generally be found to be very indifferent. Further, it would seem, that persons who have been inoculated for Smallpox or have had Smallpox, are liable to be attacked with this disease a second time, under the cir- cumstances mentioned, and that a predis- position to contract the disease is renewed by any great change of climate, either to a hotter or colder temperature. In commendation of re-vaccination we may state that but very few patients have been admitted with Smallpox into the Smallpox Hospital, who stated that they had been re- vaccinated with effect, and that these few have had Smallpox in a very mild form. For just upon thirty years we have re-vaccinated all the nurses and servants who had not had Smallpox, on their coming to live at the Smallpox Hospital, and not one of them has con- tracted Smallpox during their stay there. Re-vaccination has been extensively prac- tised for some years past, at stated inter- vals, and seemingly with good elFect, on the troops of some of the foreign armies, more especially and perseveringly on the armies of Germany. Combining all these circumstances together, we therefore feel perfectly justified in reconnnending re- vaccina'tio'n for extensive adoption, after adult a!ze, in England; especially to per- sons who appear,"from their cicatrices, to have been but indilferently vaccinated in infancy. For" a very masterly summary of the effect produced by vaccination on the in- habitants of different parts of the world, and a thorough investigation into the whole subject of vaccination and Smallpox, at home and abroad, we earnestly recom- 156 SMALLPOX. mend to all persons interested in vaccina- tion, the perusal of the Blue Book, by- John Simon, Esq., Medical Officer of the Privy Council, entitled "Papers relating to the History and Practice of Vaccina- tion. 18-57." It is to be liad of Messrs. Longman and Co. Epidemic Diffusion of Sjiallpox. — Epidemics of Smallpox begin generally, in London, in the autumnal period of the year. The moist weather of the autunm seems to be favorable to the spread of the disease. When, however, it has once been set going, it continues often throughout all the seasons of the year, quite uninflu- enced either by the frosts of winter, or the heat of sunnner. A larger number of pa- tients have, on several occasions, during epidemic outbreaks of the disease, been admitted into the Smallpox Hospital dur- ing the month of Ma}- than in any other month of the year. The present epidemic of Smallpox has lasted an unusually long time ; it has now (September, 1865) been going on continuously for tliree years. Prom 1796 to 1825 there was not any epi- demic of Smallpox in London. After that came the epidemic of 1838. Since then epidemics have followed in rapid succes- sion. There was one in the winter of 1840-1. Smallpox was epidemic again in 1844-5, in 1848, in 1851-2, in 1854^5-6, in lS5',)-60, and in 1863-4-5. The epidemic of 1S44 began in May; all the rest had their commencement in the autumnal period of tlie 3car. We are quite unable to explain why the disease becomes at times epi- demic, then culminates, and then de- clines; nothing has yet occurred to lead us to the solution of this question. The decline would not seem to be for want of subjects to act on, as of late years fresh epidemics have commenced two or three years only after the preceding epidemics had ceased, and the disease has attacked numerous persons of adult age who were residing in the same place when the dis- ease was raging there Ijut a short time before, but who missed taking it then. A probable explanation of this would be that during the epidemic that bad just before pass-od, these persons were not so suscepti- ble to the influence of the variolous poi- son, although they became so a short time afterwards ; this would seem to be the most obvious explanation of the occur- rence, whether it is, or is not, the true one. iNOCTJLATIOSr FOR SMALLPOX. It is a remakable fact in the history of medicine and the treatment of disease, that the inventor of variolous inoculation should be unknown: even the place where inoculation originated is unknown. What we do know for certain is that inoculation was practised at Constantinople in 1700. Dr. Gregory' writes: "About the year 1703, rumors of the great success of this operation attracted the attention of Dr. Timoni, a Greek pliysician, who had studied and graduated at Oxford. He subsequently settled at Constantinople, and being convinced of the importance of the discovery, wrote an account of it, in 1713, to his English correspondent, Dr, Woodward, which in the following year was published in the Philosophical Trans- actions. In 1715, Dr. Pylarini, the Ve- netian consul at Smyrna, having also learnt the success of this Turkish prac- tice, published an account of it at Venice. A notice of this work appeared in the Philosophical Transactions for 1716, and these favorable accounts were fully cor- roborated by the reports of Mr. Kennedy (an English surgeon who had travelled in Turkey) in his Essay on External Kerne- dies, published in London in 1715. "No notice, however, was taken of these important facts by any English phy- sician, and the idea of transplanting or engrafting Smallpox (as the process was called) was well-nigh forgotten in London, when the celebrated Letter of Lady Mary Wortley Montague appeared, which de- scribed the practice in so lively a manner as to attract public attention.^ ' The Smallpox,' she writes, 'so general and so fatal amongst us, is here entirely harmless by the invention of engrafting, which is the term they give it. " There is a set of old women who make it their business to perform the operation. Every year thou- sands undergo it, and the French Ambas- sador observes pleasantly that they take the Smallpox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died of it, and you may believe I am well satisfied of the safety of the experiment, since I intend to try it on my dear little son. I am patriot enough to take pains to bring this careful invention into fashion in England. ' "She kept her word, and to the spirit and enterprise of this lady the introduc- tion of inoculation into this country is altogether due; her own daughter was re- served to be the first example of inocula- tion in England. This event occurred in 1721, and its success was complete." Through the advice of Drs. Timoni and Pylarini, inoculation was begun in Ame- rica in 1721, by Dr. Boylston; 244 persons were inoculated, and six died. About the same time, in England, a son of Lord Sunderland, and the butler of Lord Bath- urst, both died of inoculation. This brought the practice into discredit, and it was not until the middle of the last cen- ' Cyclop, of Pract. Med., vol. iii. p. 748. 2 Vol. ii. Letter xxxi., dated April 1, 1717. INOCULATION FOR SMALLPOX. 167 tury that it was revived. In 174(5, the Smallpox and Inoculation Hospital, Lon- don, was founded, that the poor might partake of the benefits of inoculation, which had hitherto been confined in a great measure to the rich. Inoculation was continued there until 1822. Dr. Gregory went carefully over the records of the hospital for this period, and found that only three in a thousand died of in- oculation. The inoculated disease was usually very mild, but not invariably so. The great objection to it was, that it spread Smallpox just as the natural dis- ease did. It could be set going anywhere by sending in a letter a bit of cotton- thread dipped in variolous lymph for the purpose of inoculation; so that, although the practice was of great advantage to in- dividuals, it was very destructive to the public at large, and the general mortality from Smallpox was thereby greatly in- creased. About the time the hospital was found- ed, two brothers, Robert and Daniel Sut- ton, one practising at Bury St. Edmunds, in Suffolk, the other at Ingatestone, in Essex, by carrying out more fully than had been done before, the practice of treating Smallpox suggested by Syden- ham, improved amazingly the mode of managing those under inoculation. Their practice was adopted by Baron Dimsdale, who obtained great celebrity as an inocu- lator. It consisted in giving purgative medicine, spare diet, and exposing the patient freely to cold air in the day, and making him sleep in a large airy apart- ment at night. '■'■Phenomena of InorMlation. — On the second day after the operation, if the part be viewed with a lens, there appears an orange-colored stain about the incision, and the surrounding skin seems contract- ed. On the following day a minute papu- lar elevation of the skin is perceptible, which on the fourth day is transformed into a vesicle with a depressed centre. The patient perceives an itching in the part. On the sixth day, some pain and stiffness are felt in the axilla, proving the absorption of the virus into the general mass of blood. Occasionally on the sev- enth, but oftener on the eighth day, rigors occur, accompanied sometimes with faint- islmess, sometimes with pain of the back, headache, or vomiting. The patient com- plains of a disagreeable taste in the mouth, and the breath is offensive, soon after which the eruption shows itself" In 1840, an Act of Parliament was passed, rendering variolous inoculation unlawful in England; the penalty for in- fringing this law is a month's imprison- ment. Still, however, under certain unfortu- ' Gregory, op. oil. p. 750. nate circumstances inoculation miaht be justifiably had recourse to. First, Tor in- stance, when Smallpox breaks out on board ship, and there is not any vaccine lymph at hand, or a probability of any being soon obtained, and persons are present who have neither been vaccinated nor have had Smallpox. Secondly, when Smallpox occurs in our colonial posses- sions, and several months must elapse be- fore vaccine lymph can be procured from England, or elsewhere. Under these cir- cumstances, on board ship where Small- pox exists, or in houses in the colonies where unvaccinated persons are unavoid- ably compelled to remain in close prox- imity to Smallpox, inoculation of them would be perfectly justifiable. Then it will have to be considered and determined, as so many persons now take Smallpox after vaccination, and the badly-vacci- nated suffer so severely and fatally from Smallpox, whether the vaccinated who have been badly vaccinated should have their vaccination tested by inoculation. It may be pretty well known, by attend- ing carefully to the previous statements in this article, whether persons have been well vaccinated or not. If they have four or five good vaccine cicatrices, readily dis- cernible, they will most likely have Small- pox in a mild form if they take it, and need not be inoculated. If, on the con- trary, they have only one cicatrix that can but just be seen, or no cicatrix at all, they will probably have Smallpox, if they take it, in a severe form. Rather than run the risk of contracting a dangerous attack of Smallpox by inhalation, it would, perhaps, be wiser that they should have their vaccination tested by inocula- tion. It is no doubt a choice of evils, but the evil is likely to be much less of having Smallpox by inoculation than of having it by inhalation. In ships, or in houses in the colonies, then, where there is Smallpox, and where no vaccine lymph can be obtained to vac- cinate those who have not been vaccinated or to re-vaccinate those who have been badly vaccinated ; and where the inmates cannot get away, no further harm would be done to the public by inoculating those who are presumably unsafe, and unavoid- ably obliged to be resident in such ships or houses. The greatest objection, as be- fore stated, to the practice of inoculation, was from its spreading Smallpox by infec- tion, to other persons ; but this objection would not be valid under the conditions above specified — these conditions and limitations being observed, inoculation might still fairly be considered to be ad- missible and justifiable, rather than to allow unvaccinated or badly-vaccinated persons to take Smallpox in the natural way. Whenever, after carefully weighing all 158 VACCINATION, the circumstances of difficulty and danger, it is delenuined toimiculate, tlie variolous lymph for inoculation should be taken when Unipiil, au) when Vaccination had become to a great extent diffused, but before any public provision was made for its gratuitous performance . . . 3. Average of nine* of the years (1841-53) when public Vacci- nation was gratuitously provided, but Vaccination was not 11,944 5,221 3,967 3,000 770 304 4. Average of the twelve years (1854-65) during which Vacci- nation has been to a certain extent obligatory 202 ' Board of Health, Papers relating to the History and Practice of Vaccination, 1857, p. 139. ! Ibid. ' Simon, op. cit. p. xxiii. 2 Report of Smallpox and Vaccination Committee of Epidemiological Society, 1853. 3 Marson, Medico-Chir. Trans., vol. xxxvi. ■• The present system of registering deaths commenced only in 1837. 6 During the years 1843-46 causes of dfiatli were not distinguished i« the Reports of the Registrar-General. PROTKCTION AFFORDED BY VACCINATION AGAINST SMALLPOX. 171 With such proof of tho protective value of Vaccination, it might well indeed bo a matter of astonishment that smallpox should still annually make such ravages amongst us, if we had not ample evidence of the extent to which, through ignorance and apathy, and to a certain degree through prejudice not yet eradicated, the practice of Vaccination has been neg- lected, as well as of the imperfect and insufficient way in which the operation has not unfrequently been performed. The inquiries made, under the direction of the Government, from 1860 to 1864, by Drs. Stevens, Buchanan, Sanderson, and myself, into the state of Vaccination throughout England, showed that the universal performance of Vaccination in early infancy which is indispensable for the effectual protection of the community from smallpox was so far from being at- tained, that the proportion unvaccinated, even among children old enough to be in attendance at public infant schools, ex- ceeded 13 per cent. Now, it is in the young unvaccinated portion of the popu- lation that the smallpox mortality chiefly occurs. Of the nearly 4000 deaths from this disease which are on an average still recorded every year in England, 56 per cent, are in children under five years of age, and as much as 70 per cent, in chil- dren under ten years of age.' We can have no hesitation in saying that in all the fatal cases at this early age there must, with very rare exceptions, have been neglect of Vaccination ; for when that operation has been performed, even with the effect of raising a single vesicle only, subsequent death from smallpox in childhood very seldom indeed occurs." We know further that of the mortality above ten years of age a very large proportion takes place in persons in whom Vaccina- tion had never been performed. So that an estimate which should ascribe foui- fifths of the present mortality from small- pox to the omission of Vaccination would most certainly be very much below the mark. Many, however, of the deaths from smallpox which take place after ' Deaths in England from Smallpox, at dif- ferent ages, for the nine yeai-s 1855-6-i : — All ages. Under 1 Year. 1—2 Tears. 2-3 Tears, 3—4 Tears. 4-5 Tears. 30,707 7,334 3,370 2,666 2,152 1,732 Under S Years. 5-10 Years. 10—15 Years. 15—2) Y'ears. 35—3.5 Years. 35 Tears aud upwards. 17,254 4,078 1,169 3,552 2,422 2,232 ' Gregory, Marson, &c., as quoted in "Handbook of Vaccination," pp. 224-5. puberty — and there are on an average above 1000 deatlis annually from this cause in England in persons over fifteen years of age — are (especially at epidemic periods) in individuals who had been vac- cinated, and who believed themselves protected against smallpox. But as re- gards these, there arises the further ques- tion, how had they been vaccinated ? Now, though we cannot, of course, an- swer this question as regards the indivi- duals, we may fairly apply to the group the observations made in the Smallpox Hospital on fatal cases of smallpox in per- sons believed to have been successfully vaccinated. Of 402 such fatal cases, oo- ciming in 20 years, 101 exhibited on their arms no evidence whatever of having ever had effective Vaccination ; 277 had but one or two vaccine marks, and these, in 191 of them, were of imperfect character ; 16 were in persons who had three cica- trices ; and only 5 in persons who had been vaccinated in the way which has been shown to be the most protective — of which 5, two did not die of smallpox, but of concurrent or superadded disease. ' We may be sure then that in only a few of those who die from smallpox after Vacci- nation in England, the Vaccination had been done in the best way. In the official inquiries above referred to, in the course of which the arms of nearly half a million vaccinated children were examined, evidem.-e was obtained of the great extent to which imperfect or in- suffldent Vaccination had heretofore pre- vailed in England ; taking the country throughout, not more than one child in eight was found to be so vaccinated as to have the highest degree of protection that Vaccination is capable of affording ; not more than one in three could, on the most indulgent estimate, be considered as well protected ; while in more than one in four the Vaccination had been of a very inferior kind indeed, resulting in marks of imperfect character, or in only one or two marks of merely passable cha- racter." These imperfections were mainly traceable to the following causes : (1) the frequency with which practitioners, in- ■ See also the article on Smallpox. 2 These observations were made on children most of whom had been vaccinated by public vaccinators, but a large number of whom had been operated on by private practitioners, and, without affording statistical evidence of the fact, they left a strong impression that, as a rule, the latter were less well vacci- nated than the former. My own experience has satisfied me in other ways that many in the upper and middle classes in England have been very imperfectly vaccinated — the chief reason why smallpox is so much less met with among them than it is among the lower classes being that they are so very much less exposed to it. 172 VACCINATION. stead of attempting fully to infect the system, had been satisfied with insertions of lymph, sufficient to produce only one, two, or three ordinary vesicles ; (2) the want of due attention to the selection of the lymph used in vaccinating ; (3) care- lessness and clumsiness in the perform- ance of the Vaccination, so that, if the operation did not wholly fail, it very fre- quently resulted in a less degree of etfect than it had been the aim of the operator to produce ; and (4) the great and unne- cessary extent to which the use of pre- served and conveyed lymph was substi- tuted for the Vaccination direct from the arm, which should be the rule of all vac- cinators. ' It is satisfactory that these, the chief causes of imperfection, are of a kind for which we have in future an obvious rem- edy (and which, it may be added, are now rapidly being remedied), in the proper practical instruction of vaccinators in the employment of more care and at- tention in vaccinating, and in better arrangements for transferring lymph. Other causes of imperfect Vaccination which are quite independent of the vacci- nator, though far less widely operative than those just enumerated, must not, however, be overlooked : as, something particular in the child's constitution or condition at the time of Vaccination, which even the most experienced vacci- nator may have been unable to detect ; aberrations of lymph — rarely indeed, but still occasionally, met with — occurring under undefinable conditions, of which the first manifestation to the vaccinator has been the unsatisfactory result ; the carelessness of parents in allowing the vaccine vesicles to be disturbed in their course and the crusts to be prematurely removed. It has been contended that, apart from imperfections in the mode of conducting Vaccination, the vaccine lymph itself ne- cessarily degenerates by repeated trans- missions through the human body, and loses something of its infective and pro- tective power. The hypothesis that lymph would de- teriorate by mere transmission through human bodies was started in the very earliest days of Vaccination. Jenner thought the notion a very improbable one, but could only then say of it that ' For evidence in detail see Reports of Medical Officer of Privy Council, iii. — vii. It is beyond the limits permissible for the pres- ent article to enter into an inquiry into the subject of the best arrangements for the per- formance of Vaccination and for maintaining stocks of active lymph : hut it is a subject of tlie utmost importance, and one which I have endeavored to treat fully in my "Handbook of Vaccination," chap. vii. time was necessary to determine the ques- tion. But after many years' experience he felt himself quite justified in pronounc- ing the hypothesis as groundless. Draw- ing, as he never failed to draw, the broad and most important distinction between such deterioration of lymph as may result if in continuous vaccinations due care be not taken in selection of the lymph em- ployed, and the doctrine of inevitable de- terioration by mere transmission : he re- marked, writing in 1816, that lymph in passing even from one individual to an- other might undergo a change which rendered it unfit for further use, but that the notion of necessary degeneration was a conjecture "he could destroy by facts :" and he referred, in proof, to the vesicles he was then producing, which, he says, "•are in every respect as perfect and cor- rect in size, shape, color, state of the lymph, the period of the appearance and disappearance of- the areola, its tint, and finally the compact texture of the scab, as they were in the first year of Vaccina- tion ; and to the best of my knowledge the matter from which they are derived was that taken from a cow about sixteen j'earsago. '" Numerous trustworthy ob- servers, who had watched the vaccine disease at the introduction of Vaccina- tion, on comparing what they had then seen with the effects produced by lymph of the earliest stocks, after a lapse of thirty or forty years, were unable to detect the slightest difl'erence either in the cha- racter or course of the vesicles. And the same appears certainly to be the case at the present day. Having for the last thirty years been a close observer of the vaccine vesicle, and having during the last nine years enjoyed such opportunities of witnessing the practice of Vaccination in the hands of various vaccinators, and of noticing the results of Vaccination in the cicatrices left on the arms of individu- als vaccinated, as have scarcely perhaps fallen to the lot of any other person, I can confidently affirm that the vaccinators of the present day who are masters of their craft do their work as surely with ordinary long-humanized lymph and in- fect their patients as completely as the earlier vaccinators did, producing vesiclis which in character and course differ in nothing from the description that Jenner has given us, and which leave cicatrices as perfect as those which I have seen op the arms of persons who had been vacci- nated by Jenner himself or by his well- known contemporary. Dr. Walker.* AVhat- ' Letter in Baron's Life, vol. ii. p- 398. M. Bousquet appears to have overlooked this passage. See his "Nouveau Traitfi de la Vaccine," p. 399. 2 See Fourth Report of Medical Officer of Privy Council, p. 04. PROTECTION AFFORDED BY VACCINATIOX AGAINST SMALLPOX. 173 3ver has been found unsatisfactory in the lands of other vaccinators, whether as regards the course of the vesicles or the character of the cicatrix, was fairly trace- ible to the causes which have been already stated, and especially to looseness and [jarelessness in the selection of lymph : md though I have sometimes found it desirable to recommend a vaccinator to change the stock of lymph he was employ- ing, I have always felt it enough to take care that the stock substituted was good active lymph without troubling myself as to the time that had elapsed since it had come from the cow. It is quite true that the earliest transmissions of lymph from the cow to the human subject have usually a peculiar intensity of local irritative ef- fect. But this result (which is so far from being an advantage that it is often found to need controlling)' is generally lost in a few transmissions, often indeed in one or two transmissions ; besides that different primary stocks are found to differ much as to the local effect they thus produce.^ Ceely, whose testimony on this subject is of the utmost importance, because he, more than any other living inquirer, has studied the natural disease in the cow, and has experimented on its transference to the human subject, entirely disclaims belief in the superior protective efficacy of lymph thus recently transferred over active humanized lymph.' Several practitioners residing near the Bridgewater Level, and in the vale of Gloucester (in which dis- tricts the natural cow-pox is still not un- frequently seen in the dairy farms), stated a few years ago to Dr. Sanderson, that they had inoculated lymph direct from the cow with success ; but all agreed that, after the first or second transmission, the results did not differ from those of ordi- nary Vaccination, either in the character or progress of the vesicles. It is in truth not to the cow, but to adequate care and skill on the part of vaccinators in the se- lection of the children and vesicles from which lymph is taken, that we must look for maintaining stocks of active lymph.'' ' To one unpleasant result frequently met with in early vaccinations from tlie cow, Mr. Ceely has especially called attention in a re- cent communication ; it is the occurrence of a special vesicular vaccine eruption called by the Germans "Nachpocken," which causes a good deal of temporary disfigurement and an- noyance, and sometimes, when copious, severe and even dangerous symptoms. (See Brit. Med. Journ., Jan. 7, 1865.) ^ Handbook of Vaccination, chap. x. ' Observations on Var. Vacc. in Trans, of ProT. Med. Assoc, vol. viii. * The important point, it seems to me, is that vaccinators should not be induced to look to anything extrinsic and inevitable for an explanation of deteriorations which, if they occur at all, may be more properly Facts are equally at variance with the supposition that transmission tlirough human bodies causes vaccine lymph "to lose anything of its proteciive i)ower. Per- sons vaccinated with lymph direct, or only a few removes from the cow, and others vaccinated with long humanized lymph, have been submittetr to the test of vario- lous inoculation ; but the result in each class of cases has been the same. This ex- periment in fact is made to hand on a large scale in every epidemic of smallpox. In each such epidemic — no matter at what period since the introduction of Vaccina- tion — it has not been the persons vacci- nated with the then current lymph, the lymph furthest from the cow, but those vaccinated some sixteen, twenty, or twen- ty-five years before, with lymph so much nearer to the parent source, who have been found to be the chief sufferers from post-vaccinal smallpox. Another subject for consideration in reference to the protective power of vac- cination is its permanency in the indi- vidual. It has been often said that it is undoubtedly a protection, but for a lim- ited time only ; that it wears out by age, and requires successive renewals. Al- though this theory is sometmies thus broadly advanced, the permanency of the protection which a single efficient Vacci- nation gives against smallpox is so com- pletely established as the law of the hu- man economy, that we need only deal with it as offering an explanation of that proixjrtion of caire good marks of previous Taccination. In those who bore doubtful or imperfect marks of previous Vaccination. In those who bore no marks of previous Vaccination or Smallpox. Wirtemberg Army, 1831-5 (13,861 cases) Perfect Modified Noue Perfect Modified None Perfect Modified None 319-5 248-1 432-3 310-4 280-5 409-2 280-7 259- 460-4 337-3 191-1 471-6 1000 1000 1000 1000 Soldiers in Brit. Army, not i-ecruits, in 1861 (2,053 cases) 451-4 159-6 389-0 484-6 157-4 358-0 236-8 505-3 257-9 326- 277-5 396-5 1000 1000 1000 1000 Eecruits in Brit. Army in 1861 (4,395 cases) 345-5 266-8 387-7 407-3 240-8 351-9 461-3 301-3 237-4 527-3 202-6 270-1 1000 1000 1000 1000 A perfect local result following a rcvac- cination is constantly appealed to by prac- titioners as evidence that the person in whom it was developed was liable to take smallpox, or, at all events, more liable than those in whom imperfect or no re- sults followed. But this conclusion ap- pears to me by no means warranted. If it were, these curious results would fol- low, that (taking as our guide the obser- vations in the Wirtemberg army) 319 out of 1000 persons having had smallpox, 310 out of 1000 who had been well-vaccinated, and only 281 out of 1000 who had been ill- vaccinated, were in present danger of tak- ing smallpox ; and of the soldiers (not re- cruits) in our own army, 451, 485, and 237 would represent the ratio in the three classes respectively, which is clearly a re- ditctio ad absiirdmn. We cannot, indeed, that I can see, draw from the local phe- nomena of revaccination any inferences whatever as to the state in which the re- vaccinated person was as to liability to smallpox. Jenner himself, indeed, pointed this out in his first treatise, and showed that the natural cow-pox might be in- duced again and again in persons who, being ijrotected against variola by their first attack of cow-pox, could not be va- riolated either by inoculation or by expo- sure, and also that cow-pox might be made to take on those who had had smallpox.* ' See Sixth Report of Medical Officer of Privy Council, p. 113. 2 Obs. on the Variolae Vaccinae, pp. 21, 22, and p. 51 ; Continuation, &c. p. 25. The utility and necessity of revaccination stand not upon any speculative reasoning from the local effects it produces, but upon the broad grounds of observation and ex- perience. IV. Kelations of Yaiiiola and Vaccinia. — Jenner believed the cow-pox of the cow and the smallpox of the human subject to be essentially the same disease, as he implied when he denominated the former Varioloe Vaccinae : he further be- lieved they had a common origin— the grease of the horse. He did not himself perform any inoculation of cattle with the Ij^mph of human variola. But, as early as 1801, Gassner, of Giinsburg, by inocu- lating eleven cows with smallpox matter, produced on one of them vesicles haying all the character of vaccine vesicles, and from which a stock of genuine vaccine lymph was obtained. Another successful variolous inoculation of cows, at the Ve- terinary College at Berlin, is referred to by M. Viborg of Copenhagen so early as 1802, but no details are given respecting it. In 1830, Dr. Sonderland, of Barmen, stated that he had infected cows with the variolous contagion by enveloping them in blankets taken from the bed of a patient who had died of smallpox, and also hang- ing the blankets up round tlie head of the animal that it might breathe the effiuvia arising from them. The cows, he says, in a few days manifested the symptoms of cow-pox, and lymph taken from them pro- duced genuine vaccine vesicles in the human subject. Dr. Sonderland's experi- ALLT5GED DANGERS OF VACCINATION. 177 ments were repeated in India b)' Mr. Mac- pherson, in this country bj- Mr. Ceely of Aylesbury, and in various places abroad, without success. But ISIr. Ceely was able, by the much more satisfactory process of direct inoculation with smallpox virus (in February, 1839), to induce vesicles iu two out of three sturks operated on, and with lymph taken from these to vaccinate many children, from whom a regular lymph- stock was continued.' In 1840, Mr. Bad- cock of Brighton, without previous know- ledge of Mr. Ceely's experiments, suc- ceeded also in variolating the cow, and deriving thence a stock of genuine vaccine lymph : and since then he has, by inocu- lating cows with the lymph of human variola, raised stocks of vaccine lymph for use on no fewer than thirty-seven separate occasions. The common origin, then, of smallpox and cow-pox may thus be con- sidered as established. The case, as regards the grease, appears to stand thus : the disease really known as grease has nothing to do with cow-pox or smallpox ; but the horse is subject at times to a true equine pox, which is pre- cisely of the same kind as the smallpox in man and the cow-pox in the cow. This disease is met with as an epizootic, parti- cularly when cow-pox is epizootic among cows and smallpox is epidemic. The equine matter used by Jenner himself,'' aud that used by Sacco and others, for the purposes of Vaccination, were derived from this equine pox ; and on various other occasions equine lymph has been employed.^ V. Alleged Dakgebs of Vaccina- tion. — Space renders it quite impossible for me to enter into the consideration of certain objections that have been urged from time to time to the general utility of Vaccination, or have been thought to prove that it was injurious : such as the displacement-of-mortality theory of M. Carnot, the allegations that scrofula and typhoid fever have become more frequent in consequence of the introduction of the practice (being in fact, it has been said, " vaccinational varieties or introversions of smallpox"), and other, like absurdities. The practitioner who desires to ac- quaint himself with all that has been brought forward on these subjects will ' Obs. on Var. Vaoo. in Transactions of Prov. Medical Assoc, vol. viii. Three years before, Dr. Thiele, of Kasan, in Russia, had made similar successful experiments (Henke's Zeitschrift, t. xxxvii. h. 1), whicli were not known to Mr. Ceely, and, in fact, were not published till 1839. ' Baron's Life, vol. i. p. 254. ' The limits of this article do not allow me to enter further into this interesting subject, which is fully discussed in chaps, ii. and iv. of my "Handbook of Vaccination." VOL. I.— 12 find the fallacies of the various statements thoroughly exposed, and the questions themselves finally settled, in the admira- ble memoir which Mr. ISimon has prefixed to the Papers relating to the History and Practice of Vaccination, to which I have already so often referred. What is before us now to consider is of more limited scope, but of much greater real import- ance, and relates not to whether Vaccina- tion is a proceeding we ought still all to adopt, but to the special care and precau- tion which should be brought to its jsrac- tice. Is it possible in vaccinating to com- municate accidentally other diseases — as cutaneous diseases, scrofula, or syphilis ? Keserving for separate consideration what has to be said regarding syphilis, I may state that the invaceination of cuta- neous and scrofulous diseases, though a popular, has never been a professional be- lief. These diseases are met with con- stantly in infancy and childhood, as well in the unvaccinated as in the vaccinated, from the influence of various exciting causes acting on constitutional predispo- sition. I am not aware of any facts which prove, or even render probable, their greater frequency among vaccinated than among unvaccinated children of the same ages respectiveljr. AVhcn eczema and other eruptions manifest themselves, as they may do, shortly after Vaccination has been performed,' this is held by some to be — and no doubt very generally is — a mere coincidence, and due in reality to one of the various eruption-producing in- fluences to which children at the usual age for Vaccination are subject, such as teething, &c. But there are many medi- cal men who hold, and with great proba- bility, that in a part at least of these cases the Vaccination may itself have been, by the febrile action it set up, the exciting cause. No medical authorities believe in the transference of scrofulous and cuta- neous diseases from one child to another by Vaccination. Parents, how^ever, as Mr. Marson observes, "are unwilling to believe that there is anything constitu- tionally wrong in their offspring ; and, when other diseases follow, Vaccination gets blamed for what is really and truly due to other causes." Hence, parental complaints that disease has been set up in this way are not unfrequent ; but, as showing the prejudice under which such complaints are preferred, it may be worth while to state that, thougli I have care- fully investigated a great number of them, I have never yet in a single instance found that the child from whom the lymph was taken was suffering from the disease it was said to have imparted. ' Such eruptions as are part and parcel of the constitutional symptoms of Vaccination have been already treated of in Sect. i. 178 VACCINATION. Those who have hnd most to do with the performance of Vaccination, on tlie one hand, and tliose who have been most concerned in the treatment of infantile disease, on the otlier, concur in tlie belief of the non-communicability of disease by Vaccination. Mr. Marson, in the per- formance of 50,000 vaccinations and more, " has never seen other diseases communi- cated with the vaccine disease, nor does he believe in the popular report that they are so communicated.'" Such also was the experience of the late Mr. Leese, whose opportunities of observation were scarcely, if any, less.^ Sir "W. Jenner stated some years ago that at University College Hos- pital and at the Hospital for Sick Chil- dren he had had, in six years, more than 13,000 sick adults and children under ob- servation, and that in no case had he rea- son to believe, or even to suspect,^ that any constitutional taint had been conveyed from one person to another by Vaccina- tion.^ Dr. West's experience on 26,000 infants and children under his care in seventeen years is to the like effect ; and in stating that he had seen nothing in that time to make him believe that Vaccina- tion excites cutaneous eruptions in any but very exceptional cases, he referred such exceptional cases to a disposition in the children themselves, brought out by the Vaccination as it might have been by teething.'' And Professor Paget, speak- ing from his large experience among chil- dren in the out-patients' room at St. Bar- tholomew's, and enumerating some of the causes which develop cutaneous diseases in young children, says, "Now, Vaccina- tion may do, though I believe it very rarely does, what these several accidents may do ; namely, by disturbing for a time the general health, it may give opportu- nity for the external manifestation and complete evolution of some constitutional affection, which, but for it, might have re- mained rather longer latent. " "This is," he adds, "the worst thing that can with any show of reason be charged against Vaccination ; even this can very seldom be charged with truth. "^ Although the direct inoculability of the syphilitic poison from one human being to another distinguishes it remarkably from cutaneous diseases generally and from scrofula, I should still, but for cer- tain recent occurrences which have ex- cited much attention, and to which I shall immediately advert, not have thought it necessary to speak separately of the com- munication of that disease by Vaccina- ' Papers relating to the History and Prac- tice of Vaccination, p. 25. 2 Seaton on Protective and Modifying Powers of Vaccination, p. 23. ' Papers relating to, &c., p. 75. * Ibid., p. 146. 6 itid. tion. It was indeed not only included with other diseases, but was specially hO included, in the opinions of the distin- guished practitioners whom 1 have just cited ; Dr. West informing us that there had never come under his notice "any instance in which there seemed the slitrht- est pretext for supposing that syphilis had been communicated to infants through the medium of the vaccine lymph," and Pro- fessor Paget that he does not remember " to have heard infantile syphilis ascribed to Vaccination, frequent as the instances of it (inf. syphilis) are among the out-pa- tients." In the experience of Mr. Mar- son, Mr. Leese, or the National Vaccine Establishment of England, such a ease has never been met with. And referring generally to the experience of practition- ers at home and abroad, it may safely be said that there is scarcely a subject in medicine in which there has been, till within the last few years, a more general concurrence of opinion.' One broad gen- eral fact seemed to be, and still probably is, conclusive on the matter. In the sev- enty years that have passed since Vacci- nation was introduced, it seems certain that, "if syphilis could be diffiised by the vaccine lymph of children with an heredi- tary taint of that disease, this possibility must long ago have been made evident on a scale far too considerable for ques- tion, "i^ Scientific authority unites with general medical experience to negative the possi- bility of the vaccinal communication of syphilis, — it being implied always of course that the vaccination is true vacci- nation, i.e., with vaccine lymph taken from a true Jennerian vesicle. Professor Paget states the pathological grounds for disbelieving the possibility of any such communication to be, (1) because iiifan- tile syx/hilis (which alone need be here considered), though conveyable in some instances by its own pecuhar morbid pro- ducts, does not render the blood of the patient capable of directly conveying the disease ; and (2) because, if the blood of a syphilitic child could so modify the vac- cine disease within it as that the vaccine lymph should be capable of conveying any other disease, there is every reason to be- lieve that the vaccine vesicle formed in the diseased child would be modified in correspondence with the modified lymph. "All pathological researches," he ob- serves, "accumulate the evidences of the constant correspondence between the ma- terial in the blood, on which each specific disease depends, and the morbid structure, by which each is manifested. Thus the ' See replies of eminent members of the profession to the queries addressed to them (in 1856) by Mr. Simon. 2 Simon, in Papers, &o., p. Ixvi. ALLEGED DANGERS OF VACCINATION. 179 transformations of the sj'philitic poison are iudicated in the successive external characters of the primary, secondary, and tertiary affections ; tlie transformation of the scarlatina poison by its regular symp- toms and its sequelae. And so, if the vac- cine virus were capable of any transfor- mations besides those which mark its regular influence in each patient, such transformations, we may be sure, would be indicated by corresponding and evi- dent changes in the vaccine vesicle. In other words, if the vaccine were changed into any other virus, there would be no vaccine vesicle. '" The opinions of Hebra and other distinguished pathologists are to the like effect. Direct experiments made on a large scale, at many times, and by many indi- viduals, have led in every single instance to the same conclusion. M. Cullerier and other experimenters in France, especially M. Taupin, have taken lymph on purpose from syphilitic children, have vaccinated healthy children with it, and watched the result. In no instance has syphilis been communicated. Ileim made similar ex- periments in Germany with the same re- sult. It was found no more possible to produce syphilis by vaccine lymph taken from a syphilitic child, than it is to pro- duce smallpox by lymph taken from vac- cine vesicles on the arms of patients who are incubating, or suffering from that dis- ease. This, it is Avell known, has been done hundreds of times, but never has smallpox been thus communicated or any- thing but a vaccine vesicle resulted.^ Cases had indeed been from time to time recorded, in which it was believed or suspected that syphilis had been com- municated form one person to another along with Yaccinia. But, in searching the literature of sixty years, notice can scarcely be found of a dozen occasions in which events of this kind were supposed to have happened, where the circum- stances are stated with sufficient detail to enable us to form a judgment of the value of the evidence; and, in all of these, the details, when they were examined, were found so wanting in scientific precision, and so open to sources of fallacy, that the cases had been rejected as worthless for proof. So that about eight years ago the mind of the profession "generally, never till then, so far as I ain aware, very se- riously disturbed, may be said to have been at rest on the subject. This quiet- ude, however, was soon afterwards broken by a very circumstantial account of a sin- gular outbreak of endemic syphilis at Ri- valta, in 1861, traceable, it was said, to a vaccinal origin, and by one or two cases — especially by one which occurred in the ' Papers relating to, &c., p. 139. ' Simon, op. cit. p. 43. wards of M. Trousseau, at the Hotel Dicu in Paris, in 1861 — wliicli allbrdud, it was alleged, direct proof of vaccino-syphilitic inoculation. To the events then an- nounced a new and adventitious interest was imparted by the bearing which proof of the occurrence of vacclno-syphilitic in- oculation, if it could be afforded, would have on the doctrines then being sharply contended for by rival schools of syphilo- graphers.' All the cases detailed from the earliest days of Vaccination were eagerly hunted up; the discussions which ensued caused a few fresh (alleged) cases to be recorded; and the evidence thus col- lected has been held by certain authorities in syphilis to establish that the inoculation of sj'philis in vaccinating from a genuine vaccine vesicle, though of excessively rare occurrence, is j-et possible, supposing that the child from whom the lymph was taken had, or was incubating, syphilis, and that some of the blood of the syphilitic child was inoculated along with the vaccine lymph. The allegation is not, it will be observed, of carelessly syphilizing instead of vaccinating, as by taking syphilitic matter instead of, or along with, vaccine lymph, in which cases we miglit expect, of course, syphilis only, or syphilis with Vaccinia, to result. It"is that in the ordi- nary performance of Vaccination (the ab- sence of syphilitic matter on the lancet being presupposed), syphilis may be acci- dentally implanted along with the vaccine. It is not contended, in the face of the ac- cumulated evidence to the contrary from pathological science, general experience, and direct experiment, that vaccine lymph would impart syphilis or any other than its own specific contagion. i5ut it is said that there may be twofold inoculation, and tlie communication may take place through the blood." Lymph and syphilitic > A reader of the recent discussion in tlie Academie de Medecine will be surprised at tlie sort of jubilant tone with which the vac- cinal inoculation of syphilis is liailed as giv- ing the "dernier coop" to a certain " gcole syphilographique," &c. &c., as well as at the mere hearsay evidence on which facts are pressed into the controversy. 2 In experiments with the mixed viruses made by Sigmund, by Friedinger, and by Boeck, syphilis onhj was produced : there was no Vaccinia. In one of Friedinger's experi- ments, however, and in one out of many ex- periments by Baumfes and Sperino with the matter of soft chancre mixed with vaccine lymph, an irregular Yes\ An resulted, which in its development had some considerable points of resemblance with a vaccine vesicle, bat the matter from which, taken on the eighth day, produced only chancre (De la Syph. Vacc, Paris, 1865, p. 280). As regards true syphi- lis, however, one cannot see any reason why, if its inoculahle products were mixed with vaccine lymph and inserted on the arm of a 180 VACCINATION. blood being inoculated together, each | within its own period of incubation ivill produce its own specific results. The vaccine disease will first run its course, and this being over or approaching its end, the efl'ects of the blood inoculation will manifest themselves. But even of the possibility of accidental communica- tion in this way it appears to me that the very strictest proof, and a complete ab- sence of every possible fallacy,' are de- manded : (1) because we have hitherto been without any evidence whatever of the direct communication of infantile sy- philis by inoculation of blood; (2) because inoculation of syphilis by blood of the adult is a matter of very great difficulty and very frequent failure, requiring al- ways the exposure of a very large absorb- ing surface, while in the cases now brought forward the inoculation seems to be effected wholesale and by the minutest drop of blood; and (3) because in the nu- merous vaccinations which in the course of seventy j-ears must have been done ac- cidentally from syphilitic children, blood must often have been invaccinated, and in many of the experimental vaccinations from syphilitic children blood was pur- posely mixed, and yet no syphilis had re- sulted. Now the cases which have been brought forward, whatever ground they may give for caution (and in a matter of such ex- treme consequence there can never be too much caution), do not appear to me to afford the strict proof requisite, or indeed anything like it ; on the contrary, each one of them is wanting in some essential point, or is open to some source of fallac}'. Either there was no evidence that the child said to have originated the syphilis was at any time sypliilitic ; or it was not shown that the alleged syphilitic vaccina- tion was not in fact a syphilitic inocula- tion instead of a vaccination ; or there was a possibility, and indeed a probability, that the lymph used had been mixed with the inoculable products of syphilis ; or there was reason to believe that the syph- ilis which developed itself after the Vaci- nation had an independent origin ; or the facts were inquired into at too great a dis- tance of time, and depended too much on the statements of ignorant persons to be wholly relied on. Thus, in the occurrences child, each infection should not within its own period of incubation produce its own spe- cific results ; and this is, in fact, by far the most probable explanation of one or two oc- currences in which there seems authentic evi- dence of vaccinia and sypliilis having been received at the same operation. (See Hand- book of Vaccination, pp. 317-18.) ' See particularly the observations made as regards some of these by Simon, op. cit. p. Ixvi. at Kivalta the circumstancss were not in- quired into till four months after their origin. it is not intended in this article to con- sider the alleged cases of vaccino-syplii- litic inoculation in detail. In none of them is the proof stronger than in the two to which I have already referred— the case of M. Trousseau at the Hotel Dieu, and the syphilitic endemic at Rivalta; it will be sufficient, therefore, to examine these. In M. Trousseau's case a young woman was revaccinatcd from a child, healthy at the time, and, so far as was known, continuing healthy, from which child four children received their primary Vaccination, went through it perfectly, and (certainly) had no subsequent syphi- litic affection. Only some small papules arose on the arm of the young woman, and the revaccination was considered to have failed. She remained in the hospital a month after the Vaccination, and after 'being out another month came back with two undoubtedly syphilitic sores on the arm on which she had been vaccinated. It was afterwards known, but not at the time, that she was a young woman of loose character. Now, assuredly no one who knows the extraordinary situations in which chancres have been met with, such as the cheek, the corner of the eye, all sorts of situations in which there was no suspicion of Vaccination, can say that there was no fallacy in this case, espe- cially when we consider, first, that there was not a shadow of proof adduced that the child from whom the lymph was taken ever had syphilis, and there was every presumption that it had not ; and secondly, the unusual length of the syph- ilitic incubation, supposing it dated from the time when the Vaccination was done. The syphilitic endemic at Eivalta was a very remarkable occurrence, and under any point of view is of the deepest inter- est. Four other such endemics, said to have occurred in 1814, 1821, 1841, and 1856 respectively, have been ascribed also to a vaccinal origin ; and not the least curious part of the matter is that all these should have occurred in Italy, and that none like them should have been met with in any other country. In their mode of communication, apart from the Vaccina- tion — for many persons were affected who were not at the time the subjects of Vac- cination — they bear a close resemblance to what we read of endemics of sibbens and other syphiloid diseases, recorded be- fore Vaccination was known ; not only was there communication of disease from babies to their nurses and from wives to their husbands, but children infected one another by the act of kissing, and we are even told that when poor people were crowded together i. confined and neglect- ed dwellings, whole families were affected. ALLEGED DANGERS OF VACCINATrON. 181 In the Kivalta endemic, the alleged vac- j cinal origin was made tlie subject of care- ful inquiry by a scientific commission. But unfortunately this inquiry did not take place till four months after the out- break ; and, as in no single case of the children said to have been syphilized by Vaccination had any application been , made to a medical man on account of the condition of the arm, facts and dates, re- quiring the closest and most accurate ob- servation, with careful record from day to day, had to be taken at that distance of time on the testimony of the parents and villagers. Under these circumstances we are not surprised that different con- clusions were arrived at ; and that though Dr. Pachiotti and the other commission- ers, after a most careful and painstaking inquiry, reported themselves satisfied of the vaccinal origin of the disease, Sperino, who also went to Eivalta and saw the cases, and treated some of them after- wards at Turin, was equally satisfied that this origin was altogether independent of the Vaccination. The story, as regards the vaccinal origin, is this : — A child (Chiabrera) apparently in good health, but really incubating syphilis, was vaccinated with some lymph obtain- ed in a tube ; this child's arm was used on the tenth day for the vaccination of 46 children, and one of these 46 children, named Manzone, again on the tenth day furnished lymph for vaccinating 17 chil- dren ; of these 63 children 46 had, within two months, a disease considered by the commission to have been syphilis, — the syphilitic symptoms having manifested themselves in some cases within ten days, and as a mean, at twenty days from the Vaccination. It need scarcely be pointed out how irreconcilable these dates are with all that we have been taught as to the incubation period of constitutional syphilis. But supposing this teaching to have been erroneous (and, unless it is, the Kivalta cases as connected with Vac- cination fall of themselves), and suppos- ing that it is possible to produce the pri- mary symptoms of constitutional syphilis within ten days of the inoculation of the poison, and that from Chiabrera's arm the whole mischief arose, there is still the question from what sort of vesicle on his arm was the lymph taken ? We have not only the higher authority of Ricord that the chancrous pustule, " initial lesion of the primary syphilic ulcer when it de- velops itself on the skin," has characters which may cause it to be confounded by careless persons with the vaccine pustule : but we know also that such a vesicle as may be produced by mixture of the mat- ter of soft chancre with vaccine virus, though according to the description given it would he impossible for any carefid person to confound it 'with the reyidar vaccine vesicle. has yet much of the vaccine character about it. Now of the vesicles on Chia- brera's arm we have no reliable account : nor of the vesicles on the arms of any of the other children, at the period of their so-called Vaccination. So far as we have details of the Vaccination, they are not such as to give us any confidence in the operation, and it is quite an open ques- tion whether the children were not care- lessly syphiUzed instead of being vacci- nated. ' When the cases were seen by Dr. Catt, or by tlieCommission of Inquiry, they presented either so many syphilitic sores, or cicatrices which, according to the de- scription given, had no vaccine character about them : and the revaccination of five of the children afterwards without effect (a revaccination which it is not stated was repeated) is far from being conclusive. In the 3'ears which have passed since these occurrences became the subject of discussion, attention in this country has been wide awake to find any that should be like them. None have been met with. On one occasion one of our ablest, as he is ' Mr. Simon informs us that in a child hav- ing latent syphilis he has known a clean incision, made in performing a trifling sur- gical operation, develop in a few days a syphilitic sore. I do not say that Chiabrera's arm had such a sore on it ; the state of his arm is the very thing regarding which we want evidence. Knowing the careless and miscellaneous way in which Vaccination has sometimes been carried on, and the ignorant hands into which its performance has some- times fallen, I am rather surprised that acci- dents have not more frequently occurred. It is only a few years ago that I was the means of stopping a druggist, who was rather an extensive vaccinator, from proceeding to vac- cinate some children from an open sore upon an arm which had nothing of vaccine charac- ter whatever about it, but which he assumed to be a vaccine sore, because he had vacci- nated the child a week before : and the de- tails of some of the Continental vaccinations in which accidents have occurred are truly astonishing. Further, the importance and necessity, in alleged cases of vaccino-syphili- tic inoculation, of having precise details, and of using care and reserve in the admission of statements, are well illustrated by the par- ticulars of a case often referred to in the dis- cussions in the Academic to show that syph- ilis had been implanted by a properly per- formed Vaccination. It is the case well known as that of " Le V^t^rinaire B." — in which 19 out of 24 persons revaccinated by him had afterwards signs of syphilis, the stuff with which all were vaccinated being, it was said, vaccine taken "sur un infant qui ^tait fort, et qui paraissait completement sain ;" but concerning whom, further inquiry elicited this important information, " On sut dejmis que I'^ruption vaccinale ne s'^tait pas fait regnliereraent chez lui, que le huitieme jour il n'y avait pas encore trace de boutons !" 182 GLANDERS. one of our most candid workers in syphilis, met with a case which he stated to the Medico-Chirurgical Society was one of sypliilitic infection communicated in vac- cinating, but it turned out that even his experienced judgment had been deceived, and that, as he "allowed subsequently, he had mistaken for a syphilitic sore a merely degenerated vaccine vesicle. Nor with aU his vast experience of syphilis has he to this day met with any case in which there was ground for believing that that disease had been communicated in vacci- nating. The real lesson which, as it appears to me, is derivable from the alleged cases of vaccino-syphilitic inoculation, is the ex- treme care with which A'accination should be conducted. We must not only be on our guard against any possible admixture of sjijhilitic matter with our vaccine lymph, either through the lancet or other- wise ; but we must be careful that our lymph itself is taken only from the heal- thiest children, from the most perfect and regular vesicles at the proper period of their course, and that it is pure unmixed vaccine lymph, free from the slightest stain of blood. We have no right to run a 1 1 lerely possible risk that can be avoided. GLANDERS— EQUINIA. By Arthur Gamgbe, M.D., and John Gamgee. DEFHTiTiosr. — A febrile disease, due to the introduction into the system of a spe- cific poison, originating in the horse, ass, or mule, and communicated directly or indirectly from them to man. It is usually ushered in by rigors, which are followed by articular pains, and great prostration. There is more or less affec- tion of the lymphatic vessels and glands, which inflame and suppurate. Ulcera- tions appear on the pituitary mucous membrane, from which there flows an aqueous or purulent discharge. A pustu- lar eruption often occurs on the surface of the skin, which in parts becomes affected with inflammation of erysipelatous cha- racter. Abscesses form in the subcutane- ous cellular tissue. The disease is usually fatal. Nomenclature and History. — ITn- the name of Mrx^^ Aristotle' described a disease atfecting the ass. which was prob- ably identical with the "malleus" or "morbus humidus" which an early writer on veterinary medicine, Yegetius, subse- quently described as aflfecting the horse," and with the disease to which, from an early period, the name of Glanders has been applied by English writers. The term Glanders includes several affections, which, undoubtedly due to the same spe- cific virus, must be looked upon as mere varieties of one disease, but which, differ- ing very remarkably in character, were ' Aristotle, Dtf Hist. Anim. lib. viii. cap. XXV, for a long period of time considered to be altogether distinct. Vegetius, and the authors who followed him, described under the term Malleus humidus. Morbus humidus,' Cymoira,* Cimoria,^ Capitis morbus, that variety to which the term Glanders has been re- stricted by Enghsb writers — to an affec- tion of horses which is characterized by ulcerations of the Schneiderian mucous membrane, accompaaied by a discharge from its surface, and by enlargement and induration of the submaxillary glands ; which may run a long or short course, and which may be, but often is not, ac- companied by marked constitutional symp- toms. They described in addition, under the terms Morbus farciminosus,'' Verniis equi,^ Vermis volativus,* Farcina equi,' Turtac, cutis equorum,* Glandulse et scro- phulEe equi,' an affection which has now been proved to be merely a variety of the one described, and of which the striking and characteristic feature is the formation of abscesses and swellings in the course of ' Vegetii Eenatl Artis Veterinarise, sive MulomedicinEe, libri quatuor, &c., lib. i. c. vii. 2 Laurentins Rusius, o. Ixxi. p. 72, quoted by Hensinger. " .Jordanus Ruffns, c. xvi. p. 48, quoted by Heusinger. ' Vegetius, op. cit. lib. i. c. iii. ^ .Jordanus Ruffus, c. i. p. 23. 5 Ibid. 0. ii. p. 27. ' Albertus Magnus, p. 92. 8 Ibid. p. 589.' ' De Cresceutiis, lib. x. o. xii. p. 275. VARIETIES. 183 the lymphatic vessels and glands, and of small tumors beneath the skin, and which is unaccompanied by any affection of the Schneiderian membrane. This, which for a long period of time was looked upon as altogether a distinct disease from Glan- ders, received, in Englisli, the name of Farcy, and will in the following pages be described as one of tlie important forms or varieties of Glanders. As Glanders is a disease which always originates in the horse and ass, never oc- curring in man except wh(!n communicat- ed, directly or indirectly from them, and the nomenclature of the disease in man having been borrowed, to a great extent, from that previously in use among veteri- nary writers, its complete history, in the first place, necessitates an account of the mode in which it originates in the lower animals, and of the forms which it pre- sents in them. Glanders and its Varieties in the Horse, Ass, and Mule. — This disease appears to affect the horse in all parts of the world, although perhaps it is modified to a certain extent by climatic and other agencies. In the deserts of Arabia it is said not to possess the dreadful characters which distinguish it elsewhere, and is a comparatively rare disease. It may occur under four forms, as, 1st, Chronic Glan- ders ; 2d, Acute Glanders ; 3d, Chronic Farcy ; 4th, Acute Farcy. Chronic Glanders is the most com- mon form affecting the horse. It is pro- pagated by contagion and infection (?). It never occurs as a termination of acute Glanders. Its period of incubation is un- certain, and has been stated to vary from a few days to a year {?). Synonyms.— Morvechronique,French; Chronischer Botz, German ; Ciamorro cronico, Morva cronica, Italian. Seiieiology. — The general health is little, if at all, affected. There is swelling and hardening of the submaxillary lym- phatic glands. A discharge occurs from one or both nostrils, generally from one only (usually the left), which is at first of watery consistence, becoming more gluey, purulent, sanious, and fetid. Ele- vations and ulcerations occur on the Schneiderian mucous membrane. A horse thus affected often appears to be in perfect health. When placed under un- favorable circumstances, especially if fed scantily, symptoms of acute Glanders rapidly make their appearance, and death then soon inevitably follows. Morbid Anatomy. — The mucous membrane lining the cavities of the nose and sinuses, presents small white eleva- tions, varying in size from a small to a large pin's head, and larger patches of a yellowish-white color, having a smooth surface. These elevations and patches soften in the centre, and then present tlie appearance of excavated ulcers. The ulcerations sometimes, though not usually, implicate the whole thickness of the mu- cous membrane, and affect the bones ; perforation of the septum narium, and of the nasal bones, sometimes occurring. The mucous membrane of the larynx, trachea, and Ijronchi, presents at an early stage of the disease, little white elevations, resembling the cicatrices of leech bites ; these afterwards coalesce, become in- jected, and ulcerate, giving rise to exca- vated ulcers, of a deep-red color. ' The lungs contain small fibrinous de- posits, varying in size from a pin's head to that of a grain of flax, around which the pulmonary texture presents quite a healthy appearance. Larger masses, of a bluish-white, lardaceous, or gelatiniform appearance, which sometimes are of the size of a hen's egg, are also observed. A condition of lobular pneumonia has been described to exist in certain cases. Al- though veterinarians have spoken of these alterations in the lung as tubercular, there is no ground for the opinion, as the re- searches of Bayer, 2 Tardieu,^ and Trous- seau* have proved. Acute Glanders occurs more rarely in the horse than the chronic form, of which, as of acute and chronic Farcy, it is a frequent termination. In the ass and mule it is the common form of the disease. Synonyms. — Morve aigue, French ; Acuter Kotz, German ; Ciamorro acuto, Morva acuta, Italian. Like the chronic, the acute form of Glanders is an intensely contagious dis- ease. The period of incubation is uncer- tain. It has been stated to be only from three to five days,^ although it is undoubt- edly longer in certain cases. Semeiology. — The disease sets in sud- denly, a short time (afew days) after ex- posure to contagion, with symptoms of inflammatory fever. The respirations are hurried. A copious yellow, purulent, or sanious discharge flows from the nostrils. There is watering of the eyes. Sometimes an eruption of small cutaneous, or subcu- taneous, tumors occurs. Then super- venes violent inflammation of the pitui- ' Tardieu, De la Morve et du Farcin chro- niques chez I'Homme et les Solipedes. Paris, 1843. P. 36. 2 Rayer, De la Morve et du Farcin chez I'Homme. MSm. de I'Acad. R. de Med. Tome sixieme, pp. 828-833. 3 Tardieu, op. cit. p. 41. * Trousseau, Recherches Anat. et Pathol, faites a Montfaucon. 6 Hering, Specielle Pathologie undTherapie fur Thierarzte. Stuttgart, 1S58. P. 98. 184 GLANDEKS. tary mcmln'anG, whinh becomes deeply and exti-eniL'ly ulcerated. Coufih and shortness of breathing occur. Death in- variably follows. Morbid Axatomy. — The mucous membrane, lining the nares and frontal sinuses, is found acutely inflamed, and generally presents a pustular eruption, which is bathed in a purulent fluid, if the disease lasts for some time, ulcers form, which are either small and round, or large and irregular ; in the latter case having been formed by the ulceration of several confluent pustules. The ulcers are excavated, often appearing as if cvit with a punch. The lungs are almost con- stantly the seat of limited pneumonia, and frequently purulent deposits are formed in them. Petechise occur on the surface of the pleura, pericardium, and peritoneum. In certain cases (morve aigue, heraorrhagique et gangreneuse, Rayer) petechia) and large ecchymoses are noticed, after death, on the pituitary membrane. In these cases the mucous membrane is generally, over some part of its extent, destroyed, softened, and ex- hales a gangrenous odor. Chronic FAKCy is, like the other forms of Glanders, highly contagious. It may be produced by the inoculation of the altered secretions of farcied or glandered horses. Syxomyms. — Farcin chronique, French; Ch. Hautwurm,"SVurm, German ; Farcino, Italian. Semeiology. — The disease usually commences by an indolent inflammation of the lymphatic vessels and glands, which become red, tender, and acquire a large size ; the swellings occurring chiefly in the situation of the valves of the lymph- atics (farcy-buds). An eruption of small subcutaneous and cutaneous tumors occurs. The large glands and cutaneous swellings have a tendency to suppurate, and indolent ulcers result from the opening of the abscesses ; these secrete an ichorous dis- charge, capable of producing Farcy, or Glanders, or both. The general health may continue good for a long period of time, the disease remaining stationary. If the animal be not destroyed, symptoms of general constitutional disturbance supervene. The animal loses flesh, has a staring coat, coughs, and usually falls a victim to acute or chronic Glanders. Morbid Anatomy. — Structural altera- tions of lungs and other organs, as in Glanders. Induration and swelling of the lymphatics. Acute Farcy is distinguished from chronic Farcy by the rapidity of its course, the urgency of the constitutional symp- toms, and by its being almost invariably associated with acute or chronic Glanders. The chief anatomical difference between the two forms is the occurrence, in the acute, of truly cutaneous abscesses or boils. Acute Farcy proves invariably fatal. Morbid Anatomy. — The same as that of Glanders and chronic Farcy. Having descriljed briefly the essential characters of the difi'erent varieties of Glanders, as they occur in the horse, ass, and mule, before proceeding to the con- sideration of the history of the disease as it att'ects man, it will be well to state shortly what appears to have been defi- nitely made out, by veterinarians, as to the nature of the disease, the relations which exist between its various forms, and the mode in which it is transmitted. It has been satisfactorily proved — 1st. That the dift'erent forms of Glan- ders are due to, or are associated with, the formation of a specific virus, which exists in the blood and secretions of ani- mals affected with it. The virus is readily absorbed by an excoriated or wounded surface, or when matters containing it are injected into the blood. It is likewise probably absorbed by the unbroken sur- face of mucous membranes. In one or other of its forms the disease may almost certainly be induced by intro- ducing beneath the skin of a healthy ani- mal, the nasal mucus of a glandered horse, or the purulent or ichorous dis- charge which flows from the ulcerated swellings of Farcy. It may be induced by injecting into the circulation of a healthy animal, the blood of one suffering from Glanders. ' The mucous membrane of the alimentary canal appears to be ca- pable of absorbing the virus under certain circumstances.^ There is reason to be- lieve, however, either that gastric diges- tion is capable of destroying the virus, or that it may pass through the alimentary canal without injurious consequences re- sulting, provided the mucous surface be not abraded.* 2d. The virus of glanders and farcy is identical. The same pus may, if intro- duced into the system of one horse, pro- duce acute glanders ; into that of a sec- ond, farcy ; into that of a third, chronic glanders. On certain points the opinions of veteri- nary writers have been much divided. The chief subjects of dispute are, (1) the possibility of the disease originating spon- ' Travers, An Inquiry concerning that dis- turbed State of the Vital Functions usually denominated Constitutional Irritation. Lon- don, 1826. Vol. i. p. 355. 2 Sainbel, Vial de St., Experiments and Observations on Glandered Horses, p. 109. 3 Parent Dvicliatelet, Hygiene Publiiiue, torae xi. p. 194. HISTORY OF THE DISEASE IN MAN. 185 taneously ; (2) the mode of its transmis- sion ; whetlier always by contagion, or by contagion and inlection. Tlie intensely contagious nature of the disease is admitted at the present day by all writers ; nearly all, however, admit- ting the possibility of the disease origi- nating spontaneously. An impure and confined atmosphere, excessive work, and insufficient food, are the chief causes which have been alleged to induce it. That these circumstances favor its spread, cannot be doubted ; that they act as most powerful predisposing causes, to this as to other diseases, has been unequivocally proved, by the ravages which Glanders has so often caused amongst the horses of armies subjected to famine and other in- jurious influences. French writers have all very strenuously maintained the possi- bility of the spontaneous origin of Glan- ders, a position which was strongly held by our countryman. Professor Coleman, who certainly has been one of the chief contributors to our knowledge of this dis- ease. It was alleged, in an important discussion on this matter in the French Academy of Medicine, in 1861,' that at a period when the fortifications of Paris were being constructed, the horses of the poor and small contractors were found to suffer to a great extent from Glanders, whilst those belonging to the wealthier contractors escaped the disease. Those who adduced these facts attributed the occurrence of the disease, in the former case, to the insufficient nourishment and the harder work which the animals be- longing to the poorer contractors received, whilst they appear to be susceptible of a very different and much more likely ex- planation. The laws which exist in France for preventing the use of glan- dered horses have been inefficiently car- ried into execution, glandered horses being by some people systematically employed ; these horses are necessarily very much cheaper than sound ones, and would be more likely to be bought by the poor, than by the rich contractor. In our own country Glanders was, at one time, a most prevalent disease, which created the great- est ravages. Glandered horses were sys- tematically sold and worked. The prac- tice caused the greatest pecuniary loss to the country at large, for one case of Glan- ders having been introduced into a stable, the chances were considerable that a ma- jority of the horses in it would sooner or later die of the disease. To remedy this state of matters a most stringent law was passed, which prevented the working of glandered horses. Carried into execution with great rigor, this law has had the ef- fect of rendering Glanders, in aU its forms, ' Recueil de M^deoine V^t^r., Aout 1861, p. 645. a very rare disease in this country. Thou- sands of horses are exposed to those causes which are supposed to give rise to Glan- ders ; are hard worked, ill-fed, and kept in badly-ventilated stables, in the same way as horses used to be a century ago, but yet Glanders does not originate. Glan- ders has now almost ceased to affect the horses of our army, and the sporadic cases which very rarely occur need cause no astonishment when we remember that the disease is one which still prevails to a certain extent, especially in Ireland, whence most of our cavalry horses are obtained, and that the disease may have a long period of incubation. The history of Glanders amongst the lower animals in this country leads us to form the opinion that it never originates spontaneously in our climate. We must fully admit, how- ever, as we have already done, that bad feeding, bad ventilation, and excessive work are powerful predisposing causes of this disease, and to a great extent explain the ravages which it has often caused amongst the horses of armies, which in time of war, from the large and indis- criminate purchases of horses that must necessarily be made, contain abundantly the germs of the disease. Whether actual contact of some article, containing the virus, with a mucous mem- brane, or a broken cutaneous surface, be required to induce the disease, or whether its germs may be communicated through the atmosphere — whether, in short, Glan- ders is always communicated by conta- gion, using the term in its more limited sense, or by contagion and infection, has been warmly argued by various writers. Probably in nearly every case actual con- tact of glandered matter with an absorb- ing surface does take place. The mucus flowing from the nose of the glandered horse becomes attached to the stable and the stable utensils, and comes almost ne- cessarily in contact with the water, hay, and straw, which horses in the same sta- ble employ, so that they are frequently exposed to conditions positively known to be capable of inducing the disease. Some cases have, however, been re- corded which cannot well be explained on the hypothesis of actual contact, and we therefort do not deny the possibility of Glanders being transmitted from one lower animal to another through the medium of the atmosphere, although we believe this to occur, if at all, only very rarely. History of the Disease iit Man. — No connection had been traced between the terrible diseases in the lower animals which have been briefly described, and an affection which then as now must have occasionally affected those who had charge of horses suffering from Glanders and Farcy, until the year 1810 when Waldin- 188 GLANDERS. ger' drew .attention to tKe fact that special precautions ought to be adopted in the dissection of horses affected with Glan- ders and Farcy, inasmuch as the direst consequences, even death, might result from the inoculation of the purulent mat- ter. The accuracy of the statements of Wadlinger was supported by the publica- tion, in 1812, of a paper by a French mili- tary surgeon, Lorin, who, under the title "Observations sur la Communication du Farcin aux Hommes," described the case of a veterinary surgeon who, having acci- dentally pricked himself whilst operating upon a glandered horse, suffered in conse- quence from inflammation of the hand.'' The statements of Waldinger do not, how- ever, entitle him to be considered the first person who pointed out that Glanders is communicable from the lower animals to man ; for although he stated that dan- gerous consequences might result from the inoculation of the purulent matter of Glanders and Farcy, he did not state that the affection induced in man in any way resembled that of the horse. Again, the observation of Lorin was of the most un- satisfactory description, for the case which he describes does not differ materially from many cases of dissection wounds, and possessed, in no respects, the pecu- liarities of Farcy. Schilling, however, published in 1821,' under the title "Merk- wiirdige Krankheit und Sections Ge- schichte einer wahrscheinlich durch ueber- tragung eines thierischen Giftes erzeugten Brandrose," the case of a man who, hav- ing washed out the nares of a glandered horse, became affected with a pustular eruption on the skin, an offensive dis- charge from the nostrils and erysii^elatous inflammation of the face, and who died after an illness of eight days. Rust looked upon this as a case of Glanders in man, and in support of this view gave the notes of another case of a similar nature. Both these were indeed most typical cases, and must be considered to be the first well- marked cases of Glanders occurring in man which were published. In the same year that Schilling's and Rusts cases were puijlished, there appeared in the Edln- hurgli MedicMl Journal^ a short notice copied from a subscription papc in the Hotel Coftce-house, Leeds. Tnis short notice (of nine lines) was signed by T. Muscroft, surgeon, Pontefract, and con- sisted in an appeal on behalf of the family of the dog-feeder of the hounds belonging to the Badsworth Hunt, who, in cutting up the carcase of a horse which had died ' Waldinger, Wahrnehmungen in Pferden. 2te Aufl. Wien, 1810. 2 Journ.de MM. Chir.etPliarm.,F6v. 1812. ' Rust's Magazine, vol. i. p. 480. * Edin. Med. and Surg. Journ., vol. xviii. p. 321. of Glanders, had accidentally wounded his hand. " In a few days he betrayed all the symptoms which are at first shown in the horses beginning in the above dis- ease. He gradually became worse, and at the end of the week he died raving mad, laboring under a confirmed complaint of Glanders." Feeling considerably interested in read- ing this notice, I wrote to Henry Mus- croft, Esq., surgeon, of Pontefract, asking if the notice which had appeared in tlie Edinburgh Journal in 1821 had been written by a relative of his, and request- ing to be put in possession of any infor- mation he might possess on the matter. Mr. Muscroft informed me in reply that the notice had been signed by his father, who at that time was practising in Ponte- fract, and added that he had never heard anything about the case. Stimulated by my questions, Mr. Muscroft, however, in- stituted inquiries, which ended in his dis- covery of the widow of the unfortunate man. The old woman is now eighty-six years of age ; she was, however, able to give a very complete account of her hus- band's illness. This account was written down verbatim by Mr. Muscroft, who has sent it to me. Information obtained from otlier sources proves that the dates men- tioned in this statement are perfectly cor- rect. Mr. Muscroft's pay-book, on being referred to, shows that he attended John Turpin from March 18, 1821, to March 27 ; and the parish register of deaths con- tains an entry to the effect that John Tur- pin died on the 2i)th March. The state- ment of the old woman is interesting, as referring to the first case of Glanders, which appears to have been recognized as such, in this country. Statement of Sarah Hazelgrave {fornurly TurjAn), aged eighty-six years. My first husband, John Turpin, whilst skinning a dead horse, in the month of March, 1821, cut the third finger of the left hand, and, heeding but little this ac- cident, on the following day he left me for a week, to fetch home to the Badsworth 's kennels some young hounds that had been reared in the neighborhood of York. On his arrival at home, he was very weak and scarcely able to walk, and he at once said that "he should never go out again, he was so ill." He complained of severe pain in the head, and there was profuse discharge from the nostrils ; and on different parts of his body there were a number of blisters of different sizes, which, after a time, became blue. Mr. Muscroft was sent for, and after he had been at my husband's bedside for some time, he said, he was " afraid Tur- pin was inoculated by the blood of the HISTORY OF THE DISEASE IN MAN. 187 dead horse ho had cut up, and that there was no remedy, the disease being horse- farcy, or glanders, but tl\at, if tlie finger had been taken off at first, this might not have happened." Mr. Muscroft gave liim medicines, and saw him daily until his death, which took place ten days after he returned from York. He retained consciousness to the last. Large lumps appeared on his fore- head and face, and his throat was swelled. His head and face became very large. The wound of his finger was very bad, and the finger looked as if it would rot off, and from the wound there were hard cords, like the stem of a pipe, up the arm, and the armpit also swelled. The smell was very bad. il/-iy 18, 1865. Before the publication of the cases of Schilling and Bust, and before the notice referred to appeared in the Edinburgh ilKlical Journal, certain cases of trans- mission of Glanders from horses to man had been observed in London, which, although not published until some years later, received at the time a thorough in- vestigation — a study which first and satis- factorily proved that the virus of Glanders is transmissible from horses to man, and generates in him affections which, although slightly different in some of their charac- ters, are identical with the disease as it is observed in the horse. These observations were first published by Mr. Travcrs, at page 350 of the first volume of his work on "constitutional irritation.'" The first and most interesting of these cases oc- curred in the year 1817, and was that of Mr. William Turner, a veterinary student, who injured his finger in examining the head of a horse which had died of Glan- ders. An ulcer followed with inflamma- tion of the absorbents and cellular tissue of the hand, and symptomatic fevor. After some days an abscess formed in the opposite arm, and another in the lower part of the back. Matter taken from the abscess of the arm was sent to Mr. Cole- man, who inoculated an ass with it and produced fatal Glanders. Mr. Turner's health was seriously affected. He became hectic, and was sent to Brighton for the benefit of sailing and tepid bathing. Sub- sequently an abscess formed in his lungs, another in his kidney, and after his return to his residence at Croydon, at the expira- tion of several months, abscesses formed successively upon each knee-joint. Trom the last, matter was taken for the purpose of iaoculating an ass, which in eleven ' An Inquiry concerning that disordered State of the Vital Functions, usually denomi- nated Constitutional Irritation, by Benj. Travers. London, 1826. days died glandered. Shortly after this, jMr. Turner's long and painful illness terminated in death. The third case, re- corded l3y Mr. Travers, that of Nimrod Lambert, is however of greatest import- ance. ]Sr. L., a healthy hackney coach- man, fct. 32, in January 1822, infected a chap on the inside of the right thumb, by inserting it into the nostril of a glandered horse, to pull off a scab. He was taken suddenly ill three days after, and suft'ered subsequently from inflammation of the lymphatic vessels and glands of the arm, which suppurated and ulcerated. "The glands at either angle of the lower jaw, and in the groin, became swollen, and he was much alilicted with pain between the eyes and do-wn the nose, and ulcerations of the membrana narium, attended with discharge." After a long and painful ill- ness the man recovered, altliough his con- stitution appears to have been violently affected and permanently injured by it. An ass, inoculated with the matter from this man's sores by Mr. Sewell, died of Glanders. The great interest attaching to Lambert's case rests in the fact that it is the first well-marhed case of Glanders occurring in man in which the diagnosis was rendered perfectly certain by the in- oculation of animals with the purulent matter. Mr. Turner's case, on the other hand, was by no means a well- marked instance of chronic Farcy, but is valuable as being the first case which proved that in its passage through the human body, the virus of Glanders loses none of its properties, and is again able to generate the disease in lower animals. \Vith these cases Mr. Travers published a letter from Professor Coleman, in which that gentleman described the experiments which he had made with the pus obtained from Mr. Turner's abscess. In this letter Mr, Coleman stated the result of a most interesting experiment, in which he suc- ceeded in'inducing Glanders, "by remov- ing the healtliy blood from an ass, until the animal was nearly exhausted, and then transferring from a glandered horse blood from the carotid artery into the jugular vein. " (Op. cit. page 3"5.) Al- though Mr. Travers published these cases, he does not appear to have considered the disease induced in Mr. Turner and Lambert, to have been glanders. "The reader," saj'S Mr. Travers, "cannot fad to perceive some points of analogy be- tween the effects produced by the absorp- tion of glandered matter, and of the fluids of the human body after death. I think there can be no difficulty in admittmg m either of these cases that a poison was imbibed, but the evidence gives no ground for the conclusion that it was a morbid poison, as regards its operation^ in the human subject." (Op. cit. p. 3(35.) 188 GLANDERS. Grubb,' Kricg,^ and Brown' described after this several interesting eases of Glanders transmitted from tlie horse to man. It was, however, by the publica- tion of a memoir entitled " On the Glan- ders in the Human Subject,"'' that Dr. Ehiotson attracted the attention of the profession to this subject. In this paper he gave the history of two interesting cases of Acute Glanders, which had been observed by Dr. Roots and himself, and of a third which had been communicated to him by Mr. Parrott, of Clapham, and he collected nearly all the observations which had, up to that date, been placed on record. In a second memoir/ entitled " Additional Facts respecting Glanders in the Human Subject," Dr. Elliotson gave an account of another case of acute Glan- ders which had fallen under his notice. Subsequently to the date of Dr. EUiotson's papers, several cases of Glanders were published in various journals. No very valuable addition to the knowdedge of tlie subject was however made until the year 18.'i7, when Rayer, in a splendid memoir, entitled " De la Morve et du Farcin chez I'Homme, "^ gave an account of all the cases of Glanders which had been observed up to that date, and gave an original and complete description of the different forms of Glanders both in the horse and in man. The subject of Chronic Glanders and Far- cy ■was afterwards made the .subject of special investigation by Tardieu, who, in a memoir entitled "De la Morve et du Farcin chroniques,"' supplemented the knowledge which Rayer had already col- lected on these subjects. It is to the re- searches of these distinguished physicians that we owe almost the whole of our knowledge of the morbid anatomy of the various forms of Glanders. Since the date of the publication of these memoirs, many cases of Glanders possessed of groat interest have been re- corded: no very important addition to the existing knowledge of the disease has, however, been made. Etiology of the Disease i>r ]).lA>r. — This section of our sulije-jt has been al- ready so fully treated of in discussing the subject of Glanders affecting the horse, that it here needs but a very brief consid- eration. Always communicated from the horse, ' Diss, sistens casum singiilarem morbi con- tagio mallei Immidi iu hominem translate orti. Berolin, 1829. 2 De Typho malloldo. Berolin, 1829. ' London Medical (Jazi-tto, vol. Iv. p. 134. * Med.-Chir. Trans., vol. xvi., 1830. 5 Ibid., vol. xviii., 1S33. " Mem. de 1' Academic do Mcdeciue, vol. vi. p. C)'2'i. ' Paris, 1843. the ass, or the mule to man, those are specially predisposed to contract the dis- ease whose avocations lead them to come in contact with these animals. The great majority of the cases recorded have oc- curred amongst veterinary surgeons, vet- erinary students, grooms, coachmen, cav- alry soldiers, horse - slaughterers, &c, ^Vriters on Glanders in man have admit- ted that, although the disease is often or generally due to inoculation of morbid matters from glandered horses, it may be occasionally communicated to man by in- fection. It has been stated, in support of this view, that a frequent cause of Glan- ders and Farcy is the custom of causing men to sleep in stables. Those who hold the above view seem to forget that these men, besides sleeping in the stables, are, from the very nature of their duties, ex- posed to the greatest danger of contract- ing, hy inoculation. Glanders from any af- fected horse which may be placed under their charge. If facts are very scanty to support the belief that Glanders is propa- gated from horse to horse by infection, they assuredly are still more so in the case of man. In the immense majority of cases of Glanders in man which have oc- curred, there is the most conclusive evi- dence that the sufferers were in constant habit of handling glandered horses, whilst in a considerable number of cases there has been actual evidence of the disease having been transmitted by inoculation. To explain, as due to infection (using the term in its more limited sense), the cases which have occurred in which no history of inoculation through a wound is to be obtained, appears to the writer altogether unjustifiable, when regard is had to the facts that the virus of Glanders, besides being capable of being absorbed by the most trifling cutaneous abrasion, is prob- ably absorbed by unbroken mucous mem- brane, and that of the very large number of persons who formerly used to be brought in contact with glandered horses, only an excessively small fraction con- tracted the disease, although a large num- ber of these people were most careless and imprudent in their treatment of glan- dered horses. It may, we think, be safely stated that Glanders is only communi- cable from the lower animals to man by inoculation. The virus of Glanders may adhere to stable utensils, clothes, and other articles, for a long period of time, and then when brought in contact with an absorbing sur- face may give rise to the disease. Not only can the disease be ti-ansmitted from the horse, ass, or mule to man, but likewise from one human being to another. Several facts have placed this beyond dis- pute. A distinguished young French veterinarian, il. Gerard, died of Acute Glanders induced by a wound which he SEMEIOLOGY. 189 inflicted on himself wliilst mailing the post-mortem examination of a vetei-inary student who had died of Glanders. ' El- liotson,^ in describing a case of Glanders, mentions that the laundress who washed the clothes of the patient, contracted Glanders. An externe of a Paris hospital died from Acute Glanders contracted I'rom a stableman suffering from Glanders.' In this case, besides dressing the wounds of the patient, the externe had taken an ac- tive part in the examination of the body after death. Although usually contact of the virus of Glanders with an absorbing surface gives rise to the disease, this does not mvariably follow. It has been erroneously stated that a weak state of the constitution, intempe- rate and irregular habits, predispose indi- viduals to attacks of Glanders. What- ever influence they may have on its pro- gress and issue, there is absolutely no proof that they exert any influence in the way mentioned. It has, indeed, been cor- rectly remarked, that a large majority of the recorded cases of Glanders have oc- curred in men of robust constitutions, and in the prime of hfe. Semeiologt. — We shall consider sepa- rately the semeiology of the four varieties of Glanders which are observed in man as in the horse. Acute Glanders occurs in man more fre- quently than the other forms of the dis- ease, and presents in him characters re- sembling those of cases in the horse in which Acute Glanders and Farcy are combined. The period of incubation of Acute Glanders varies probably from twenty-four hours to a fortnight ; its limits, in the majority of cases, being from three to eight days. The mode of invasion of the disease va- ries considerably. In those cases where a distinct wound exists, through which the virus has been introduced, redness, pain, and tension, accompanied by an erysipelatous appearance around the wound, and swelling of the lymphatics, are often noticed before the supervention of any constitutional symptoms. Occa- sionally no wound can be discovered, or the wound through which the virus was introduced may remain in a passive con- dition. Whether local symptoms have been developed or not, the disease is usu- ally ushered in by feelings of lassitude, headache, and rigors, frequency of the pulse, and often by vomiting and diar- rhoea. Articular and muscular pains oc- ' Bresohet, Revue M6.1., tome ii. p. 96, 1820. = Elliotson, Lancet, 1838. ' Tardieu, op. cit. pp. 140, 141 ; and Be- rard, Bull, de I'Acad. de M61., Nov. 1 84) , tome vii. p. 182. cur from an early period of the disease, and increase during its progress. The limbs and body become the seat of subcu- taneous abscesses, which are specially found on the face, and near the articula- tions. Over the abscesses the skin be- comes of a red and violet color, and some- times limited gangrene sets in. The pus which forms in the abscesses is serous and fetid. A remarkable pustular eruption generally appears on the surface of the body, being specially found on the cheeks, arms, and thighs. The pustules com- mence as little red spots, which after- wards present the appearance of white papules, and become full of pus; they are often surrounded by a red areola. The pustules vary greatly in size, presenting a flattened or pointed surface, and either occur singly or so closely aggregated as to be almost confluent. The pustules are often accompanied by bullae of a dark color, on the face, trunk, and organs of generation. An erysipelatous inflamma- tion of the nose, eyes, and neighboring parts of the face, sometimes extending to the scalp, is far from infrequent. The cutaneous eruption, which has been de- scribed, has been compared to that of varicella, variola, ecthyma, and yaws, but is considered by all the best writers on Glanders to be quite distinct and charac- teristic. (Bayer.) Amongst the most con- stant and pathognomonic of all the symp- toms of Glanders, is however one -n-hich has been noticed in the large majority of the recorded cases. A yellow, viscous, purulent discharge, often mixed with blood, and not infrequently possessed of great fetor, exudes from the nares. This proceeds from the Schneiderian mem- brane, which is invariably the seat of a pustular eruption, or of ulcerations. The mucous membrane of the mouth is sometimes likewise the seat of ulcerations or pustules, and from it, in certain cases, a purulent fluid has been observed to ex- ude. The submaxillary lymphatic glands are usually not enlarged. The prostration, which has been stated to usher in the disease, increases during its progress. The pulse becomes exces- sively frequent, small, and compressible. The voice is feeble, and the breath fetid. The constipation, which frequently exists at the commencement of the disease, is replaced by diarrhcea ; the stools are ex- tremely fetid. A hard, dry cough, ac- companied by a little expectoration, and often by diflftculty of breathing, testify to the existence in man, as in the horse, of pulmonary complications. With the in- creasing prostration, delirium sets in, which is followed by coma, and ultimately by death. The duration of the disease has varied from three to fifty-nine days. As a rule, death has occurred about the end of the second or connnencement of 190 GLAXDEllS. the third week. Acute Glanders runs an unusually rapid course when it occurs as a sequela of the other and more chronic forms of the disease. Chronic Glanders is the rarest form of the disease in man. "When it occurs, it is usually as a sequela of Farcy. Uncom- plicated by Farcy, the disease has but seldom been observed. "When Chronic Glanders occurs primarily (i. e. not as a sequela of Farcy), it commences with las- situde and very severe articular pains, A\-hicli readily pass away, and are followed by a cough, sore throat, and a disagreea- ble feeliug in the nose. "\\'htu Farcy has existed before the ap- pearance of Chronic Glanders, no lassi- tude or pains may be noticed. In these cases, the first symptoms are the sore throat, cough, and aifcction of the nose, which have been alluded to. A pain is then felt in the trachea, the voice becomes altered in character, or true aphonia may occur. The cough is accompanied by dyspnoea, and often by expectoration. Capillary bronchitis and pneumonia some- times supervene. The disagreeable sen- sations in the nose increase — the patient complaining of a feeling of its being stojjped up ; sometimes, although by no means always, there is a dull acliing pain at the root of the nose. On blowing the nose, a puriform mucus, mixed with little bloodclots, becomes detached, or there may be a regular discharge {jctage) from the nose. On examining the nares at this stage, ulcerations may not infrequently be perceived on the Schneiderian mem- brane. By the introduction of a probe, inequalities of the surface, and even per- foration, of the septum narium, may be detected. Ulcerations may sometimes be likewise observed in the pharynx. There is very rarely any induration of the submaxillary glands. The skin is free from eruption. In addition to the special phenomena which have been described, the patient is usually prostrated, suffers from articular and muscular pains, diarrhoea, and nausea, loses flesh, and falls into a state of maras- mus, lie may die of simple exhaustion, or jVcute Glanders may set in and rapidly close the scene. This form of Glanders has been once observed to terminate in recovery (case of Ximrod Lambert). Its duration is excessivel}^ various ; those cases which are complicated with Farcy proving more rapidly fatal than others. As a general rule, the course of the dis- ease extends over several mouths, and cases have been recorded where it appears to have lasted for some years. Anite Farcij presents, almost constantly, all the characters which have been de- scribed as those of Acute Glanders, with the single exception that there is a total absence of afleciiou of, or discharge from, the nares. So great is the resemblance between the two afll-ctions, that only cer- tain special points in connection with Acute Farcy need be alluded to. X sub- division of all cases of Acute Farcy may be made, into cases accompanied by a cu- taneous eruption, and cases unaccom- panied by eruption. In some cases of Acute Farcy, there is merely an inflam- mation of the lymphatic vessels and glands, accompanied with the fomiation of soft subcutaneous tumors in various parts of the body. In other, and by far the greater number of cases, an eruption, exactly similar to that of Acute Glanders, occurs, such cases being distinguished from instances of the latter disease only by the absence of affection of the nose. These cases are very much more serious than those without eruption, and follow exactly the same course as Acute Glan- der.'-, proving fatal usually between the thirteenth and nineteenth day. (Eayer, op. cit. p. 787., In the cases where there is no eruption, and which have received the special name of cases of acute far- cinous angeioleucitis, the disease very fre- quently terminates in recovery, or passes into Chronic Farcy. Chronic Farcy may exist alone, or asso- ciated with Chronic Glanders. It is ush- ered in by lassitude, wandering pains, uneasiness, anorexia, accompanied by fever, which often assumes a tertain type. An abscess usually forms on the forehead, the calves of the legs, or some other part of the body, which is followed by other indolent and fluctuating tumors. Some of these open spontaneously, and give exit to blood, or ill-conditioned pus. The lym- phatic glands only secondarily, and to a slight extent, become affected. "With the successive appearance of abscesses, the general health and strength of the patient decline ; he loses flesh ; the skin becomes dry, and earthy ; the countenance yellow and livid. Frequent rigors occur. The open abscesses become converted into hor- rible ulcers, which have no tendency to heal. A dry cough harasses the patient, who, with his body covered with foul ul- cers, falls into a condition of most miser- able marasmus. The course of the disease is tedious and uncertain. The abscesses commence to form from the third to the fifteenth day of the disease. The subse- quent stage is, however, most protracted and uncertain in its issue. It may termi- nate by an attack of Acute Glanders, or of Chronic Glanders, or the patient may die of exhaustion, or from an attack of pyaemia. Lastly, recovery may occur. The duration of the recorded cases of Chronic Farcy has varied from four months to three years ; it usually tcrmi- DIAGNOSIS M.OHBID ANATOMY. 191 nates in from ten to fifteen months. Of twenty-two cases of the disease, cited by Tardieu, six recovered.' Diagnosis. — Having described tlie clia- racters of the different varieties of Glan- ders, there remains for consideration their differential diagnosis. Acute Glandera is distinguished by such remarkable characters, which are always associated together, that when fully devel- oped it would be impossible to confound it with any known disease. In its early stage, when the articular and muscular pains are very urgent, it might be mis- taken for acute rheumatism. The occu- pation of the patient, the existence of a wound in a state of irritation, tlie much greater degree of prostration than is com- mon in acute rheumatism, the absence (usually) of redness and swelling around the painful joints, would arouse the sus- picions of tiic pliysician. At a later stage, the association of the peculiar and charac- teristic eruption of pustules and bulte, with ulceration of, and discharge from the nose, taken in connection with the history of the affection, distinguish in the clear- est manner Acute Glanders, from erysipe- las of the face, typhoid fever, malignant pustule, pyaemia, and some other diseases, to which it has been supposed to present points of resemblance. Chronic Glanders offers much greater difficulties in diagnosis than the acute form of the disease. "When uncompli- cated by Farcy, it might be readily mis- taken at first sight for one of the different forms of ozpena. The occupation of the patient, the mode of invasion of the affec- tion, the absence of other evidences of strumous or syphilitic affections, would furnish the data for forming a diagnosis. Cases of uncomplicated Chronic Glanders are, however, as has been already stated, of great variety. In the cases where Chronic Glanders and Farcy are com- bined, the diagnosis is more simple, for an association of symptoms then exists which is not presented by any other dis- ease. Cases of Chronic Glanders must, however, occasionally of necessity occur, in which the physician must experience great difficulty in forming a correct diag- nosis. In these cases an ass, or a horse, might be inoculated with some of the nasal mucus, if the case were one of un- complicated Chronic Glanders; or with pus from an abscess, if the affection were Chronic Glanders and Farcy. Acute Farcy, when occurring in a char- acteristic form, could scarcely be mistaken for any other disease. The history of the case, the great rapidity of its course, and ' See Tardieu, op. cit. p. 75, from whom the above description of Chronic Farcy has been abridged. the extraordinary pustular eruption, to- gether with the "nuaierous subcutaneous abscesses and tumors, would distinguish the case from cases where multiple ab- scesses occur from the introduction of other septic matters into the system. In cases of Acute Farcy without eruption, and of uncomplicated Chronic Farcy, only an accurate acquaintance with the early history of the case, and an accurate study of its progress, could enable the physician to arrive at a correct opinion. The super- vention of Acute or Chronic Glanders would, in a large proportion of such cases, remove the difficulties wliich they at first present. MoKBLD Anatomy. — Having describ- ed, in the preceding pages, tlie morbid anatomy of the various forms of Glanders in the liorse, there remains little to be said of the morbid anatomy of the disease as it aflects man, for the structural alter- ations of the nasal fossee, of tlie larynx, trachea, and lungs, are as characteristic of the disease in man as they are of it in the horse. The chief point of difference in the morbid anatomy appears to be tliat, in all the different forms of Glanders seen in tlie horse, the lymphatic system is very much more involved than in man. 1. Acute Glanders. — In all cases where the nasal fossae have been examined, tliey have been found the seat of disease. Sometimes the Schneiderian membrane is ecchymoocd and gangrenous, whilst often it presents numerous little pustules of the size of millet seeds. The frontal sinuses are frequently found filled with puriform mucus. The larynx has been the seat of eruption and ulceration in several cases. The lungs frequently present patches of pneumonia, or purulent formations are formed in them. 2. In Chronic Glanders, the affection of the nose differs considerably in character. At an early stage, the mucous membrane is often found injected and much swollen. Small submucous abscesses form. These open and become ulcerated ; the ulcera- tion spreads to the bones and cartilages, and necrosis generally follows. These ulcerations generally occur on the septum, which, in almost every case of Chronic Glanders becomes ultimately perforated. Ulcerations of the larynx-, trachea, and bronchi are very commonly found. The epiglottis is sometimes ulcerated, but the \'ocal cords are usually unaffected. The ulcerations of the trachea are often very extensi\'e, and affect the whole thickness of the mucous membrane. They exhibit a remarkable tendency to heal spontane- ously. The lungs are, by no means so constantly as in Xcute Glanders, the seat of the disease. The pleura is often cov- ered with small yellow elevations, which, on being incised, are found full of pus. 192 HYDROPHOBIA. Beneath the pleura, deposits of a purely fibrinous nature are found. Occasionally a portion of lung substance is indurated, in consequence of fibrinous exudation ; jn the centre of the indurated portion, pus is formed. The lymphatic glands are often somewhat enlarged, reddish, and of soft consistency. The bronchial glands have, in cases where ulcerations of the air-pas- sages existed, been found enlarged, soft- ened, and in state of suppuration. The alimentary- canal, the liver, and spleen present no peculiar appearance. The morbid anatomy of Acute Farcy is identical with that of Acute Glanders, ex- cept that the Schneiderian membrane is found perfectly healthy. In Chronic Farcy, the morbid appear- ances resemble those of Chronic Glanders. There is, however, no aflection of the nose. Progitosis.— In all the forms of Glan- ders, the prognosis is of the most unfavor- able description. Acute Glanders and Acute Farcy, when accompanied by the cliaracteristie eruption, are almost neces- sarily fatal. One case of Acute Glanders, and several of Acute Farcy, have been re- corded, in whit'h recovery took place. In Farcy, unaccompanied by eruption, the prognosis is much more favorable, re- covery being the rule, and not the excep- tion. Chronic Glanders, especially when complicated by Farcy, is almost invaria- bly fatal. The case" of Lambert, which has been referred to, proves, however, that even under these desperate circum- stances recovery may take place. Chronic Farcy, although a most danger- ous disease, usuallj- terminates in re- cover}'. In forming a prognosis, in apparently slight cases of Chronic Glanders or Farcy, it must not be forgotten that Acute Glan- ders often suddenly supervenes, in the course of these affections, and then inva- riably proves fatal. Therapeutics.— This section of the subject need unfortunately be treated of very brieflj^, for no treatment which bas been adopted, in the cases which have hitherto occurred, has appeared to exer- cise the slightest influence in checking or modifying the progress of the disease. Characterized as it is by sj'mptoms of the greatest constitutional prostration, a stimulant and supporting plan of treat- ment appears to be indicated, and has been recommended by all writers on Glanders. All attempts which have been made to cure Glanders in the horse have proved futile. There is considerable evidence, liowever, that arsenic, especially when administered with nux vomica or strych- nia, has in some cases of Chronic Glanders excited a remarkable influence in check- ing the progress of the local affections ; and we therefore think a trial of these remedies might with propriety he made, in cases of Chronic Glanders occurring in HYDEOPHOBIA. By Johx Gamgee, and Arthur G.\mgee, JM.D. _ Defin-ition. — A disease due to a spe- cific animal poison which resides in the saliva of animals affected with it. It never originates spontaneously, and is commu- nicated directly or indirectly, and usually by biting, from carnivorous or omnivorous animals, and especially dogs, to man. It is alone recognized by its physiological effects on man or animals. It induces pain and stiffness in the inoculated part, exalted sensitiveness and irritability, feverishness, mental anxiety, flitting pains, spasm of the throat on the sight ol" liquids, tremors, headache and delirium, vomiting, eructations and tympanites, great prostration, and death. Its period of incubation varies from a few days to many mouths. Synonyms. — Avaaa, xvm'kvana, i&po^o0ia \ Phobodypson, Pheugydron, Kabies, Ea- bies canina, Rabies contagiosa, Entasia Lyssa, Canine Madness ; La Ra^e, Hy drophobie (French) ; Die Hundswuth, Wasserscheu, ToUwuth (German) ; Rab' bia, Idrofobia (Italian) ; Hidrophobia (Spanish) ; "Watervrees (Dutch). History.— Few diseases have, at dif ferent periods of the history of medicine, excited greater attention, curiosity, and study than Hydrophobia, and few have HISTOKY. 10:J been described in a more grapliic or more accurate manner by ancient writers. Cel- sus,' Dioscorides," Crolius Aurelianus,' and Galen, liave left us accounts of the disease which equal those of the best writers who have followed them. It has been argued and indeed generally admitted, that the disease was not un- known to Homer, and the word yvaaa, which is so often employed in the Iliad to describe a wild and reckless fury, is sup- posed primarily to have been used to de- signate the madness of dogs. This view has been held since the days of Coslius Aurelianus, and is supported by the best authorities.* Thus Dr. Bardslcy, in a very learned memoir on Hydropho- bia,* says : — "We have already said that the disease was well known to Homer, and applied by him, with his usual critical exactness of similitude, to the indiscriminate havoc with which Hector sweeps through the battle-field of his enemies ;" and after quoting several passages^ in which the word >.i;(j(ja or one of its derivatives is used, he adds : " The poet with much propriety puts these words into the mouth of Ajax his enemy, for dog was already a term of reproach among the Greeks as well as the Jews." The passages alluded to do not appear to us to prove satisfactorily that their author was acquainted with Hydro- phobia. The word xiaaa, and its deriva- tives, is used by Homer on all occasions, as it is by many other Greek writers,' to denote martial rage ; and in spite of the occurrence of the expression xvva 7.vaarirrjpa, we feel inclined to believe that this was the primary meaning of the word, which was only secondarily applied to designate the disease of the dog, in the same man- ner as madness, rage (Fr.) and rabbia have in modern European languages been secondarily used in a limited and specific sense to denote Hydrophobia. Excepting that the word was subsequently used to designate the madness of dogs, there is no evidence that it had that meaning at the period when the Homeric poems were written ; whilst in using the expression ' A. C. Celsi Med. lib. v. cap. sxvii. ^ ^ P. Dioscoridis Op. omnia. Vienna edi- tion, 1598. JnfAUa XLJVof >.u5-tr5jvToj, jtal rsoy vir' avTav ii^yfxivojv, XE-^. a. ^ C. Aurelianus, De Morbis acutis et chro- nicis, lib. iii. cap. ix.-xvi. * See Thesaurus GreciB Linguae ab. H. Ste- phano construct, vol. iv. fasc. 2 ; also Damm. Nov. Lex. Grrascum etymol. et real. ; cui pro basi substratje sunt concordantise et elucida- tiones Homericas et Pindaricse. This author derives Xuiro-a from Xwoj,, wolf, this animal being very often subject to Hydrophobia. ' Cyclop, of Pract. Med., vol. ii. art. Hydro- pbobia. ' Iliad, lib. Tiii. 299 ; ix. 237 ; xiii. 53. ' Plato, Herodotus, Sophocles. VOL. I.— 13 'xiva, ^.vsatjtr^pa,' already referred to, the author of tne Iliad much more probably referred to dogs infuriated with anger than to dogs sulfering from Hydrophobia. All who are practically acquainted with the disease will admit that whilst on the one hand it is most improbable that the snappish ill-temper of rabid dogs should have been referred to, as a point of com- parison, by Homer in the passages quoted by authors, there is on the other hand nothing more natural than that he should compare an angry man to a furious dog, inasmuch as tliere is nothing more sug- gestive of ungovernable passion than the frenzy of an infuriated (but not rabid) dog. "Whatever may have been the primary meaning of the word, there can be no doubt that, in course of time, the word i^vaaa and its very numerous derivatives — Xuffffau, 'Kvaaai^vi-i, ^vaOTjSov, ^vtjai^cty, Xvaorj'r^p, Xvaau&Tji, 7i.ma6Sr]xtos, XvaariTfixo; — were em- ployed to express Hydrophobia, and in this sense the word >.vooa is employed by Plutarch and Dioscorides. Hippocrates only alluded in the faintest manner, if at all, to Hydrophobia, and we agree with Dr. Bardslcy in the opinion that when speaking of the " ^pttEVixot /3pa;jurtofcxt,"' the father of medicine proba- bly only means to treat of a "variety of phrenitis or mania." Democritus, however, who was the con- temporary of Hippocrates, if we are to believe the statements of Ceelius Aure- lianus,^ was acquainted with the disease, and wrote upon its nature and treatment. " Etenim Democritus qui Hippocrati con- vixit, non solum hanc memoravit passio- nem, sed etiam ejus causam tradidit, cum de opisthotonicis scriberet. ' ' In two other passages in his interesting account of Hj-- drophobia, Ca;lius alludes to the opinions of Democritus as to the aflbction being one of the nervous system, and mentions the remedies which that author recom- mended for its treatment. Aristotle was undoubtedly acquainted with the Hydrophobia of dogs. In his "Historia Animalium,"'' besides describ- ing it, he mentions that the disease is com- nmnicable to all animals but man. The opinion, although erroneous, points to the fact of his having directed attention not only to the characters but also to the mode of propagation of the disease. Both Asclcpiades and Themison, according to Cselius Aurelianus and Dioscorides, were acquainted with Hydrophobia, and enter- tained peculiar views as to its nature. Themison is indeed said to have been himself subject to an attack of Hydro- phobia, but as he recovered from the 1 Predict., lib. i. p. 69. Prsenot. Lect. ii. p. 131. 2 Op. cit., lib. iii. cap. xv. 3 Hist. Animalium, lib. viii. c. 22. 194 HYDROPHOBIA. affection we may with probability conjec- ture that its nature was very different from tliat of true Hydropliobia. Of the ancient writers, Celsus and Dios- corides, Cselius Aurelianus, Galen, and Avicenna, are those to whom we are chiefly indebted for our knowledge of Hy- drophobia, and to their opinions we shall, on more tliau one occasion, revert. Since the period when they wrote, all systematic writers on niedicine have treated of Hy- drophobia. Foremost amongst those who have contributed to our knowledge on the subject are Van iSwieten, Sauvages, Cul- len, Fothergill, Mead, Trolhets, and Bardsley. The recent history of Hydrophobia re- fers principally to Europe, not only be- cause greater attention has been paid to this as to every other disease of men and animals in the Old "World, but because the malady has been to a very great ex- tent confined to Europe. "\Ve shall after- wards attempt an explanation of this fact, but in the mean time we may state that the oldest report of scientific interest that we can trace, refers to wolves afflicted with rabies, in Fraconia, in 1271. Con- trary to their usual habits, these animals spared the herds and flocks, and attacked shepherds in the fields, or followed human beings into the towns and villages. Up- wards of thirty men fell victims to these attacks.' Canine madness prevailed con- siderably in Spain in 1500. '^ In 1590, we are told by Bauhin,' rabies raged in an epizootic form amongst the' wolves in the province of Monthelliard. In 1(304 it pre- vailed in Paris, and although it was doubtless common there, and after in various parts of Europe, we do not hear of it again until 1691,'' when the heat of summer proved insufferable, the crops withered for want of rain, animals died in great numbers in Italy, and dogs went mad. This reference to the dependence of rabies on the hot season must simply be regarded as pointing to a coincidence. Severe outbreaks of rabies occurred in France and Germany from 1719 to 1721, in Hungary in 1722 and 1723, and atmo- spheric influences were blamed for similar attacks in various parts of the continent, from 1725 to 1726.^ We learn, however, that wolves were aftected as well as dogs at this period, and special mention is made of wild animals being seized with the disease in Silesia and Lusatia {now Bautzen, in Saxony). The malady was rife in London in 1760, in Philadelphia in ' Addit. ad Lambert, Schafnaburg. 2 Blaine's Canine Pathology. ^ J. Bauhin, Memorab. Historia Luporum, 1591. * Eamazzini, pp. 157-186, and Baglivi (1828), vol. ii. p. 331. ^ Breslau, Samralungen, xxxiii. p. 90. 1779, in the West Indian Islands in 1783,' and in various parts of Europe from 1785 to 1789.^ At this period special notice is again taken of rabid wolves which com- municated the disease and terrified the people far more than even rabid dogs. It was not till the commencement of the present century that foxes were dis- covered to suffer much and frequently from canine madness. In 1803 these ani- mals were seen rabid in large numbers in the Pays de Vaud, in various parts of the Aubonne, Cossenay, Orbe, and Yserden districts at the foot of the Jura, and in 1804 similar outbreaks were witnessed on the northern shore of the Lake of Con- stance, and thence extending throughout the whole of Germany. Blaine tells us that in 1806 rabies in the dog became so prevalent in the vicinity of London that a day seldom passed without his being consulted on one or more cases of it, and sometimes he would see three, four, or five a day for weeks together. The king- dom of Wirtemberg and Grand Duchy of Baden were sadly ravaged by it in 1808 and 1809. Foxes continued to he affected, and these usually shy animals faced or followed men, cattle, or dogs in open day- light, bit them, and communicated the disease. The Wirtemberg Government ordered a report to be published on this subject in 1829, which contains particulars of these outbreaks. From 1803 to 1820 is a memorable pe- riod in the history of Hydrophobia. In 1810 it spread rapidly through Southern Russia, and the same year it appeared in America, in the State of Ohio, where it destroyed dogs, wolves, and foxes, besides other domestic animals, and no small number of human beings. In 1815 the malady was raging in Denmark. Blaine tells us that in 1820 it was again on the increase in England, and for three or four years "continued alarmingly common" but moderated again for a few seasons. During the years 1819 and 1829, rabies was rife in Italy, and Brera speaks of a wolf which bit thirteen persons, of whom nine died hydrophobic. Wirth specially notices the period from 1819 to 1826 as remarkable for rabies amongst the foxes of Switzerland and Germany,' and the foxes communicated the malady to dogs, cats, horned cattle, horses, pigs, goats, and sheep. In 1824 rabies prevailed ex- ' Moseley's Treatise on Tropical Diseases. 2 Schnurrer, ii. p. 389 ; and Fehr, Ueber die Hundswuth, Miinster, 1739. 3 Franque, Die Seuche nnter den Fuchsen und die ursprflngliche Wuth Krankheit der Hunde ; Frankfort, 1827. Koclilin, Ueber die in unsern Zeiten herrsohende Krankheit unter den Fuchsen ; Zurich, 1835. Wirth, Lehrbuch der Seuchen und ansteckenden Krankheiten der Hausthiere ; Zurich, 184C. CAUSES. 195 tensively amongst foxes, wolves, cats, and remdeer in Sweden, Norway, and even Russia. In the Riiine Provinces, various cantons of Switzerland, and in the kingdom of Wirtemberg, many men were bitten by mad foxes in the year 1827, but owing to the prompt measures usually adopted tlie individuals escaped ; dogs and cats thus bitten, however, became rabid. In 1830 the subject of rabies attracted great attention in England, and evidence on the subject was laid before a select committee of the House of Commons. Sir Benjamin C. Brodie, Professor Cole- man, Messrs. William Youatt, Morgan of Guy's Hospital, Earle of St. Bartholo- mew's, Benjamin Travers, and others were examined. Some idea of the state of popular terror, if not of the number of bites by rabid dogs, may be gleaned from Mr. Youatt's statement in evidence, to tlie effect that he had applied lunar caus- tic to about 400 bitten people, and a sur- geon at St. George's declared that within a Umited time he had similarly operated on 4,000 without an accident. Mr. Youatt particularly referred to a great increase in the prevalence of the disease as contrasted with eighteen months previously. Mr. Henry Earle, of St. Bartholomew's, fur- nished unmistakable evidence of the in- creased frequency of the disease in Eng- land, and stated tlmt he had seen twenty- five cases of Hydrophobia in man in twenty-five years, whereas his father had only seen one in fifty years, before his time. It is certain from the statements of Blaine, Coleman, and others, that prior to 1830 foxhounds were affected in this country to an extent never witnessed be- fore nor since. Tlmt there has been a decided abate- ment in the frequency of the malady in England during tlie second quarter of the present century, as compared witli the first, cannot he doubted, and it is believed that the law abolishing the use of dogs as beasts of burthen has operated greatly in favor of the change. That law not only led to a diminution in the number of dogs owned by a class of persons who could not keep these animals in a way calculated to prevent the spread of contagious diseases amongst them, but indirectly it led to the destruction of a lot of roving curs, kejjt by the poorer classes. The dog tax, too, which might have been beneficially en- forced to a greater extent tlian it had been, no doubt tended to limit the num- ber of valueless animals kept. Whatever niay be the cause, it is certain that there is far less canine rabies, hence much less human Hydrophobia, in the British isles than on the Continent, and during recent severe outbrealts of this disease abroad little has been heard or seen of it amongst us. Some remarkable statements have been published regarding Hydrophobia in France and the German States during the thirty-five years of comparative im- munity which we have enjoyed. In 1830, when attention was attracted by the prevalence of the malady in London, there was occasion for alarm in Vienna, where thirty-nine cases of rabies in the dog were reported in rapid succession. Few instances of the disease were seen there for the succeeding seven years, but in 1838, 117 cases occurred ; in 1839, sixty- three ; in 1840, 317 ; and in 1841, no less than 141. Of the last number only thirty- one animals were affected with the dumb rabies. Only fifteen of tlie 141 were bitches. Two cases occurred in animals under one year, and only one in dogs be- tween seven and fourteen years of age. The disease was specially rife in the months of February and May, in each of wliich twenty-one cases were observed ; in January there were sixteen, seventeen in April, and eighteen in June. Tlie few- est attacks were in the montlis of Septem- ber, November, and December. From 1839 to 1842, rabies in the dog was very prevalent in Wirtemburg, and this was attributed by Professor Kemy to commu- nication from foxes. From the 1st of January, 1840, to the last of February, 1842, no less tlian 230 cases of rabies oc- curred in dogs, and twenty-one in bitches in the small Grand Duchy of Baden. In 1840-41-42, the malady was very destruc- tive in Lyons and other parts of France. In the space of thirty years, no less than 779 dogs have died of rabies in the Lyons Veterinary School, giving a yearly aver- age of nearly twenty-six cases. The largest number of these cases occurred in the months of June and of April. Only so late as 1864, the city of Lyons was in great commotion owing to the terrible frequency of rabies canina. Some idea may be formed of the great difference between Great Britain and the Continent in relation to the frequency of this disease, from the fact that having been more or less connected with veteri- nary colleges in this country since 1840, not a single case of rabies has come under our own observation here, whereas many instances have been seen by us abroad, on almost every occasion that we have visited foreign schools. When in Lyons and Paris in 1854, many were the cases we saw, and often did we see ladies un- consciously carrying their rabid pets to be visited by the professors. Causes.— A glance at the history of Hydrophobia suffices to prove that, so far as man is concerned, the specific disease is due to only one cause, contagion. The poison is a fixed one, and flows from the sick animal's body with the abundant 196 HYDROPHOBIA. saliva which is secreted. It must pene- trate tlie S3'stem to take effect, and. is usually deposited by the teeth of rabid animals in and beneath the skin. It is not volatile, and the disease is therefore not infectious. Many circumstances af- fect its transmission, and on this we shall say more, after having spoken of the malady as it attacks the lower animals. It is generally supposed that rabies originates spontaneously in the dog and other carnivorous animals. So deeply- rooted is this belief, that even men of eminence have attempted various explana- tions of the supposed fact. One of the oldest views refers canine rabies to the heat of the "dog-days" and the tortures of thirst. Another, recently revived, is that the malady is developed in dogs kept under restraint, and from indulging at proper seasons in sexual intercourse. These and other theories are so absurd, and so opposed to many of the facts which we must incidentally allude to in these pages, that we may state dogmatically they have no foundation in truth.' With- out entering into a discussion on matters of theory, we consider it more profitable to refer to the peculiar features of rabies in those of the lower animals which un- doubtedly are capable of inoculating hu- man beings with the rabid virus. We shall, therefore, speak of the disease as it occurs in the dog, wolf, fox, badger, mar- ten, cat, horse, or sheep, pig, and goat. Dog. —One of the facts of primary im- portance, in the history of canine rabies, is that it is far more prevalent in dogs than bitches. Professor Coleman stated in evidence in 1830, that on the occasion of rabies entering fox-kennels, the mad dogs bit dogs, but spared the bitches. We well know that, as a rule, rabid ani- mals retain a certain affection for animals and people they know and care for. A dog will not bite its master at first, but rather avoid the presence of all he likes. There is some method in their madness, and we have no better proof of this than in the way in which bitches are spared by the rabid dog. Leblanc has published statistics, confirming the extraordinary prevalence of the disease in the males of the canine species, but he tried to bend the facts to demonstrate his theory that the disease is connected in its develop- ment with the repression of the desire for sexual intercourse. There are no experi- ments, no rehable facts indicating any ground for the belief that canine rabies originates in anything else than conta- gion, even in the dog ; and the best Brit- ish authorities, such as Blaine and Youatt, long since advocated this, the undoubt- edly correct view of the subject. It is singular that, even in relation to so active and certain a virus as that of rabies, we find instances of remarkable constitutional resistance to its effects. Thus when I visited the Lyons Veteri- nary College, in 18-53, a pointer dog was in the infirmary which had been bitten no less than seventeen times by dogs af- fected with rabies, with which he had been purposely confined by Professor Kay. Other cases of a like kind have been recorded, but they may be consid- ered rare and exceptional. The period of incubation of the disease in the dog has been set down as between three and seven weeks. Blaine has met with a case in which rabid symptoms succeeded a bite in a week, though Youatt never saw a case with less than seventeen intervening days. In 1862 M. Renault made a communication to the Academy of Sciences at Paris, and stated that during twenty-four years he had made numerous experiments with a view to ascertain the period of incubation of Hy- drophobia in the dog. During that pe- riod, 131 dogs have, under conditions which he describes, been either bitten by mad dogs, or inoculated with the foam as immediately collected from the mad ani- mals. Of this number, 63 having pre- sented no signs of disease during the four subsequent months, were not further ob- served. Of the 68 others, the Hydropho- bia was developed at various periods, as shown in the following table : — In 1 dog between the 5tli and 10th days. 4 dogs '( lOth 15th 6 " H 15th 20th 5 " li 20th 25th 9 " 11 25th 30th " li 30th 85th o u tl 35th 40th 8 " 11 40th 45th 7 " ti, 45th 50th 2 " a 50th 55th 2 " tt 55th 60th 4 " it 60th 65th 1 dog li 65th 70th 2 dogs a 10th. 80th There are no premonitor}' signs of an attack of the disease in the dog. "When the period of incubation is passed, the animal is restless, dull, watchful, and snaps at dogs, other animals, or men, which come in its way. It shuns the light, but with much slyness seeks an op- portunity of escape, and roves about town or country, manifesting extraordi- nary powers of exertion, and marked in- sensibility to blows and ill-usage. The habits of an animal may not change com- pletely at first, and the recognition of persons it has been daily in contact with is sometimes very remarkable. The di- lated pupils, the manner in which the eyes follow any object moved before them, and the peculiar modification in the bark, which is more of the nature of a howl, are amongst the most characteristic symp- HYDROPHOBIA IN MAN. 197 toms. The appetite is lost, thirst often considerable, and the animals usually drinlt without difficulty. The coat is staring, skin tiriit on the ribs, abdomen tucked up, head depressed, and nose pro- truded, with a dirty mouth and tongue, and sometimes a discharge of mucus and saliva from the sides of the mouth. In a certain number of cases, the nervous symptoms are very prominent at this pe- riod, and the lower jaw drops from pa- ralysis of the muscles connected with it. The howl is tlien lost, hence the name dumb rabies for the cases associated with this symptom. Emaciation, craving af- ter filtli, which is swallowed with some difficulty, constipation, and a scanty dis- cliarge of high-colored urine, are amongst the noticeable symptoms. Mad dogs have been known to eat portions of dead dogs, and mad bitches to devour their young. Tliere is a singular absence of any marked acceleration of tlie pulse and breathing during the disease ; the animal sinks, often paralyzed in the hind quar- ters, and dies somewhat tranquilly from the fourtli to the eighth day. Schrader says that, of 257 cases of ra- bies, 223 belonged to tlie barking or raging variety, and 44 to the dumb or paralytic form. [There is good evidence to show that Hydrophobia may be produced by the bite of a healthy dog, much enraged; as in flgliting with anotlier animal. — H.] Foxes show signs of the disease, as stated above, by losing all their shyness, following animals and men, biting them, losing their consciousness, and becoming paralytic, and otherwise presenting most of the characters of the disease m the dog. Wolves are more to be feared than foxes, from their greater strength and ferocity. They attack human beings without fear, and usually bite them about the face, neck, and hands. As tliey approach death, they skulk away, and die in retired spots, blind, powerless, and in the quiet stupor seen in typhus. Cats have scarcely less propensity to attack the uncovered parts of the bodies of individuals, and especially the face, than foxes. They scratch, whine in a hoarse manner, and die from the third to tlie fourth day. Martens and badgers present most of the Symptoms seen in cats and foxes. [The slcunlc, in the United State, is lia- ble to rabies, and has several times been known to communicate it, by its bite, to human beings.— H.] In the pig tliere is a peculiar restless- ness, squealing grunt, disposition to bite, gaping, salivation, marasmus, paralysis of the hind quarters, and death from "the fourthto the fifth day. Rabies canina has been often observed in herbivorous quadrupeds, horses, oxen, sheep, deer, and other animals. The symptoms arc marked and unmistakable, presenting all the characters of the signs of rabies in the dog. Prom the imperfect powers of biting, communication of the disease from vegetable feeders to man is rare, and we need not, therefore, enter into further particulars on the subject here. Hydrophobia ix Mak.— As actual contact of the saliva of a rabid animal with a wounded or abraded surface is re- quired for the development of Hydropho- bia, wo should expect that, of the total number of persons bitten, only a certain proportion should fall victims to the dis- ease, and this is really found to be the case. Whether some individuals are, from idiosyncrasy, less prone to contract Hydrophobia than others, is not known, and it does not appear that age, sex, or constitution materially modifies the trans- mission of the disease. Tlie situation and character of the wound aflect, in all prob- ability, the result, for it would appear that where the injuries are situated on the uncovered portions of the body, as on the hands or face, there is greater danger of the supervention of Hydrophobia than when they have been inflicted on the cov- ered portion of the body or limbs. The clothing, in the latter case, protects the wound from the action of the saliva. Tlie bites of wolves appear to have been more frequently followed by Hydrophobia tlian those of dogs ; probably owing to the fact that, from their natural ferocity, the for- mer animals, when attacking men, very commonly inflict severe injuries on the face and neck. Such circumstances as prevent the adoption of an energetic pro- phylactic treatment of those bitten by rabid animals, obviously favor the devel- opment of the malady. The actual ratio of cases of Hydropho- bia to the total number of persons bitten by rabid animals, has been very variously estimated bj' different writers on this sub- ject. Whilst some have stated that only 5 per cent, of all persons bitten by rabid dogs become afiected with Hydrophobia, others have estimated that 55 per cent, of the bites inflicted by rabid dogs are effec- tual in transmitting the disease. The ratio varies very greatly ; probably be- tween the limits we have mentioned. In the case of the bites inflicted by rabid wolves, the ratio of cases of Hydrophobia would appear to be as high as 60 per cent. Symptoms of Hydrophobia in Man. — As it affects man. Hydrophobia pre- sents symptoms which differ from those which have been described as character- istic of the affection in the dog. The chief point of difference is the almost con- 198 HYDROPnOBIA. stant occurrence in man of the peculiar spasms of the pharynx,' excited Avhen the patient maizes an eilbrt to driulv, and wliicli gives rise to tlie dread of fluids, to wliich the disease owes its name. The cerebral symptoms appear to he less con- stant in man than in the dog ; for — whereas amongst the most prominent of the symptoms in the dog is the thorough change in the natural instincts of the ani- mal, and an uncontrollable tendency to attack and bite all around him — it would appear that in man delirium, although a frequent, is by no means a constant or necessary accompaniment of the affec- tion. Period of Incubation.— We are probably acquainted with no disease which pos- sesses go long a period of incubation as Hydrophobia, or in which the period of incubation varies to so great an extent. This fact was well known to the earlier writers on Hydrophobia, one of which most accurately remarks that whereas the affection usually supervenes within forty days after the infliction of a bite by a rabid animal, some are only affected after a year or more has elapsed.^ The disease has been \Qvy rarely devel- oped sooner than eight days after the bite of a rabid animal, and rarely after a longer period than two or three months. The large majority of cases has occurred within four or eight weeks. Many au- thentic cases have occurred in which the period of incubation extended to eight or nine months, and a few where it appeared to be much longer. A remarkable case has been placed on record, in whicli a man who had been in prison for a period of more than two years, became atl'ected with Hydrophobia, although he had only been bitten by a mad dog seven years previously. During the period of incubation there is nothing which specially distinguishes the bite of a rabid from one inflicted by a healthy animal. The wound may heal rapidly, or it may continue in an irri- table condition, no peculiar train of symp- toms occurring which can enable us to form a prognosis as to the probable issue of the case. The period of latency, or de- litescence, as it has been termed, having elapsed, the following train of symptoms usually occurs. The wound becomes in- tensely painful, the pain often shooting from the extremities (if it be situated upon them), towards the trunk. If the wound have cicatrized, the cicatrix be- comes red and irritable, or if, as is gene- rally the case when the injuries inflicted by the rabid animal have been severe, it have not healed, it assumes an unhealthy ' [The respiratory muscles are usually still more afl'ected. — H. ] 2 Csel. Aurel., lib. iii. cap. ix. appearance. With this local irritation, there is sometimes, though very rarely, some affection of the lymphatics of the part. In addition to the local plienomena, others of a constitutional character soon set in. The patient becomes peevish, irritable, and depressed ; the skin is hot, the pulse rapid, and the appetite is Inst. The peculiar depression of i-pirits just alluded to has been thought to be very characteristic of this, the first ttage of Hydrophobia, and is indeed rarely ab- sent. The unfortunate patient, who has been dreading the consequences of an ac- cident of wliich the gravity is well known to him, often deludes himself with the hope, from the absence of all symptoms for a time, that all fear of danger has passed, and only awakens to a feeling of the real horror of his position when the local phenomena, which have been de- scribed, supervene. It is not strange, then, that they should be accompanied by a feeling of melancholy and impend- ing evil. The first stage of Hydrophobia has been termed that of "recrudescence." Its characters are not fixed and invari- able, for it has been noticed, in some cases, that no local symptoms occurred be- fore the development of the true hydro- phobic phenomena, and in others that melancholy and irritability were absent. In these cases, a feeling of general "ma- laise" and p}rectic phenomena have alone been present. This stage of recrudes- cence, of irritation and melancholy, as it has been variously styled, is usually of very short duration. After a few hours, or at most a day or two, the patient be- gins to complain of stiffness about the head and neck ; and then the most char- acteristic manifestation of the disease sets in — an affection of the pharyngeal mus- cles, which throws them into the most painful spasms when the unfortunate suf- ferer attempts to eat, but specially to drink. The patient suffers from the most agonizing thirst, whilst the knowledge of the spasms which will accompany any at- tempts at drinking cause him to dread even the sight of liquids. "Miserrimum genus morbi ; in quo simul seger et siti et aqufe metu cruciatur.'" The hot and parched mouth becomes full of a clammy and viscid saliva which the poor sufferer is continually attempting to spit out, giving rise to the sound which the older writers compared to the barking of a dog. The heat of skin, and the frequency of the pulse, become excessive ; the counte- nance is intensely anxious ; the eye is bright and restless, and shuns the sight of a bright or luminous object, which often causes a fit of the painful spasms which, at first, attempts at deglutition only pro- • Celsi Med., lib. v. cap. xxvii. DIAONOSIS — MORBID ANATOMY. 199 duced, but which afterwards the mere sight or even thought of fluids brings on. Delirium may be, and often is, absent ; wlaen present, it is often violent, and al- most maniacal. In some cases a fit of general convulsions supervenes ; in others, the spasm becomes weaker, and the pa- tient, sinking into a state of comparative quiet, may regain, after a period of agita- tion and delirium, composure and quiet. Death may supervene early ; it is often preceded by a stage of profound coma. A certain paralysis of the lower jaw, which drops, and allows the saliva to flow from the angles of the mouth, often marks the later stages of some cases of this sad disease, from which probably no one ever recovered. The hydrophobic stage, which has just been described, is of short duration, death usually occurring before the end of the second day, life very rarely having been prolonged beyond the fourth day. Diagnosis. — In its first stage, when the phenomena of recrmlcsccnce, as they have been termed, are first manifesting them- selves, it is impossible to form an accurate diagnosis. The feverish symptoms, and the fresh accession of pain in the bitten part, are symptoms which may, and often do occur in persons who have been bitten by animals not in a rabid condition — bites being very liable to heal slowly, to become the seat of neuralgic pains, and to give rise to considerable constitutional disturb- ance. When Hydrophobia is fully developed, a careful study of all the phenomena can- not fail to lead to a correct diagnosis. It has apparently been confounded with dis- eases whose only resemblance to it con- sisted in the occasional occurrence of pharyngeal spasms, as inflammation of the larynx, trachea, and oesophagus. Hy- drophobia may, however, moi-e readily be confounded with hysteria, acute mania, and tetanus. A perusal of many of the recorded cases, especially of those which are said to have terminated in recovery, will readily convince the inquirer, that acute mania has sometimes been mistaken for Hydrophobia. In certain cases of this disease, it would appear that a dread of fluids has been manifested, whilst the general appearance of the patient has sin- gularly resembled that of patients affected with Hydrophobia. The absence of a his- tory of a bite, the history of premonitory symptoms of mania having existed, the duration of the disease, and the rapidity of the pulse — which in acute mania is very rarely above 90, whilst in Hydro- phobia it is usually much higher — are the data upon which a differential diagnosis should be based. French writers have described a defi- nite disease under the terms "hydro- phobienon rabique," "hydrophobie rabi- formo," "raj^e spontanoo," which is said to resemble in the closest manner true Hydrophobia. This affection, it is alleged, has gener- ally been caused by fear, which has super- vened after the bite of a rabid dog, or after communication with persons suffer- ing from the disease. Its symptoms are, it is said, occasionally quite undistinguisli- able from those of true Hydrophobia ; there is in the spurious form, however, very commonly a desire to bite. The patient may die in a few hours or days, or may remain afi'eoted for weeks or years. The diagnosis, it is stated, rests chiefly on the non-discovery of a part which has been bitten. We cannot see the propriety of admitting the existence of a non-rabid Hydrophobia, for the cases which have been described as examples of it may be more accurately classified as cases of either hysteria, acute mania, or true Hj^dropho- bia, which had not been recognized. Tetanus presents certain points of re- semblance to Hydrophobia, tetanic spasms sometimes afiecting the pharvngeal as well as the other muscles. 'The chief points of difference are, that Hydropho- bia supervenes on a bite, whilst tetanus usually follows some other injuries; that the latter disease supervenes sooner after the injury than does Hydrophobia ; that in tetanus the spasms are usually not in- termitting ; that trismus usually exists ; that it is not marked by the distressing thirst, or the abundant discharge of sali- va, which is so common in Hydrophobia ; and that delirium very rarely occurs dur- ing its course. ' [The excess of excito-motor suscepti- bility is most extreme in Hydrophobia. — H.] Morbid Anatomy. — There are no ca- daveric lesions which can be said in any way to characterize Hydrophobia. The most constantly observed phenomena have been the following : — Eedness and swelling of the fauces and gullet, occasionally accompanied by en- largement of the salivary glands, and sometimes with redness of the stomach. The trachea and bronchi have often been found injected, and filled with frothy mucus. The lungs are congested, occa- sionally infiamed, sometimes empty and oedematous. (Trolliet.) The brain has been found occasionally congested ; sometimes there has been ef- fusion into the arachnoid and lateral ven- tricles. The medulla oblongata, and the origins of the seventh, eighth, and ninth nerves have been noticed to be congested, thickened, and softened. I Holmes' Surgery, vol. i. p. 313, art. " Te- tanus," by Mr. Poland. 200 HYDKOPIIOBIA. Prognosis. — When the disease is fully established, the prognosis is necessarily of the worst description, death being in- evitable. Under tlvis section a question of greater practical importance may be discussed, and the solution of which de- pends upon the facts which have already been referred to. A patient having been bitten by a rabid dog, when can the phy- sician give a tolerably favorable opinion as to the issue of the case ? when can he express a pretty confident opinion as to the safety of his patient ? As the large majority of all those who are bitten by mad dogs escape Hydrophobia, even when no treatment is adopted, a favorable and en- couraging, though a guarded, opinion can and should be given, even immediately after the accident. As the greater num- ber of cases occur between the thirtieth and fortieth days, when the latter period is safely passed the prognosis becomes more and more favorable. After the end of the second month the large majority of patients may be considered safe. Therapeutics. — Since Hydrophobia was first described, all authors have de- voted considerable attention to the treat- ment of the disease, both prophylactic and curative. It has long been known that the evil effects of the bite of the mad dog are probably often prevented by the adoption of an active local treatment of the bitten part. Celsus accordingly re- commended the application of the cup- ping glass to the bitten part, or even the employment of the actual cautery. Since his time, in addition to the supposed spe- cific methods of prophylactic treatment, nearly all authors have recognized the use of local treatment. Excision of the bitten part, the application of the actual cautery, or a combination of excision and cauterization; the application of various caustics, amputation of a bitten limb above the seat of the injury, have all been suggested and emj^loyed by different sur- geons, and there appears to be good rea- son for believing that good effects have followed all these various methods. Complete and early excision of a bitten surface, as soon as possible after the in- fliction of the injury, is the method which has found most general favor in this coun- try, and is perhaps the best which can be adopted. When, from the situation of the wound, excision is inadmissible, re- course should be had to the free use of caustics, and of these we should prefer the most powerful at our disposal — such as, presumably, would decompose such an animal virus as that of Hydrophobia; potassa fusa, or strong nitric acid, should have the preference. It must be men- tioned, however, that, in the opinion of some, recourse need not be had to such severe methods. The late Mr. Youatt, who in the course of a long experience had treated a very large number of per- sons who had becu bitten by dogs un- doubtedly rabid, placed the greatest reli- ance upon cauterization with solid nitrate of siher, which in his experience had in every case prevented the development of Hydrophobia. Besides the local modes of treatment, the older physicians believed in the etD- ciency of other remedies. Prolonged and sudden immersion in cold water was from the remotest times considered of great value in warding off a fit of Hydrophobia, and was practised to within a compara- tively recent period. Celsus speaks of tiie plan with much favor, and Desault, in his well-known treatise on rabies, describes the mode in which the operation was per- formed in his day. It is in the memory of persons still living, that those bitten by mad dogs were, in England, taken to the sea-coast and dipped in the sea. From the fact that so few of those bit- ten by rabid animals actually contract Hydrophobia, we should expect that a large number of specifics would have been proposed for its treatment. A credulous physician who happened to have adminis- tered some remedy to a few persons bitten by a mad dog, finding that no evil conse- quences followed, and forgetful that had nothing been administered his patients would, in all probability, have enjoyed equal immunity, was only too ready to believe that he had at last discovered a specific for a terrible disease. Thus, doubtless, it was that the Ormskirk medi- cine, a compound of chalk, alum, Arme- nian bole, elecampane root, and oil of anise; the Tonquin medicine, a mixture of musk and cinnabar; and the Tanjore pills, a combination of arsenic and mer- cury, acquired for a time a wide and fic- titious reputation. The use of the hot-air and vapor bath has lately been recommended as a pro- phylactic in Hydrophobia, and it has been stated even to have cured the dis- ease when fully developed. In the ab- sence of any well-authenticated cases, we cannot decide upon the value of the rem- edy. That it might help to eliminate a virus which lurks so long in the system before producing its specific effects, is, however, not impossible. [The hypodermic injection of cifrara, and also that of chloral, are among the later experimental remedies employed.— Amongst the most important questions for discussion, in considering the treat- ment of Hydrophobia, is the following: In the event of the peculiar phenomena of recrudescence manifesting themselves after a very long interval in a person who has been bitten by a rabid animal, should any local treatment be adopted ? Should ENTERIC OR TYPHOID FEVER: SYNONYMS. 201 the bitten part or the cicatrix which has i formed be excised or amputated ? Tliis question cannot at present be answered positively. As, however, cases have un- ! doubtedly occurred in \v'liicla sucli a local treatment of a bitten part has, even after the always-to-be-dreaded symptoms of recrudescence had set in, appeared to prevent the development of Hydrophobia, we are of opinion that the local treat- ment, severe though it may be, should be tried. In the treatment of Hydrophobia, when fully developed, we must rely entirely upon general principles of medicine in at- tempting to relieve the sufferings of the patient. No specific method of treatment has been shown to have the slightest in- fluence in checking or modifying this dis- ease, from which, in all probability, no one ever recovered. We should try to soothe and comfort the unfortunate pa- tient in every way in our power, to attempt to allay the great nervous excitement by i means of sedatives, to support the failing strength by stimulants, and chiolly to prevent all noises, draughts, and other sources of excitement, which are so liable to bring on the painful pharyngeal spasms. Desault suggested, and apparently with good reason, that large fluid enemata might with ad\-antage be administered. By checking the agonizing thirst they would, in all probabiHty, greatly lessen the sufferings of the patient. [While the production of mere eiitlw/iia- sin will not justify the unlimited employ- ment of powerful narcotics, it would seem that the use of chloroform by inhalation is made suitable by its effect in quieting the respiratory spasms ; and the system is found, in hydrophobia, to have a re- markable tolerance of chloroform. A child eight years old, under my care, in the height of the attack, inhaled several drachms of it, with the eftisct of producing tranquillity only, without deep narcotism. EN^TEEIC OE TYPHOID FEYER. By John Harley, M.D. Lond., F.L.S. Definititb Description. —A con- tinued febrile condition of uncertain du- ration, accompanied by marked intestinal derangement, and invariably associated with lesion of the solitary and agminated glands of the intestines. It commences in anorexia, with nausea or vomiting ; its progress is marked by profuse diarrhcea of light ochre-colored watery stools, asso- ciated with abdominal pain, tenderness, and tympanitic swelling ; and, if the issue be unfavorable, it terminates in exhaus- tion, intestinal hemorrhage, or perfora- tion of the bowel. Death usually occurs in the fourth week. In the early period, the disease is attended by more or less pyrexia ; as soon as it is fully developed, tliere is well-marked hectic fever. Dur- ing the height of the disease a scattered papular rash appears in successive crops on the abdomen and chest. The rapidity with which the symptoms are manifested, and the degree to which they are devel- oped, vary greatly in different cases. The intestinal disease is frequently obscured by the concurrence of pulmonary or cere- bral complications. Synonyms.— Gerwicm— Abdominal Ty- phus, Darm-typhus, Typhus gangliaris vel entericus, Ileo-typhus. French — Fievre Typhoide, Enterite septicemique, Fievre muqueuse, Fievre entero-mesen- terique, Gastro-enterite, Dothienenterite, Enterite-folliculeuse. English — Typhoid Fever, Autumnal or Fall Fever, Slow Nervous Fever, Common Continued Fe- ver, Hectic Fever, Infantile Hectic Fever, Infantile Remittent Fever, Entero-mesen- teric Fever, Gastric Fever, Enteric Fe- ver, Intestinal Fever, Pythogenic Fever, Cesspool Fever. Comivon — Bilious Fe- ver, Gastro-bilious Fever, Muco-enteritis. The above are the principal synonyms in use. Many others could be given ; but as they may lie either ri-cognized as modi- fications of the foregoing, or have no re- stricted application to the particular dis- ease under consideration, they need not be mentioned here. All may be found in Dr. Murchison's valuable work on the "Continued Fevers of Great Britain," p.. 385, et seq. The appellations "Typhoid," "Ab- dominal Typhus," and the like, lead to an association of two diseases in the mind, which does not exist in reality; such terms therefore lead to confusion. "Gastric" has reference to an organ which, at most, only functionally symp^- 202 ENTERIC OK TYPHOID FEVER. thizes with the principal lesion ; the term " Pj-thogenic," introduced by Dr. Mur- chison, to imply the putrid source of the disease, is, on the one hand, too general, since it may be argued, with equal rea- son, that otlier acute diseases, besides the one under consideration, arise from this cause ; and, on the other hand, it is not sufficiently comprehensive, since it would appear that Enteric Fever may arise from other causes than putrid or sewer emana- tions. In adopting a term to distinguish the disease, we should select one which at once marks it out from all others, and points to a constant feature. Such a term is " Entero-mesenteric," employed by MM. Petit and Serres, in 1813. This ap- pellation is a brief definition of the dis- ease, and but for its inconvenient length we would employ it here. Acknowledg- ing the direct sympathy which the mesen- t(;ric glands have with the intestinal le- sion, we prefer, however, to use the shorter term, "Enteric Fever." PEELiMiisrArvY Observations. — No disease presents, in the mode of the acces- sion of its characteristic sj'niptoms, in the gravity and sequence of these, and in its whole course and ending, so many varia- tions, irregularities, C( implications, and accidents as Enteric Fever. A complete and consequent history of the disease will be best obtained by considering : 1st, The symptoms attending its development and progress, the condition of the secretions, and the modes of termination, the acci- dents, and sequences of the disease ; 2dly, The morbid anatomy ; 3dly, The pathol- ogj' ; 4thly, The associated pathology, meaning thereby a comparative view of the development of the particular intesti- nal lesion in other acute diseases — an in- vestigation of great importance in the comprehension of the relation of acute diseases generally, but one of especial value in the elucidation of the nature of Enteric Fever ; 5thly, The varieties ; 6thly, The distribution; 7thly, The causes; and subsequently, there will remain to be considered the Diagnosis, Prognosis, The- rapeutics, and Prophylactics of the dis- ease. Clinical History of the Disease. Development and Progress. — In consid- ering the clinical history of Enteric Fever, it will be convenient, with reference to the mode of access and development of the symptoms, to group the cases into three classes, viz. (1) Those in which the symptoms of gastro-intestinal irritation remain latent for days, or even weeks, after the patient has declined in health ; (2) Those in which gastro-intestinal de- rangement is the chief feature of the dis- ease from its outset to its termination; and (3) those which, in the suddenness of the invasion, the severity of the symp- toms, and in the rapid course of the dis- ease, closely resemble cases of narcotico- acrid poisoning. Many of the cases of Enteric Fever be- long to the/r,sf cZc/.ss. The disease indeed usually commences insidiously, and with- out premonitory indications of intestinal disorder. The decline of his health has been so slowly progressive and uniform, that the patient cannot state precisely when his illness commenced. For days or weeks past he has lost appetite, and felt weak, languid, and disinclined for bodily or mental occupation, complaining of a little headache, chilly sensations, chiefly referred to the spine, and of weariness and pains in the limbs. His increasing weakness sooner or later compels him to relinquish his ordinary occupations, and to apply for relief. We find the tongue moist, and tolerably clean ; the skin cool, pallid, and free from rash ; the pulse is rather small, and slightly accelerated ; the mind is clear, and the expression natural; the bowels have responded to a purgative, but now they are regular, or perhaps again constipated ; the abdomen is natu- ral ; the other functions of the body are regularly performed. The patient may remain in this condition for some time, but sooner or later the nature of the dis- ease is manifested by the appearance of its characteristic symptoms. At first, there is increase of the early symptoms, anorexia is aggravated to nausea, and sometimes there is vomiting of green fluid ; the skin becomes hot and dry ; the pulse is increased in frequency ; [bleeding at the nose is common ; bronchial cough is rarely absent ; — H.] the tongue is fur- red, and usually presents red prominent papillffi at the margins and tip ; there are great restlessness and increased headache; the bowels become loose, and the abdomen is a little full, painful, and tender— the right iliac fossa especially so, and pres- sure upon this part usually produces gur- gling. A few round rose-colored papules may now be observed upon the abdomen, chest, or back. They disappear on pres- sure, and closely resemble the papules of variola during the first few hours of their existence ; but they are not quite so large, nor so hard. Their number varies much, and the quantity of rash bears no propor- tion to the severity of the disease. Usu- ally we do not find more than three or four papules ; occasionally the chest and abdomen are closely spotted with them. In one case we observed them profusely scat- tered over the thighs, legs, and feet. Dur- ing the prevalence of the diarrhoea a fe^f fresh spots appear every day, and after i forty-eight hours the old ones begin to CLINICAL HISTORY OF THE DISEASE. 203 3e away. Diarrhoea, frequently associ- ed with bilious vomiting, now prevails, d the abdomen becomes distended, and many cases more or less tympanitic ; e alvine dejections are watery, and of light ochre color, and putrid odor. At st they are acid, but they soon undergo ange, and become ammoniacal and have I alkaline reaction. With the supervention of diarrhoea, all e symptoms become greatly aggravated; e pulse ranges between 120 and 130 ; e skin is often pungently hot, and occa- jnally attains, toward night, a tempera- re of 107 or 108°. During this stage ere is great irritability, and often con- ierable delirium, especially at night. In me cases there is no delirium and the ind remains clear to the last. Symptoms ■ active pulmonary congestion, — acceler- ed breathing, pain in the chest, mucous ,les, and expectoration streaked with ood, — are also liable to arise. The as- ;ct of the patient is usually indicative of iffering, but the countenance is clear, id the eyes bright, as in scarlatina ; the leeks are suftiised witli a hectic flush, he urine is clear and copious ; it is fre- jently retained. The patient may continue in this condi- on for several days, the body meantime Qdergoing rapid emaciation. The tongue lay continue moist, in which case it be- )mes pale, large, and llabby, and is liable ) ulceration about its margins, and the irmation of deep fissures with everted largins across the dorsum. In many ises the tongue becomes dry, red, con- ■acted, and fissured at this period. The lucous membranes become dry and in- amed ; the gums are liable to bleed, epis- ixis frequently appears, and sordes begin ) form upon the dry teeth. Here is the irning point of the disease. If we can -ibdue the gastric irritation, and keep )od in the stomach, and restrain the iarrhcea, the symptoms will usually take favorable turn. The abdominal pain nd hectic fever diminish ; more nourish- lent is taken ; the tongue begins to loisten at the edge, and the cracks to eal ; the rough cuticle, especially that of le abdomen, to desquamate. Sometimes syeating is re-established suddenly, and 'ith the appearance of a copious eruption f sudamina over the chest and abdomen ; le bowels may continue loose, but the tools are of a darker, greener color. At lis stage a relapse is very common — the iarrhoea, vomiting, and hectic returning 'ith the former severity. The patient is ot free from the danger of a relapse, un- ;1 the stools have become solid. The im- rovement is slow, and, the diet being istricted, the emaciation persists for ■eeks. The desire for food is usually reat ; the digestive function is ultimately smpletely restored, and the patient re- nins his former weight and strength. When the case tends to an unfavorable issue, the diarrhtt'a continues unchecked ; the abdominal pain, and usually the tym- panities also, increase ; the exhausted patients lies motionless upon his side or back, drowsy or apathetic, and uttering feeble moans ; the knees are drawn up, and his pinched, flushed countenance manifests pain on the slightest disturb- ance ; the skin is pungently hot, the pulse very fast and thready, the teeth and tongue are blackened with sordes, [deaf- ness, more or less marked, comes on. — H.] the continuous delirium lapses into coma — the typhous condition is complete. "Watery stools are passed involuntarily, the patient hourly sinks, and at last quietly expires. As soon as the diarrhoea appears, and as long as it continues, the patient is liable to intestinal hemorrhage. The blood niaj' appear repeatedly and in considerable quantity day after day in the stools, or the patient may become sud- denly blanched and die of syncope, with- out any discharge of blood per anwn. In such a case the intestines will be found distended with blood. Hemorrhage, however, is not the only accident we have to anticipate. The pa- tient is often cut off by perforation of the bowel. This dreaded event may be ex- pected if, with a persistence of the diar- rhoea, the tenderness and tympanites in- crease, and vomiting and hiccup super- vene. Perforation is most commonly preceded bj^ symptoms of general peritoni- tis accompanied by excessive tympanites, persistent hiccup, and vomiting. A par- oxysm of more intense abdominal pain sometimes indicates the occurrence of this fatal result. As an illustration of the insidiously progressive class of cases, I give the fol- lowing outline of the history of a patient who came successively under the care of Dr. Murchison, Dr. Buchanan, and my- self, in the London Fever Hospital. Case 1.— C. Bushell, aged 24, a well- nourished, dark - complexioned woman, experienced a feeling of lassitude, accom- panied by chilliness, pains in the limbs, and slight headaches, with loss of appetite, for about four days. She took to her Ijod on the fifth day, and was admitted on the sixth. A mild attack of typhus was sus- pected, and from day to day the tongue, pulse, surface of the chest and abdomen, and the nature of the secretions were ex- amined. Still no positive disease declared itself, and no diagnosis was made. The pulse was 80-84, tongue natural, skin not hot and free from rash, bowels not acting every day, abdomen natural. During the time she remained in the hospital she ex- hibited no new symptom, complaining only of weakness, chilliness, general pains, anci want of appetite. She ate fish, and subsequently meat, and was kept in bod 204 ENTEKIC OR TYPHOID FEVER. during a portion only of the time of her sojourn in the hospital. As she was ap- parently suflering from mere debility, and had improved a little, she was discharged on the fifteenth day. She was again ad- mitted on the twenty-ninth day, and stated that she had not been well shice she had left the hospital, having still sufferedfrom excessive weariness and pains in the limbs, headache, and chilliness followed by a little feverishness. Lately she has had shivering, the bowels have been rather constipated, she has lost all appetite, and feels rather sick ; pulse 1-20, feeble ; tongue moist and white ; no rash ; no cerebral or pulmonary symptoms. Thirty-first day: tongue clean and red at edges, a moist thick fur on centre ; bowels became rather loose, and six or seven rose-colored pap- ules appeared on the abdomen ; pain and gurgling in the riglit iliac fossa ; pulse 120 ; skin hot ; face flushed ; sleeps badly. Day after day, to the thirty-eighth day, the purging increased, and fresh rose papules appeared ; the abdominal pain increased ; the tongue became dry, brown, and cracked ; the pulse rose to 164. She died exhausted on the thirty-ninth day. Autopsy. — Rotundity of the body pre- served ; lungs healthy, excepting engorge- ment of one lobe. Stomach, duodenum, and jejunum appeared healthy. The soli- tary and agminated glands of the lower part of the ileum swollen and inflamed ; those near the valve were ulcerated and sloughy, and formed almost one continu- ous surface, raggedly disintegrated, and greatly swollen, extending around the whole of the last two inches of the bowel. A few of the solitary glands of the caecum and ascending colon were inflamed and ulcerated. The corresponding mesenteric glands much swollen, congested, and softened. Spleen soft,, twice its normal size ; liver enlarged and fatty, weighing three pounds nine ounces (avoir.). Gall bladder distended with pale brown, watery bile, of excessively acid reaction and sul- phuretted odor. The secojifZ class of cases are perhaps the most frequent. In these the nature of the disease is manifest in the begin- ning. The patient may have felt a little indisposed previously ; but he is in the midst of his usual occupations, or upon a journey, when he is overtaken with head- ache, shivering, and purging, followed by general pains and more or less pyrexia ; there is complete anorexia, and nausea and vomiting are frequently amongst the earliest symptoms. There is pain in the abdomen, and great thirst. The prostra- tion of the strength is very great, and the patient soon takes to his bed : the bowels continue to act two or three times a day, and the febrile symptoms and abdominal pain and tenderness persist ; tlie tongue is moist, and usually coated with white fur ; the edges and tip are red, and ex- hibit prominent fungiform papillae. On the seventh day, or a little later, a few rose-colored papules appear upon the ab- domen, chest, or arms ; the belly is a little full ; there is great tenderness and gur- gling in the right iliac fossa ; the patient is unable to take food, and is distressed by occasional vomiting of bilious fluid.' The fever runs high, there is great rest- lessness by day, and broken sleep and delirium at night. [Dulness of hearing is almost invariably present. — H. | Great pains are complained of in various parts of the trunk, the hepatic and splenic re- gions are tender, and there is increased dulness in the latter, indicating enlarge- ment of the spleen. The breathing is often quick ; there is some cough ; and evidence of the presence of active conges- tion, or of acute inflammation of the lungs, is rarely wanting at this or a little later period. The bladder is very liable to become distended at this stage. These symptoms may persist with greater or less severity for the next week or ten days, the patient passing from two to six watery ochre-colored stools, containing a few shreddy flocculi, every day. The tongue becomes dry, with red irritable edges and tip, and elsewhere covered with a yellow- ish-brown cracked fur. If the patient have escaped the dangers of hemorrhage and perforation, he may, at the end of this time, begin to progress towards re- covery, or, if the symptoms take an un- favorable turn, he will almost surely die. When the purging has persisted for weeks, the days are critical. The following is a common case of Enteric Fever, beginning apparently in ordinary diarrhaa : — Case 2. — E. K., aged 19, a well-nour- ished healthy woman, taken while on a journey of pleasure with shivering and purging, followed by headache and gene- ral pains. The bowels had been regular previously. The purging and other symp- toms continued, and she became slightly feverish, and lost appetite. She took to bed on the fifth day of her indisposition, and was admitted into the hospital on the ninth, presenting the following symp- toms : — Pulse 104, full ; skin hot ; tongue moist, and coated with white fur, which is disposed to form cracks ; bowels very loose ; motions fluid, light, ochre-colored; abdomen tender, three distinct rounded and elevated rose-colored papules here and there ; there is great thirst, and the patient is very feverish and fretful. Tenth day : tongue very thickly coated, cracked in the centre, clean and red at the tip and edges; bowels very loose ; stools of green- ish fluid ; twelve or thirteen fresh papu- lar spots on abdomen. Eleventh day: [' Vomiting is mucli more common in chil- dren than in adults. — H.] CLINICAL HISTORY OF THE DISEASE. 205 ilse 96 ; tongue moist and superficially sured ; bowels still very loose ; twenty- mo fresh spots on abdomen ; great pain ross the abdomen and round the back. •iielfth day: tongue dry and brown at e tip and down the median line, aside which it is covered witli a thick crust ' cracked yellowish-white fur ; sides are oist and clean ; stools frequent, copious, ■ light yellowish-brown fluid, possessing 1 acid reaction, and containing ragged sUowish flocculi ; abdomen a little full ; •eat tenderness and gurgling in the right iac fossa; some fresh spots. Sixteenth ly : the patient is emaciating very ra- idly ; pulse 90 ; tongue dry and red, de- aid of tur except at base ; purging a little iminished the last few days ; yesterday's ad this morning's stools together dark- h-brown, fluid, alkaline ; retention of fine, three pints drawn off; a few fresh Dots, most of the old ones having faded lid disappeared. Eighteenth day : no ■esh spots ; pulse 104, feeble ; passes rine spontaneously. Niiieteenth day : ulse 120 ; tongue dry, somewhat con- racted, covered with a thin, dry, cracked, ellowish crust ; much pain in the back nd belly; cannot lie on the back "be- ause it hurts her breath;" respirations Ij ; some fine crepitation at both bases ehind ; abdomen very tender ; only two r three spots now visible ; one copious chre-colored stool this morning. Twen- 'elh day : pulse 136, feeble ; one copious .ght-brown watery stool ; skin cooler ; leeps well ; has been sick two or three imes. Twenty-third day : is much better; lulse 100; tongue clean and moist, ex- epting a dry median streak ; bowels not pened for two days ; the rash has wholly .isappeared ; hunger. Twenty-fifth day : lulse 80 ; bowels act once in two days ; tools light fawn-colored, semi-solid ; ab- lomen natural, bears moderate pressure ; ongue moist, but furred ; hunger ; to ake soUd food for the first time— fish and iread. Thirtieth day : slight relapse to- iay_; pulse 108 ; anorexia ; thirst ; pains Q limbs ; headache ; skin hot ; abdomen lainful ; no action of the bowels to-day ; 10 fresh rose spots. Thirty-first day : in- rease of the feverish symptoms; pulse 2b ; a little diarrha3a ; stools light yel- ow ; a copious eruption of sudamina upon he abdomen. From this date she con- inued to improve, and was convalescent m t\ie, fortieth day. In the third class of cases the symptoms -re so sudden and severe that there may >e suspicion of poisoning by some acrid larcotic, such as colchicum or poisonous nushrooms. We find the patient in a tate of high fever ; there is intense heat if the head ; acute delirium ; frequent omiting and purging ; the tongue is red nd dry ; the abdomen tense and painful. Ve learn that his illness commenced a few days ago, with vomiting, purging, and great headache. The patient lapses into a state of stupor ; the diarrhcea per- sists, and he soon passes into the typhous condition, and dies on the eighth or fifth day, or even earlier. Tlie foUowing is a good example of this class of cases : — Case 3.— Alfred S., aged 20, a powerful well-developed man, was admitted into the London Fever Hospital, October 7, 1865, in a state of stupor, pulse 156, very feeble, tongue dry and brown, conjunc- tivfe injected, head hot. He lay pros- trate, passing liquid stools involuntarily, and died comatose twelve hours after ad- mission ; there was no rose spot or other rash upon the skin. His friends stated that he was suddenly taken ill with sick- ness and purging, followed by fever and delirium. The matters voided were of a bilious character. Autopsy. — Body well nourished, skin clear. Head — meninges, and brain, quite healthy ; the ventricles and theca verte- bralis contained only one ounce and a half of serum. C/iest— lungs engorged, weigh three pounds, everywhere crepi- tant. Heart healthy, small clot in right ventricle. Abdomen — liver weighs three pounds three ounces, softish and flabby, a little fatty ; gall-bladder distended with pale watery faintly acid bile of the color of urine. Spleen enlarged, weighs four- teen ounces, natural in color and consist- ence. Stomach slightly injected at the great end; duodenum and jejunumhealthy; ileum of a violet color externally ; seven feet from the ileo-csecal valve, a Pe3'er's gland, an inch long, was slightly swollen, and presented a prominent vascular ele- vation at one end. In the last six feet every Peyer's gland partially or wholly red, swollen and reticulated. In the last four feet the glands were much elevated and the villous surface abraded ; the larger patches were raised a fourth of an inch above the level of the mucous mem- brane ; all were very soft, and exceed- ingly vascular, and of a fiery red color. Between the Peyerian glands were innu- merable solitary glands, forming eleva- tions the size of a pea, surrounded by bright red areote, and presenting yellow- ish unbroken apices. The intervening mucous membrane highly inflamed. The valve much swollen and deeply wrinkled. Cfecum and first foot of colon thickly strewn with swollen solitary glands as large as peas, having sloughy centres. A biliary calculus, the size of a kidney bean, lay at the lower end of the dilated appen- dix, which was healthy, excepting where one solitary gland formed a vascular ele- vation. A few of the solitary glands in the transverse colon were enlarged ; with this exception, the large intestine was quite healthy. The follicular glands, at the root of the tongue, were injected and 206 ENTERIC OR TYPHOID FEVER. swollen. The mesenteric and mesocolic glands were enormously swollen, congest- ed, and soft. The mucous membrane of the larynx, trachea, and bronchi was very red and covered with frothy mucus ; the kidneys were congested ; the bladder con- tained eight ounces of clear urine. The two following cases illustrate the difterence in the progress, termination, and effects of the disease in different indi- \iduals under the same general con- ditions : — Two young men — J. Bennett and C. Beale — of the same age, and equally strong and well nourished, and resident together in a house in the immediate vicinity of King's College Hospital, were taken ill with febrile symptoms, the former on the 14th of August, 1865, the latter a week afterwards. Both patients died ; Ben- nett on the 12th of September — the thir- tieth day of the disease ; Beale on the 13th of the same month — the twenty-third day of his illness. The rose spots were not developed in either case. Case 4. — Bennett was admitted into King's College Hospital on the fourteenth day. He stated that he was attacked with headache and shivering, followed by sweat- ing, general muscular pains, and sore throat. An aperient produced a loose state of the bowels for a day or two. De- glutition was very painful for three or lour days. He got better, but remained very feeble, and did not recover his appe- tite. On admission he was pallid and weak, the throat had recovered; the tongue was moist, and the pulse but slightly ac- celerated ; there was no diarrhoea, no rash, no abdominal pain or tenderness. He appeared to be suffering debility from a previous febrile attack. He continued to improve, regaining a little strength and appetite, and was discharged at the end of a week. On leaving the hospital he went to his work, but soon felt too weak and ill to continue it, and after three days he again applied for advice, and was readmitted into King's College Hospital on the 8th of September, when he came under my care. He was dull, peevish, and prostrate ; since he left the hospital the bowels had been loose. At this date there was moderate diarrhcea. The face and skin were pal- lid, the latter hot, perspiring, and free from rash ; the abdomen slightly tympa- nitic and tender. Pulse 108. Tongue dry and brown, covered with a thick cracked crust. Kespirations 42 ; slight dulness and fine crepitation over the back of the chest. During the next four days he lapsed into stupor, and lay on his back with the eyes closed, the knees a little drawn up, moaning occasionally, and picking with -his fingers, the wrists and forearms being constantly twitched. The diarrhcea was soon checked by sulphate of copper and opium, but he resisted when attempts were made to open the jaws and administer drinks ; the pulse and respira- tions increased, and he died comatose, four days after admission, on the thirtieth day of the disease. jSfecroscrypy nine hours and a half after death.— Body somewhat emaciated, vis- cera warm, blood fluid. Chest — lungs congested, bronchi much injected, two yellow masses of solid matter, the size of peas, like tubercle, in the lower lobe of the right lung near the border. Heart healthy, contained a pale soft clot. Abdome'nr— liver enlarged, weighed three pounds nine ounces ; bile pale, watery, small in quan- tity. Spleen of natural consistence and color, weighed ten ounces and a half. Mucous membrane of the large end of stomach much congested. Peyer's gla" Is of the upper portion of the ileum swollen, vascular, and reticulated ; all those, and great numbers of the solitary glands in the lower four and a half feet of the ileum greatly swollen and superficially ulce- rated, the larger glands forming fungous elevations, with margins raised a fourth of an inch above the level of the thin wall of the bowel, and resembled lar^e indu- rated chancres. Fig. 9 (p. 211) repre- sents one of these glands situated at a distance of 15 inches from the lleo-csecal valve. The centres were slightly de- pressed, and stained of a dirty greenish- iarown color. The swollen glands were firm and transversely wrinkled. The solitary glands formed smooth rounded elevations, the greater number corre- sponding in size to the tips of the fingers; each one presented a firmly adherent cen- tral slough. Caecum healthy, but the solitary glands throughout the rest of the large intestine, including the upper part of the rectum, formed sloughy elevations like those of the ileum. In the sigmoid flexure there were fifty-four such eleva- tions. In the transverse colon only six. In the ascending colon they were as thickly strewn as in the sigmoid flexure, The mesenteric and mesocolic glands were greatly enlarged, vascular and sottish. The brain was not examined ; all the other orgahs were healthy. Case 5.— Beale was admitted under my care into the London Fever Hospital on the 1st of September. His illness com- menced a week previously with anorexia, cold chills, headache, sickness, pain in the bowels, and diarrhoea. Eighth day: pulse 96; tongue moist and furred at the margins; skin pallid and not, no rash, no headache ; mind quite clear. Abdomen slightly distended; gurgling in the right iliac fossa. Eleventh da.y: bowels became very loose, and the abdomen tympanitic and tender. Twelfth day: pain in the ab- domen; in the evening bowels very loose. Eighteenth day : febrile condition con- CLINICAL HISTORY OF THE DISEASE. 207 tinues ; pulse 108 to 120 ; tongue moist and furred; skin hot, free from rash; face very pale. The abdominal symptoms — diarrhoea, tympanites, and abdominal pain — have daily increased in severity since the twelfth day, and to-day there is evidence of general peritonitis ; six leeches were applied to the right iliac fossa. Nineteenth day : leeches caused profuse bleeding, which was stopped with difficulty by the nitrate of silver; pulse 132, weak; tongue dry and brown; bowels quiet. He gradually sank, and died on the twenty-third day of his illness, retain- ing a clear intellect to the last. Autopsy. — Body somewhat emaciated. Chest — lungs weighed fourteen ounces, floated in water, contained a dirty-brown fluid. Heart healthy, contained a color- less clot in the right ventricle. Abdomen displayed the effects of general peritonitis, the lower part of the cavity contained about a quart of turbid serum, and the coils of the small intestine were adherent to each other, and to the lower part of the abdominal wall, by layers of solid lymph. Liver weighed three pounds and a quar- ter, soft, friable, and fatty. Bile mode- rate in quantity, of light ochre color, wa- tery, and very acid, instantly turning blue litmus paper bright red. Spleen weighed ten ounces, of natural color and consist- ence, but flabby. Intestines distended ; on separating the purple adherent coils of the ileum, a perforation a fourth of an inch in diamgter was discovered six inches from the csecum; the opening in the intestinal wall was plugged with the solid lymph that adhered to the contiguous coils of the bowel, so that there was no escape of fecal matter into the peritoneal cavity. Stomach, duodenum, and jeju- num liealthy. Intestines contained some smooth, soft, formed feces, varying in color from light ochre to dirty white. Macous membrane of the ileum uniformly red and inflamed, covered over with tena- cious firmly adherent mucus of a bright ochre color. The solitary and agminated gknds of the upper portion of the ileum quite healthy; lower down they were vas- cular and swollen; two feet from the ca3- cum the first signs of ulceration, and in this last portion of the ileum the solitary glands were swollen to the size of a pea, and presented ragged excavated centres. The last twelve inches contained several Peyer's glands in a ragged state of ulcera- tion, the ulcers having raised, firm, very vascular, and angry-looking edges, and irregular depressed surfaces, formed ap- parently of yellow sloughs, adhering to a raw, almost bleeding surface, beneath. These sloughs could be readily separated with the finger-nail. Their lower surface had a yellowish color; they were friable, and some parts had an almost cartilagi- nous consistence and paler color. After washing and careful examination these sloughs were found to be composed of solid lymph, agreeing precisely in physi- cal and microscopical characters with the solid lymph which adhered to the cor- responding peritoneal surface of the bowel. The harder and whiter portions were com- posed of lymph contained in the meshes of the areolar tissue of the gland, and were, therefore, really sloughs. The more advanced ulcers were seated on the in- flamed and tliickened muscular layer. The perforation corresponded to the cen- tre of one of the large ulcers. The csscum, colon, and rectum, free from inflamma- tion and perfectly healthy throughout, and the solitary glands inconspicuous. Mesenteric glands greatly congested and swollen; those lying in the angle of junc- tion between the large and small intes- tine, the size of pigeons' eggs. Pancreas hardish, but apparently healthy. Blad- der emptj-, healthy, as were the remain- ing viscera. These two closely-associated cases are interesting, as illustrating the influence of constitution upon the progress of the dis- ease. Bennett died in a typhous state from nervous complication, and with an amount of intestinal disease at least six times greater than that to which Beale succumbed a week earlier. Yet the in- testinal disease in Bennett's case was la- tent to within five or six days of his death; the solid thickening of the affected glands (see Morbid Anatomy) forming, and promising to continue to do so, an effectual security against perforation. One of the parents of this young man died of consumption, and he himself had evi- dently been aflected with syphilis. Condition of the Alvine and Urinary Ex- cretions in Enteric Fever. — (a) The Stools are remarkable for their fluidity and the absence of healthy bile; they have a pale ochre or drab color, and a sickly, offensive odor. On standing, a flaky matter is de- posited, composed of epithelium, disinte- grated sloughs from the intestinal ulcers, and undigested particles of food. Accord- ing to i)r. Parkes (Med. Times, June, 1850, p. 39C), the supernatant liquid has a specific gravity of 1015, and contains about 40 parts in 1000 of solid matter, consisting chiefly of albumen and soluble salts, particularly chloride of sodium. The stools are already in a state of de- composition, and after standing a short time are almost invariably alkaline. Im- mediately after they are passed they often have a neutral and sometimes an acid re- action. The offensive ammoniacal fluid contains much triple phosphate. If salts of bismuth, lead, silver, or cop- per, have been administered, the dejec- tions have a dark greenish-brown, or black color. (6) The Urine in Enteric Fever does 208 ENTEKIC OR TYPHOID FEVER. not differ appreciabljr from that excreted in other inflammatory diseases. On tlie first accession of tlie febrile symptoms its quantity is usually diminished, but after- wards it becomes copious. As in all other febrile states, the chlorine is greatly diminished and the urea and uric acid in- creased. The chlorine is often reduced to a mere trace. The quantity of urea and uric acid excreted appears to be pro- portionate to the degree of fever ; when the p3-rexia is at its height, the quantity of these constituents excreted in twentj-- four hours is usually doubled, sometimes trebled. As the fever declines the quan- tity of urea and uric acid diminish to the normal quantity or below it, while the chlorine reappears more slowly. In case 2, sixty ounces of darkish-colored, clear, acid urine were drawn from the bladder on the sixteenth day. After standing twenty-four hours it was quite bright and free from deposit ; specific gravity 1024. One fluidounce contained a quantity of chlorine equivalent to 0'3G grain of chlo- ride of sodium, 14-8 grains of urea, and ■3 grain of uric acid : or, in the sixty ounces, 22 grains of chloride, 889 grains of lu'ea, and 18'9 grains of uric acid. On the ticenty-first day, when the febrile S5'mp- toms began to subside, the urine was co- pious and neutral ; specific gravitjr 1016'4. A fluidounce contained a quantity of chlorine equivalent to 3 '9 grains of chlo- ride of sodium, and 5'8 grains of urea. On the tioenty-third, the urine was copious, of specific gravity 1010, clear, pale, and a fluidounce contained a quantity of chlo- rine equivalent to 3 '2 grains of chloride of sodium, and 5-8 grains of urea. A small quantity of albumen often appears during the height of the fever. Occasional Symptoms and Accidents. — Peritonitis, local or general, is liable to arise whenever the ulceration of the coats of the bowel extends deeply towards the peritoneum. This membrane becomes highly inflamed in places corresponding to the bases of the ulcers, and from these circumscribed patches of inflammation the increased vascular action may spread and involve the peritoneum more gen- erally, and produce considerable serous effusion. Perforation is occasionally pre- vented by the adhesion of the inflamed patch to a neighboring coil or coils ; and if it should occur after this adhesion has been effected, a circumscriljed abscess, which may ultimately discharge itself into the bowel, is formed. Perforation frequently occurs, however, under less favorable cir- cumstances, and the fecal matter is ex- travasated into the peritoneal cavity. Sudden increase of pain, accompanied by vomiting, and soon followed by cold, clammy sweats, and collapse, announce the nature of the accident. Sometimes sudden collapse alone is the only indica- tion of this fatal issue. In other cases the jjcrforation has taken place so gradu- ally, the aperture formed is so small, and the extravasation so inconsiderable, that the symptoms of peritonitis come on and attain their maximum very gradually and without any sudden increase in the severity of the sj-mptoms. Perforation of the Powel usually occurs within six inches of the ileo-csecal valve, and in almost every case it is the small intestine which is perforated Kcxt to the lower end of the ileum, the csecum is most liable to perforation. "Out of 435 autopsies recorded by Bretonneau, Cho- mel, Montault, Forget, Waters, Jenner, Bristowe, or made at the London Fever Hospital, perforation was observed in sixty cases, or 13 '8 per cent." (Murchi- son, p. 511.) Tympanites is present to some degree in almost every severe case. It usually comes on a week or nine days after the purging sets in. When excessive, it is a very grave symptom. It usually precedes perforation. Intestinal Hemorrhage is a frequent acci- dent in severe cases. It was observed in twenty-nine out of 139 cases observed by Murchison, Louis, and Jenner. It is a grave S5-mptom, inasmuch as it generally indicates deeply-extended ulceration. The hemorrhage, however, frequently has its source in the congested capillaries of the common nmcous surface, near the junc- tion of the large and small intestines, The blood is never much changed. If the intestinal fluid be acid, it will be dark. The quantitj' of blood passed from the bowel does not always indicate the amount of the hem orrhage. In the case of a young girl which I witnessed, under Dr. Todd's care, in King's College Hospital, a trilling hemorrhage appeared, and shortly after, death occurred from syncope. The small intestines were found distended with red, clotted blood. Retention of Urine is frequently present at the height of the early pj-rexia. This condition cannot be overlooked for many hours unless there be considerable de- lirium. Pregnancy. — Abortion is almost certain to occur if a pregnant woman be attacked with Enteric Fever. The only two preg- nant women who have come under my care aborted, the one at the third month of gestation, the other at the fifth. Both recovered well. Phlegmasia dolens is apt to be a secondary complication in such cases. Scqxiclcc. — Marasmus is the necessarj' attendant and consequent of extensive and prolonged disease of the mesenteric glands. After morbid action has ceased in these, they often become atrophied, and remain fcr a long time in a shrivelled, flaccid condition. In some cases the di- MORBID ANATOMY. 209 gestive and assimilating functions remain so defective tliat tlie patient lails to regain appetite and tiesla, and slowly starves to death. Imbecility. — Patients who continue long in a state of extrenxe emaciation com- monly manifest proportionate defect of mental power. Tliey become forgetful and apathetic. Tubercle of the Lung is considered by some physicians to be a common sequel of Enteric Fever. Many cases presenting such an apparent sequence may be re- garded as instances of tubei-culosis ab initio. See "Associated Pathology" of Enteric Fever. Partial Anasarca, unassociated with albuminuria, is an occasional sequel of Enteric Fever in enfeebled constitutions. Oeneral Anasarca is rare. A scrofulous girl, E. Gain, aged 18, lately came under my care in the London Fever Hospital, with well-developed Enteric Fever. Gen- eral anasarca suddenly appeared on the thirty-fourth and thirty-tiftli day of the disease, when the stools were solid, and she was convalescing favorably ; she had not, however, left her bed. (Edema ap- peared simultaneously in the lower ex- tremities, the face, and hands ; it was preceded by acceleration of the pulse and increased heat and dryness of the skin, which was pallid, and rough from flna desquamation of the cuticle. The tonguj was red and glazy, with very prominent fungiform papillffi— a condition which had existed throughout. The anasarca in- creased from day to day, and was asso- ciated with considerable ascites. The integuments of the abdomen and chest were very oedematous. At one time the eyelids were closed by swelling, and the patient altogether presented the same appearance as one laboring under an attack of acute dropsy after scarlatina. Simultaneously with tne development of the anasarca, albumen appeared in the urine, and became very abundant. The secretion, however, retained its natural color, and was normal in quantity, and, as long as the patient remained under my care, was free from renal casts or other deposits.' Morbid Anatomy. Wherever the source of morbid action m Enteric Fever may lie, its effects are constantly manifested in the small intes- tine, and it is upon the solitary and ag- minated glands of the lower third of the ileum that the disease usually expends its virulence. Without positive evidence of inflamma- tory action in these glands, the disease would not be Enteric Fever. How far the converse of this— the inflammatory VOL. 1.-14 lesion of Peyer's patches is always due to a specific Enteric Fever— is true, will ap- pear upon consideration of the Associated Pathology of the disease. Morbid changes, consequent upon En- teric Fever, are found (a) in the solitary and agminated glands of the intestine ; (b) in the mesenteric glands ; (c) iu the spleen ; (d) in the liver. («) The Solitary and Agminated Olands. — A Peyer's gland or "patch" presents in a state of health a variable number of rounded, shallow, concave depressions, averaging j'g of an inch in diameter, and separated by narrow linear ridges of mu- cous membrane, running in from the gen- eral mucous surface and on a level with it, and forming a network, in the meshes ot which — i. e., in the depressions — the so-called "closed follicles" lie. In death, after the ninth day, from Enteric Fever, we shall rarely fail to find these and the solitary follicles iu every stage of inflam- mation. At the distance of four feet from the ileo-ciBcal valve we shall generally find Peyer's glands in their normal condition. Six inches nearer the valve we may find one in the earliest stage of inflammation ; it is slightly swollen, and raised above the general level of the surrounding mucous membrane, and it is a little more vascular than in health. ' On careful examination the swelling is found to implicate the net- work of mucous membrane chiefly ; the ridges between the closed follicles are more vascular, wider, and more prominent than in health ; and the intervening de- pressions are thus contracted and deep- ened, and the patcli is more distinctly reticulated. The follicles themselves ap- pear to remain unaltered ; minutely ex- amined under water, they have a dark, semi-transparent, violet-gray appearance, while the intervening ridges are injected with minute divergent bloodvessels. Seen 'at a distance, the patch is clearly distin- guishaljle from the common mucous sur- face. The general appearance is that of a fine pink oV white swollen network, with dark rounded meshes. Passing downwards towards the ileo-C£ecal valve, each succeed- ing gland presents the above-described characters in a more marked degree, and the patches consequently become more ' Roederer and Wagler call attention to a black dotted appearance of these glands, " resembling a freshly-shaven beard." Tliis is the forme pointille of French writers. We have frequently seen this appearance, in per- sons dead of disease not affecting the intes- tines, produced by the exhibition of metallic salts. The cellular constituents of the intes- tinal glands become impregnated with the iron or copper salt, and on contact with the bile, a black sulphide of the metal is formed, dyeing these minute corpuscular masses black. 210 ENTERIC OR TYPHOID FEVER. prominent and distinct. Fig. 1 repre- sents an ^_agminate(l gland in this early stage of intlamniatiou. It was situatetl thirty inches from the ileo-csecal valve. Commencing Inflammation in a Peyer's patcli. The ridges were wide, prominent, and very vascular, and the depression con- tracted and deep ; at «, the swelling and contraction were greatest. Pig. 2 repre- Fig. 2. -^!^Z^^^4^il^^^t^ Inflamed agminated gland. sents the next patch, nearer the coecum. This gland was much s^vollen and soft, and formed a prominent, fungous-like projection of the mucous membrane. Its borders rose abruptly from the general mucous surface, and were smoothly round- ed, devoid of reticulation, and slightly more elevated than the central parts of the patch. The ridges were greatly swollen, so as to convert the depressions into minute deep pits. The next stage consists in the breaking dovrn of the swollen mucous membrane around the dark pits, and the formation of circular aphthous-like ulcers, each having for a centre a depression corresponding to a closed follicle. If this disintegration be general, the swollen gland soon presents a ragged, spongy appearance ; examined under water, we find the irregular surface to be composed of a fine stroma of dirty, shreddy, fibrous tissue, containing a num- ber of circular, rounded excavations : these are the follicles ; they have not un- dergone further enlargement than slight thickening of their walls, which are thus rendered very distinct. In many places the follicles are seen to be dissected out, and only loosely connected with the sur- rounding shreddy tissue. The glands in the last foot of the iUaim are always more or less implicated, and the innumerable and closely-placed solitary glands which form an almost continuous layer around the last two inL-hes of the small intestine, — and which in some subjects are aggre- gated into one great terminal gland, the margin of which is coincident with the margin of the valve itself, — never alto- gether escape : and usually, indeed, the tnflammatioii appears to have expended its ^vhole force upon the glands of this part, and we find nearly the whole circum- ference of the last two inches of the mu- cous membrane greatly swollen, and in a ragged state of disintegration. The mar- gin of the valve is not infrequently found as thick as the lips of the subject, and this part of the bowel usually presents a dirty ash-gray appearance, veined with blackish-purple ramifications. Some glands are merely swollen, and their turgid, evert- ed margins overlap the contiguous mu- cous membrane ; others are converted into ashy sloughs {forme ganyreneuse, Cruveil- hier), and often deeply stained with bile, sometimes dyed with blood. In some cases the ulcers are vascular and angry- looking ; in others they are pale, anaemic, and have but slightly raised margins. Just as the inflammation does not always equally affect all parts of the Peyer's patch, so we very often find that the ulcer- ation may be partial. A given gland may present one or several distinct ulcers. They rarely exceed fths of an inch in dia- meter ; they have rounded, elevated bor- ders, and at first sloughy, ragged, broken- down centres ; the most advanced ones have the bare, smooth layer or circular muscular fibres, or only a little interven- ing areolar tissue, for their bases. In the early stage the muscular tissue is pale and free from inflammation, but sooner or later it becomes red, thickened, and soft, and soon yields to the ulcerative pro- cess. The longitudinal layer yielding in like manner, the diminishing base of the ulcer comes to lie upon the peritoneal coat. In proportion as the base of the ulcer now nears the peritoneum, so does that membrane increase in inflammation: and if the ulcers be deep and numerous, the inflamed patches become confluent, and the outer surface presents the appear- ance of intense inflammation, and is oc- casionally covered with a layer of plastic lymph. Occasionally the ulcerative pro- cess extends through the peritoneal cover- ing, and symptoms of perforation ensue immediately, or are retarded for a time by the adhesion of solid lymph exuded MORBrD ANATOMY. 211 upon its outer surface. The aperture formed in tlie peritoneum rarely exceeds tliree lines, and it is almost alwaj's formed within a distance of six inches from the ileo-csecal valve. Sometimes the whole patch is converted by the confluence of smaller ulcers into a single deep ragged one, the sharp and perpendicular edges of which irregularly excavate the red, tumid mucous membrane immediately surrounding the diseased gland. Occasionally the inflammatory process does not pass so soon into the gangrenous or ulcerative stage, and the glands become firmer and more prominent ; the reticula- tions are completely eftaced by the swell- ing, and the surface of these expanded, mushroom-like projections has a granular appearance (forme granuleuse^ Cruveil- hier). Glands in this condition may be restored to their natural state by resolu- tion, or they may pass into the subsequent stages of gangrene or ulceration. The ^'■Plaques dures'''' of Louis, which "aTin- cision offrent une section ferme, lisse, et brillante," are very rarely observed in Enteric Fever distinguished from tuber- culosis. In upwards of thirty fatal eases which I have examined, I have found this condition in only one (case 4), and in this I am inclined to attribute it to syphilitic taint. Fig. 3 represents one of the Fis; Thickened and altered Peyer's gland, c above, b. Vertical seetion. , View from chancre-like Peyer's patches from case 4 : h will serve to convey an idea of the uni- form thickening of the gland, overlying tlie unaltered muscular and peritoneal layers. ^ The solitary glands of the small intes- tine, and frequently also those of the ciecum and ascending colon, share more 01' less in the above-described changes. These minute glands occur in increased numbers towards the ileo-csecal valve, whore they become closely aggregated. Placed beneath the mucous membrane, and attached to its under surface, they lie loosely imbedded in the siibmucous areolar tissue, and in their healthy con- dition are hardly perreptible. In many cases of Enteric Fever we find the last two feet of the ileum strewn with minute, round, semi-transparent eleva- tions, varying in size from a mustard to a hemp seed. These are the solitary glands in a state of inliamniation. In this early stage of the inflammatory process they have the appearance of a fine miliary eruption, and constitute the condition known as "Psoreiift/j'e." Wlien the soli- tary glands attain a larger size, and be- come a little harder and more opaque, the mucous membrane appears as if studded with pustules [ftirme jjM,<.(»/t'».sc, Cruveil- hier). This appearance gave origin to the idea that Enteric Fever was ''intestinal Variola." These swollen glands, how- ever, are almost always solid : in only one case have I observed them to contain a yellow pultaceous matter, resembling in- spissated pus. If all the solitary glands be involved in the inflammatory process, the mucous membrane is thickly studded with them, and in the last two feet of the ileum the distance between them will average about |th of an inch. When an aggregation of a few solitary glands is swollen, a stud- shaped elevation is usually formed. According to my own observations, the solitary glands are affected in proportion to the severitj' of the inflaunnation of the Peyerian glands. In very rare cases the solitary glands alone are aflTected in Enteric Fever. In many cases the disease is equally de- veloped in the small intestine and caacum; once I have seen death from ])erforation of the ca;cuni. Occasionally the large in- testine is more extensively ulcerated than the small. In case 19, for example, the small intestine escaped, and the inflam- mation affected the solitary glands of the large intestine almost exclusively. In proportion as the solitary glands are inflamed and swollen, they cause a pro- jection and thinning of the mucous mem- brane. Attentively'exaniined underwater with a pocket-lens, they are seen to be of a delicate pink color, aiid exhibit a minute dark central point. Occasionally the swol- len gland presents a yellowish summit surrounded by a minutely injected areola of converging liloodvessels. Ulceration commences by the softening and abrasion of the mucous membrane around the sum- mit of the gland, the disintegration then becomes deeper, and spreading outwards, minute circular ulcers, with sloughy, shreddy centres, and purple, tumid mar- gins, are formed. These ulcers rarely ex- ceed |ths of an inch in diameter. Their further progress is identical with that of the ulcerated agminated glands, and they are equally liable to produce hemorrhage 212 EiNTERIC OR TYPHOID FEVER. and to perforate the bowel. In most cases we find a few of the solitary glands of the Cfecum and large intestine thus inflamed and ulcerated." Occasionally the glands of the large intestine are more or less im- plicated along the chief part of its extent, and by the confluence of the small ulcers very large ones are sometimes formed in the caecum and ascending colon. The direction of these ulcers is generally trans- verse. In Enteric Fever, ulceration al- ways commences in the solitary or agmi- nated glands ; and if these were the only "follicular glands" in the intestinal canal, the term "Follicular Enteritis," byAvhich Enteric Fever has been distinguished, would be a very suitable one. We have now to consider the nature of that morbid process, the elfects of which have been described. From the descrip- tion just given, it is clear that the process is an inflammatory one. Usually there is evidence of very acute inflammation. It will be inferred from the foregoing de- scription of the diseased glands that the inflammatory products arc formed around the closed follicles, and not in their inte- rior. Very careful observation leads me to speak positively on this point. If the new material ^vere formed within the closed follicles, as Goodsir concludes, the follicles would indeed " become much dis- tended," and, as a result, they would form projections upon the surface of the Peyer's patch, which I have never observed to be the case. On the contrary, I have always found them in the earliest stages of the inflammation to be placed far below the swollen ridges of mucous membrane and submucous tissue surrounding them ; and in the latter stages, the follicles are com- pletely buried beneath the inflamed sur- face of the patch, and concealed from view, and it is only when the excessively vascular and turgid ridges of the mucous membrane and subjacent tissue are dis- integrated, that the follicles are again dis- covered, lying deeply in the abundant submucous tissue, and exhibiting little or no increase of size. The parts imme- diately surrounding them appear to have undergone consideralMe disorganization ; for the follicles are often dissected from the surrounding parts, and remain at- tached to them by only a few tough fibres. In health, each follicle is surrounded hy a close network of bloodvessels, which, as far as I have observed, chiefly constitutes the wall of the little gland ; from this pa- rietal network other branches, exceedingly tine and delicate, pass towards the centre of the parenchyma. If the vascular ex- citement be moderate, the central, as well as the circumferential parts of the gland, may increase in size ; but usually the in- flammation is acute. Cut ofl:'from all otlier parts of the circulation, and surrounded by inflamed vessels, congestion and stasis would very soon occur in the delicate ves- sels whicli pervade the parenchyma ; aud thus, whilst the parts external to the fol- licles would be increasing under the influ- ence of the inflammation, the central parenchymatous parts would undergo no increase, but would tend to atrophy and disintegration. Hence the formation of the centrifugal ulcers and sloughs around the foUicle ; and such, indeed nmst alwa}'s be the results of inflammation in parts which have a similar arrangement of bloodvessels within them. Slrmiure and Chu.ructers of the Inflam- matory Product. — This we find to be cel- lular. On examining vertical sections of Peyer's patches in the early stage of in- flammation, represented in iig. 1, we find that the submucous tissue is composed of a very loose network of very elegantly waved and reticulated fibrous tissue, from which the so-called walls of the closed fol- licles are not defined. The meshes of this network are filled with finely granular corpuscles of various sizes, chiefly spheri- cal, and averaging jn'.nth of an inch in diameter. (Fig. 4.) A few cells of adi- Fig. 4. Fibrous reticulum, with inflammatory corpuscles. pose tissue, arranged in single rows, are occasionally seen. .Sections through the more advanced and ulcerated patches pre- sent the same arrangement of the fibrous stroma ; the cells are equally numerous, but they are a little larger, and of more uniform diameter, averaging j^sth of an Eulargel graoular corjuisfles and reticulated structure. inch, and a little more darkly granular. (Fig. 5.) Here and there a corpuscle is MORBID ANATOMY. 213 observed containing one or more spherules of oil. Sections of the firmer swellings (forme gaiifree), and of those in a more advanced stage of ulceration, show that the corpuscles undergo fatty degeneration, and subsequent molecular disintegration. In these we observe multitudes of en- larged corpuscles containing spherules of oil, and much intercorpuscular molecular matter. (Fig. 6.) Eokitansky speaks of "the deposition of a typhous product" in the inflamed glands. The swelling, ac- cording to my own observation, is due to the rapid growth of the corpuscles form- ing the parenchyma of the glands, whether Peyerian or mesenteric. Not unfrequently fibrinous exudation forms upon the surface of the ulcerated gland (case 5), or amongst its cellular con- stituents (case 4). Sections of the gland, which I have delineated in fig. 3, showed the elements represented in fig. 6, inter- spersed with minuter corpuscular matter and molecular fibres. Fis. 6. Corpuscles from ulcerated gland. The villi upon the diseased patches and contiguous mucous membrane have a smooth outline and are denuded of their epitlielium. They present a finely granu- lar appearance, due to the presence of in- numerable homogeneous, yellowish-tinted, refracted granules, which average -EnVtith of an inch in diameter. Some attain iiVsth of an inch ; others are mere mole- cules. Fig. 7 represents a minute portion of such villus highly magnified. Fig. 7. Portion of granulated villus, Peyer's gland. Stages of the Local Disease.— Since the disease is usually developed so very in- sidiously, it will be difficult, and in the early stages impossible, to predicate with certainty the actual condition of the in- testinal glands. The following generaliza- tions, however, may prove useful (see also Diagnosis). For the first nine days the glands arc undergoing inttammatory swell- ing, and at the end ot this period they will be found projecting three or four lines from the mucous membrane, in the form of red, or purplish, fungous, soft excres- cences, free from erosion. If death occur any day before this period, we shall find the glands more or less advanced towards this condition. About the tenth day the inflammation either subsides or increases. Resolution is eflected in the usual way by diminution of the vascularity and swelling. If the inflammation increase, the swollen glands become a little firmer, and on the eleventh and twelfth days present softening, and erosion of the mucous membrane covering them. Fourteenth day : circular disintegrations around the follicles ; a spongy sloughy ajipearance of the abraded patch, which is frequently stained of a deep ochre color by the bile — the formation and separation of ashy sloughs. Sixteenth day : complete separation of the sloughs, leaving ulcers limited below by muscular fibres or peritoneum and surrounded by red, swollen margins of mucous membrane ; erosion of bloodvessels, and hemorrhage. Twentieth day : cicatrization begins. For- tieth day : cicatrization completed. Separation of the Intestinal and other Lesvms. — In those who have died during a relapse of Enteric Fever, or at an ad- vanced period, of pulmonary or other com- plication, we may often observe the pro- cess of reparation of the local disease. The following case exhibits the condition of the abdominal viscera during recovery from a severe attack of Enteric Fever, with pneumonia. Tlie patient died of gangrene of the cheek (cancrum oris) and lungs. Case 6. — Joseph Taylor, aged 15, came under my care, August 15, 18G5. He had been ill three days with headache, nausea, diarrhoea, and fever, and presented on ad- mission all the sjrmptoms of well-developed Enteric Fever (without rose rash, which never appeared), and pneumonia of the left lung. On the sixteenth dfiy : pulse 144 ; respirations reduced to 28 ; diarrhoea and abdominal tenderness somewhat abated ; dulness and fine crepitation over both bases of lungs behind. Three black sloughs, the size of peas, have formed in the mouth, two on the gums and the third on the centre of tiie left cheek. Nineteenth day: pulse 102, hardly perceptible ; tongue dry and brown ; bowels very loose ; passed a considerable quantity of blood in tbe stools to-day; slough on the cheek spread- ing; cheek hard and swollen. Twenty- second day : pulse 144 ; moderate inteslinal hemorrhage every day; diarrhccva re- strained ; cheek much swollen, duskily 214 ENTERIC OR TYPHOID FEVER. fluslied, hard, and sliining ; respirations less frequent. Twcnti/-fourih day : bowels quieter ; no more hemorrhage ; takes drink well aud sleeps fairly; slough of cheek extending, those of the gums sepa- rated with the loss of two molar teeth. Twenty - sixth day : remains quite con- scious and takes drink well. The left cheek is livid externally, and the eyelid closed by the swelling. From this date the pulmonary and abdominal symptoms declined, and the bowels acted naturally, the stools becoming solid. The gangrene, however, spread e.^ternally, and involved all the central parts of the cheek in a large circular slough, and the patient gradually sank, retaining a clear intellect through- out the disease, aud died on the thirty- second day. Autopsy. — Body much emaciated. Chest — lungs weighed together twenty - four ounces ; apex of the left gangrenous, and partially broken down ; lower lobes of tooth firm, slightly crepitant, pale -red, friable — recovering from pneumonia — here and there a small circular ashy slough ; no trace of tubercle. Heart healthy ; blood fluid ; right internal iliac vein, at its junction with the cava, firmly plugged with a j'ellow, friable clot. AhiTo- vicn — liver weighed two pounds six ounces; firm ; lobules indistinct, with a whitish speckling in the form of minute stelliB ; the gland did not appear to me to be fatty, but microscopic examination showed the cells to be greatly enlarged, destitute of pigmentary matter, and replete with oil. Bile abundant, pale oclire-colored, water}', acid. Excepting a few patches of minute injection of the nmcous membrane of the stomach, the alimentary canal was healthy to within four feet of the ileo-c£ecal valve. This lower portion of the ileum was much injected and dark red. At four feet from the valve, a small Pe^-er's gland, the lower end of which presented a round, gently elevated swelling, witli a central irregular excavation the size of a hemp seed, limit- ed externally by the healing, granular margin of the pink mucous membrane. Three inches lower down, a larger gland, the lower half healthy, the upper with four cicatrizing ulcers — three so far healed as to be converted into minute stellate chinks, surrounded by pale red, wide, smooth borders, scarcely elevated above the surface of the healthy portion of the gland. Below this gland were nineteen minute cicatrizing ulcers, chiefly of tlie solitary glands, all with rounded, smooth, very soft vascular borders firmly attached to the less vascular transverse or longitu- dinal layers of muscular fllircs, whicli formed clean, smooth bases to all the ul- cers. Next occurred six large ulcers caused by the destruction of the" whole of the large Beyer's glands of this part ; they [ formed large, smooth, and soft, interrupt- \ ed depressions, hmited below by the very distinct reddish-gray muscular fibres, and surrounded by pale-red, raised, and round- ed sinous borders reposing upon the mus- cular layer : two or three of these ulcers presented rounded islets, or projections of smooth red, mucous membrane running in from the raised border of the ulcer, and on a level with it. (Big. 8.) One of these large patches presented a minute con- tracting ulcer at either end, the interven- ing space being occupied by a smooth, grayish-white, opaquish, slightly-depress- ed membrane. Nearer the ileo - cascal valve were thirty-one other ulcers chiefly affecting the solitary glands, and varying in dimensions from mere linear chinks to three-fourths of an inch. All were in process of cicatrization. In the next por- tion of the ileum — the last four inches — there were a great many similar ulcers, all clean and healing, but not quite so far ad- vanced in this process as those situated higher up. There were three small and distinct healing ulcers in the colon, the last one situated at the distance of a foot from the ciBcum. The csecum, and rest of the large intestine, including the rectum, were perfectly healthy. The solitary glands were all visible aud marked by a central black dot just as they appear in the meconium-stained bowel of a newly- born infant. The mesenteric glands were, for the most part, as large aw almonds, and so flac- cid that they could scarcely be distin- guished, in the mesenterj', between the thumb and finger : they were of a duskj'- gray or ashy color, and of an almost leathery toughness. Entire sections of them could be readily made, and these were as tough as fibrous membrane, and presented an abundant, finely fibrous stroma, the ordinary corpuscles, and a considerable quantity of highly refractive granules. Fis. 8. -,...*" •'* /■ -»i.»^ Ulcer of Payer's gland, healing. The recaptaculum chyli and thoracic duct were collapsed and empty. The spleen weighed five ounces and a drachm ; it was of natural consistence, and pre- MORBID ANATOMY. 215 sented a bright reddish-brown color on section. Tlie remaining viscera were ap- parently healthy. Floated under water, the rounded vas- cular borders of the healing ulcers present a double margin, the villi are seen to ter- minate in a wavy line, and from within and below the border so formed projects the paler and quite smooth soft border of ad- vancing granulations. (Fig. K. ) Some of these spring up from the base of the ulcer, and form islands, which ultimately become confluent with each other and the margins of the ulcer, to form a smooth depressed membrane, which always remains desti- tute of villi and of closed follicles. In some of the cicatrized ulcers we occasion- ally observe a little cluster of closed folli- cles, but this simply points to the fact that R portion of the closed follicles of that par- ticular gland escaped injury. After these follicles have been removed in the inflam- matory process they are never regene- rated. Years after an attack of Enteric Fever the ulcerated Peyer's patches will be found to be replaced by pale smooth, slightly depressed, but unwrinkled mem- branes, which are more firmly adherent to the muscular layer than the healthy gland, and remain permanently destitute of villi. tb] The Mesenteric and MesocoUc Glands. — Just as inflammation of the tonsils in- duces vascular excitement and swelling of the lymphatic glands, situated about the angle of the jaw, so does inflammation of the soUtary and agminate glands excite inflammation in the corresponding glands of the peritoneal folds. Tiie swelling of the latter is always proportionate to the degree of the intestinal irritation ; the glands, therefore, which lie in the angle of junction between the small and large intes- tine are those most affected. In ever}- case of Enteric Fever we find that the mesente- ric glands are more or less congested, sa\o1- len, and softened. They are usually of a dark purple color and of the size of hazel- nuts. Some often attain the size of a wal- nut. Bisected with a sharp scalpel, the outer portions are seen to be of a uniform dark purple color, the central parts are less vascular, and the yellowish-white parenchyma is veined with diffuse purple streaks and a mottled appearance thus produced. The parenchj'ma seems 3'el- lower than usual, but this is simply the efiect of contrast. The gland is so soft that it is difficult to make a thin section of any extent. Microscopically examined, we find it to be composed of an exceedingly delicate, friable, scarce stroma of indis- tinct fibres and of molecular corpuscles of various sizes. These latter constitute nearly the entire gland ; they are for the most part spherical and nucleated : the formed nuclei, and average .g'^jth of an inch in diameter. (Fig. y.) Fig. 9. most numerous average nth of an inch in diameter ; the larger present well- Stroma and corpuscles from a mespnteric gland. In the subsequent progress of the dis- ease the glands may return to their nor- I mal condition, or the cells may break j down to a creamy fluid. In one or two cases this puriform fluid has increased to such an extent as to rupture the peritoneal covering of the gland, and general perito- nitis has followed the extravasation of its contents. As soon as resolution of the inflamed, and cicatrization of the ulcerated, glands of the intestine have taken place, the me- senteric glands begin to decrease, and be- come for a time shrunken, flabby, and tough. In those cases in which I have made the necessary examination, I have found the receptaculum chyli and thoracic duct empty and collapsed. (c) The Spleen is severely congested in almost every case — probably, during the inflammatory period of the disease, in every case. It is usually enlarged to twice or thrice its natural size ; occasion- ally it is found four or five times larger and heavier. Its color is uniformly pur- plish-black throughout, and it is so soft and friable tliat it may be reduced to a semi-fluid pulp with the greatest ease. Minute granular corpuscles, fibre-cells, and molecular branched fibres are the only structures I have been able to detect under the higher powers. (d) The Liver. — A morbid condition of this organ and its secretion has been very generally observed. Forget does not spe- cially mention the condition of the liver in many of his cases. Of others he records the following observations: " Liver nor- mal, sail-bladder containing much or lit- tle, thin bile." (Obs. xlv. xlviii. Iv.) "Liver voluminous, possessing a fatty appearance." (Obs. Ix.) "Liver volu- minous, gall-bladder almost empty." (Obs. Ixviii.) "Liver presented a little softening in its right lobe; the gall-blad- der contained a thin bile, slightly colored, like water." (Obs. Ixxiii.) The liver was softer than natural in thirty-two out of seventy -three cases examined by I^ouis, 216 ENTERIC OR TYPHOID FEVEK. Jenner, and Murchisou. (Murchison, p. 555.) Louis states that the voJurue of the gland was augmented in -^^ of his eases, and in tliese it had lost its consistence; the con- sistence was diminished, the tissue of the organ being sometimes soft, sometimes friable, in the majority of his cases, and in none did it appear to him to be firmer than natural ; softening existed in nearly half the eases, and in four to such a de- gree that the fingers sunk into the gland substance without resistance ; the color was natural in only twelve of the subjects examined by him ; it was redder than usual in eight, five of which were exam- ples, more or less marked, of sanguineous engorgement. This appearance was no- ticed a little more frequently in those who died at an early period — from the eighth to the twentieth day. The bile was some- times red, and very fluid in different de- grees in about half the cases ; in ten it was more abundant than usual. (Louis, Kech. Fievre Typhoide, vol. i. p. 209 et seq. ) Another careful observer, Gross- heini, remarked that, in all the cases ob- served by him, " the liver never retained its normal color, and the bile was alwa3-s much thinner and clearer than in the healthy state. It was frequently trans- parent, sometimes clear yellow, sometimes of a dirty whitish color ; in quantity, it was sometimes normal, rarely increased, but most frequently of all it was so dimin- ished that scarcely any was left." (Edin- burgh Med. and ^urg. Journal, 1837, vol. xlviii. p. 178.) Stannius examined twen- ty-three cases of Enteric Fever. "In the majority, the liver appeared to be of nor- mal consistence and color; not infre- quently it was softened generally or par- tially. Almost always, both in those cut off at the height of the disease, and in those destroyed at later stages, the gall- bladder contained pale yellow, or yellow- ish-green, often watery mucous fluid, not reddening litmus paper nor tinging the skin." (Ibid. p. 174.) My own observations agree with the foregoing ; but as to the frequency with which the liver is found in a morbiii con- dition, I am led to conclude that the gland never escapes without some alteration in its texture. In every case which I have examined, I have found the liver in a more or less advanced state of fatty de- generation, and in almost every case noted an increase of weight. Even when the gland is of normal size and to all ap- pearance healthy, or only a little pale, microscopic examination will show very consideralile degeneration of hepatic cells. In case 1, above recorded, the liver cells were greatly enlarged, averaging j^^^ of an inch in diameter, and frequently con- taining spherules of oil ^^^j; of an inch in diameter. The bile in this case had the low specific gravity of 1018 and strongly reddened blue lithius paper. After de- positing an abundant pale ochre-colored granular-looking matter, composed of col- umnar epithelium, it had the color of whey, or pale urine with a faint greenish tmge. I have constantly found the bile thin, watery, and easily filterable; in one case the specific gravity 'iN'as as low as 1011 "i. Filtered, and evaporated on a water bath, such altered bile yields only a small quantity of black solid matter, greenish-brown, bj' transmitted light, and wholly soluble in water. The bile itself, or this solution, gives slowly and faintly, sometimes imperfectly, the characteristic reactions of bile when tested with the mineral acids, or Pettenkofer's test. The bile has a strong post-mortem odor, and in one case ^vhich I examined tweh'e hours after death, when the viscera were still warm, and the blood steamed on ex- posure to the frosty air, it smelt strongly of sulphuretted hydrogen. The morbid changes, above described as affecting the intestines, the mesenteric glands, the spleen, and the liver, are the constant and essential lesions of Enteric Fever, ^^^e now pass on to a cursory ex- amination of such morbid phenomena as are exhibited by the other organs of the body. Tongue. — The general condition of this organ has been described The charac- teristic features are, unusual redness of its edges, with enlargement and promi- nency of the fungiform papillse, in the early period of the disease; and a wrink- ling and cracking of the dry glazed sur- face, with contraction and reddening of the whole organ, at a later period. The cracks are very painful and often bleed. If the tongue remain moist, it is usually flabby, indented, and covered with white fur. In this condition it occasionally pre- sents spreading ashy ulcers upon the tip and sides ; and sometimes deep fissural ulcers, with pale everted margins, form across the dorsum. When nervous symp- toms predominate, the tongue becomes covered with a thick, brown, flrmlj'-adhe- rent crust, very dry and hard, and reticu- lately fissured. In Several cases, I have obsei'ved great congestion and swelling of the follicular glands at the base of the organ. The Lips and orifices of the nostrils are often cracked and inclined to bleed. The Tonsils are rarely affected ; ab- scesses have been observed in them in a few cases. The Pharynx and GSsophagns.—'Lows, found small round or oval ulcers of the mucous membrane of the lower portions of the pharynx and oesophagus in about a sixth of his cases. The Stomach, Duodenum, and Jejunum are usually healthy. In some cases they MOKBID ANATOMY. 217 present morbid conditions, sucli as soft- ening and minute nleerations of tlie mu- cous membrane, whicli are common to all inflammatory diseases. The Pancreas. — I have usually found tills gland harder and with the lobules more distinct than in health, as if shrunk- en. Otherwise it has appeared healthy. The JJr'mary and Gcncmtivc Organs are in the normal condition, or only slightly congested. [The Peritoneum shows all the signs of acute inflammation when perforation of the intestine has occurred. — BtJ The Epiglottis, Larny.c, and Trachea are occasionally ulcerated. The mucous mem- brane of the bronchial tubes is usually red and swollen. The Lungs present in almost every case evidence of pre-existing inflammation. (See Associated Pathology of Enteric Fe- ver.) The Muscular System. — Agreeably with what is observed in other protracted dis- eases of an acute character, the muscular tissue is found to be liable to degeneration in Enteric Fever. Zenker (Veranderun- gen der Muskeln in Abdominal. Typhus, 1864) describes two forms of muscular de- generation — granular and waxy. The granular form consists in the deposition of minute, highly refracting granules in the contractile tissue, giving to the fibres a dark appearance by transmitted light and obscuring the striiB. This molecular deposit is not wholly composed of fat. The degenerated fibres are very friable. The waxy form consists in the transforma- tion of tile sarcous tissue into a homoge- neous colorless mass, glittering like wax, and causing a complete obliteration of the [Fig. 10. A portion of the eoleus muscle frora a case of typhoid fever. Pieparittion trased alter treutrnent with Mnller 8 fluid. Xim. Reduced K- (t'teen.)] striae and nuclei of the fibres, the sarco- lemma remaining intact. The waxy cyl- inders, thus formed, crack up into numer- ous fragments, which crumble down into a finely granular detritus, and this is gradually al sorbed. The muscles mos-t hable to dtgeneration are the adductors of the thigh and the abdominal recti. The afiected muscles are of a pale grayish- red color. Erikitansky observed rupture of the abdominal rectus in Enteric Ee\'er, and attributed it to spasm. Virchow noticed rupture of the muscles associated with friability of the muscular fibres in four cases of Enteric Fever. Zenker noted eleven such cases, all of which oc- curred in Enteric Fever. The rupture occurred most frequently, but by no means exclusi\'ely, in the rectus abdomi- nis, pectoralis minor, triceps biachii, and psoas. The author last mentioned at- tributes the rupture of the muscles, and extravasation of blood into their sub- stance, to the degeneration of the fibres above described. The rupture tends to produce hemorrhage, and this leads to the formation of collections of sanies or pus, which must be distinguished from general pytemic deposits. Abscesses in the muscles are very rare in Enteric Fever. The Skin presents us with one of the characteristic symptoms of Enteric Fever, the ''''taches roses lenticulaircs" oi TjOius. These spots closely resemble the papules of variola during the first few hours of their existence, but they are not quite so large nor so hard. They form slight, rounded, discrete elevations of a pale rose color, which fades away at the base, form- ing a moderately distinct circular outline. Each rose papule is a minute circ^um- scribed inflammatory centre, from which the blush disappears on pressure. These spots usually appear on the abdomen and chest alone, but they are often found on the back. They are seen occasionally on the face and upper and lower extremities. The eruption is not always present. "Of 1820 cases admitted into the Loudon Fe- ver Hospital during ten years, it was noted in all but 221, or 12-3 per cent." (Murchison, p. 470.) The rash usually appears on the supervention of the acute febrile symptoms. It may be looked for at the end of the first week, and may con- tinue as long as the febrile symptoms and diarrhrea persist. The total number of spots rarely exceeds fifty ; in some cases they are innumerable. There is no rela- tion between the quantity of the rash and the severity of the symptoms. It appears in successive crops ; at first only two or three spots may be observed, next day four or five fresh ones, the next as many more. Each crop persists for a few days and then di.sappears. According to Bar- thez and Rilliet, and Murchison, the spots are fewer in children than in adults ; and the former two observers state that m the same class of patients they are oftener absent in the severe cases than in the 218 ENTEKIC OK TYPHOID FBVEK. r.iild. These rose spots occasionally ap- pear in other acute diseases. In a severe case of typhus in a powerful fair-complex- ioned man I noted a very copious erup- tion of rose papules upon the chest and abdomen ; they preceded the typhus rash, and had wholly disappeared when this became petechial. The departure of the fever and the re- establishment of the cutaneous function is often announced by the eruption of siida- viina over the whole of the chest and ab- domen. Eoughness and minute desquamation of the cuticle, especially of that covering the abdomen, are observed after the ces- sation of febrile symptoms in severe cases. The desquamation occurs independently of the pre-existence of sudamina, which alone is sufficient to produce it. The temperature of the skin usually undergoes a progressive increase during the first fourteen days of the disease, at- taining, in severe cases, 104°, subject to the morning and evening vacillations, which are observable in other febrile con- ditions. If the abdominal or pulmonary symptoms undergo no amelioration, this temperature is often maintained during the earlier part of the day. When the intestinal inflammation proceeds to exten- fcive ulceration, this high temperature may persist more or less continuously for weeks ; but usually during the third week there are peculiar alterations of tempera- ture, ranging from 4° to 6° per diem, the higher readings being observed during the hectic exacerbations which take place in the evening. Recovery in such cases is attended by a gradual diminution of tenaperature. In more favorable cases the resolution of tlie inflammation is de- clared by sudden falls of temperature. When the Fever is prolonged, the pun- gently hot skin becomes very harsh, and the papillae as prominent as in the cutis ansfrina. The Lyrnphatic Glands are usually only secondarily aftected in cases complicated ■with ulceration of the pharynx and ery- sipelas of the surface. In young children, suppuration of the cervical glands about the angle of the lower jaw is not very un- common : three such cases have lately come under my care. Parotid inflamma- tion, which is so common in typhus and in scarlatina, is rare in Enteric Fever. Nervous System. — The only lesions dis- coverable are slight subarachnoid effu- sions, fulness of the bloodvessels, and slightly increased vascularity of the cere- bral substance. Circulatory Organs. — In protracted cases the muscular tissue is liable to fatty de- generation, and this change becomes first apparent in the left ventricle of the heart. The Blood. — M. Trousseau, in speaking of intestinal hemorrhage in Enteric Fever, says the blood is exhaled by the mucous surface, as occurs in hsematemesis, epis- taxis, &c. " The proximate cause of this sanguineous exhalation," he goes on to say " is a profound alteration experienced by the blood, and which is found in that state which one has termed 'the state of dissolutiom'" (Clin. Med. p. 230.) M. Forget examined 123 specimens of blood, derived from persons in all stages of En- teric Fever. Of the blood drawn during the first period of the disease, only about -fijfth of the specimens presented appreci- able softening. In the second period ;th of the specimens exliibited this change. He concludes generally that an appre- ciable alteration of the blood in the seve- ral periods of Enteric Fever cannot be accepted as a general fact ; that the blood is rarely altered in the first period ; that the alteration is more marked in propor- tion as the disease is more advanced; that the alteration is not always in proportion to the gravity of the disease. (Forget, Sur I'Etat du Sang dans I'Enterite folli- culeuse; Gaz. Medicate.) My own observations of the condition of the blood of those who have died from Enteric Fever accord with those of M. Forget. In subjects dead in the third week of the disease, I have frequently found firm colorless clots of fibrin in the heart and roots of the great vessels. In protracted cases the blcod not only be- comes very thin, but is also much dimin- ished in quantity, from sheer inanition. Pathology. If we carefully regard the incipient symptoms of Enteric Fever, we shall find that they have reference to derangement of the hepatic function. Often, long be- fore the graver symptoms are developed, the patient loses appetite, the bowels are constipated, and the stools pale ; the tongue is foul, and the digestion much impaired. All these symptoms point to a defective secretion of bile, and to a state of approaching inanition. Such a torpid condition of the liver may be produced in two ways in the development of Enteric Fever. It may result from severe or pro- longed vascular congestion, in which the other internal organs participate ; or it may be the effect of some morbific agent, carried by the portal vein from the intes- tinal surface into the liver, and causing, by a direct action upon its secreting cor- puscles, derangement, or more or less complete paralysis, of its functions. If in any case a poison be not decom- posed in its passage through the alimen- tary mucous memljrane, it must of neces- sity be admitted into the liver. We know how readily mineral poisons are conveyed and arrested here, and we recognize the PATHOLOGY. 219 cllects of certain ver;ctable. substances upon the hepatic secretiou. From these facts, and from its situation between the intestinal and general circulations, we may reasonably conclude, that it is one of the offices of the liver to arrest noxious matters in their way from the portal into the general circulation, to neutralize or decompose them, or to eliminate them from the blood, and throw them out again through the bile ducts into the intestine. The very admission of deleterious agents into the portal circulation must lead, by diminishing the reciprocal attractions of the portal blood and the hepatic corpus- cles, to congestion of the whole portal circulation. Thus prepared, and by that concurrence of related actions which we everywhere witness in the bod}', the congested capil- laries of the intestinal mucous membrane relieve themselves by a copious watery exudation, by means of which the poison set free by the liver is washed out of the alimentary canal. Such probably is the mode of action of elaterium, colchicum, &e. But it is the special function of the liver to prevent putrid decomposition within the body. If therefore the func- tion of this gland be depressed, as in a case of simple vascular congestion from exposure to cold, for example, a septic poison may be generated within the body, and set up all the symptoms which follow the introduction of a similar poison from without. Doubtless, so long as the liver is in active healthy condition, any septic poison taken into the alimentary canal would generally be neutralized ; but if the gland should happen to be torpid at the time, then the unaltered poison, upon ad- mission into the liver, would possibly arrest the secreting corpuscles in the elim- ination of that very fluid which has the power of rendering it innocuous. Very Uttle is known of the derangements to which the liver is liable, and of the alter- ations which its secretion undergoes. We readily obtain evidence of the grosser ir- regularities of the kidneys, but we can judge of those affecting the liver only by the color of the feces — a good general guide, no doubt ; but only rarely'is this means of diagnosis available in the inci- pient stage of diseases. Primary vascular congestion of the liver, no matter how produced, leads to a vitiation of the secretions of the alimen- tary canal ; nervous exhaustion results from^ arrested nutrition. Under these conditions the liver begins to degenerate, and the intestinal mucous membrane tends to ulcerate, the blood is imperfectly depurated, and general febrile disturbance ensues. Surely if high fever, violent de- lirium, and coma are the consequences of acute suppression of the bile, the pyrexia, headache, and the most severe delirium, which ever accompany Enteric Fever may be fairly attributed to that diminu- tion and derangement of the hepatic func- tion which invariably accompany this dis- ease. That the liver is early and gravely de- ranged in Enteric Fever is proved by the facts already mentioned in the morbid anatomy of the disease, and by the promi- nency of those symptoms which have led observers in all ages to designate it by the terms, "bihous, gastro-bilious, " &c. In place of a thick, heavy, alkaline se- cretion, rich in biliary acids and coloring matter, we find a watery, neutral, or often excessively acid bile, notably deficient in its essential constituents, and sometimes putrid at its very source. M. Trousseau considers the flux from the bowels to be of the nature of a specific catarrh. But what is the nature of this specific catarrh? Is the bowel endeavoring to supply defec- tive action of the liver by carrying away, in some unformed state, constituents of the blood which tliat gland should have removed as glycocliolic and taurocholic acids? We do not think such a theory necessary. At the commencement of the disease there is probably some attempt at elimination, but in the subsequent stages we believe that the diarrliwa and intes- tinal lesions are rather due to congestion and mere local irritation than to any specific cause. Tliis would appear to be the case from consideration of the fact that if we restrain the diarrhoea — the as- sumed means of elimination — we do not aggravate the general symptoms, but positively ameliorate them ; and in most cases marked improvement follows the complete arrest of the diarrhoea. Not the least important function of the liver is to prevent by its antiseptic pro- perties the decomposition of the chyme ; take away this preservative influence al- together from the system, and fermenta- tion with the escape "of gas and tympanitic distension follow. The impure chyme irritates the debilitated and congested mucous membrane, and what wonder then if inflammation, ending in ulceration of Peyer's patches and the follicular glands, should result ? But why should these particular struc- tures suffer more than any other parts of the intestinal canal? For two reasons, we think : first, on account of the greater vascularity of these glands, whereby they most readily participate in local conges- tion, and, as has been shown, the arrange- ments of bloodvessels within them, which, when the circulation is obstructed, ren- ders them liable to sloughing ; and sec- ondly, on account of their delicate cellular structure, for in febrile conditions it is the active growing corpuscles of the paren- chymatous organs which most readily participate in the inflammatory process. 220 ENTERIC OR TYPHOIB FEVER. That the glands of the lower three feet of the ileum should be most affected may perhaps be regarded as a significant fact, and it is one for which it is difficult to find a satisfactory explanation. Anatom}' will not allow us to ascribe a diflference in func- tion between the solitary and agminated glands lying near the junction of the small and large intestines and those removed to a greater distance from it ; nor do we find tliat the glands of the upper and lower parts of the ileum have such a diflerence in their immediate associations as would account for unequal participation in gene- ral disease ; and we sliould, therefore, be led to assume that if tlie solitary and Peyerian glands were employed in some general process connected with the elimi- nation of a blood poison, they would be similarly affected. Such, however, is rarely or almost never the case in Enteric Fever, for the Peyerian glands of the lower third of the ileum are almost always found in a state of extreme inflammation when those of the upper two-thirds exhibit no morljid change, and we never find Peyer's glands of tlie upper portion of tlie ileum ulcerated when those of the lower are uninflamed. The following considerations may afford some explanation of these facts. First : there appears to be a greater tendency to congestion of the lower than of any other portion of the ileum, due to the greater nmnber of vascular solitary and agmi- nated glands situated there, and also to tlie manner in which the small and large intestines are united. The abrupt fold forming the ileo-csecal valve is similarly constituted to the anal sphincter, and, like it, necessarily causes some arrest in the flow of blood beyond its margins. We recognize, therefore, a predisposition in the lower part of the ileum, to participate in inflammatory action. Secondly : if we now regard the derangement which exists within the digestive canal we may be able to find an exciting cause in the altered action, which doubtless results from dis- turbance of the reciprocal action of parts engaged in the same function, but sepa- rated from each other by a considerable distance. Can we, for example, attribute the lesion of Peyer's glands in the lower portion of the ileum to defective action of the glandular apparatus situated in the higher portions of the alimentary canal ? The liver, we have found, secretes bile deficient in those essential constituents which exert an important influence upon the digestive process. The defective bile probaijly contains sufficient of these con- stituents to maintain healthy action in the upper portion of the small intestine, but becoming exhausted of these in the lower, it there fails to exercise any anti- septic influence, and of itself induces un- healthy action. But, it may be argued, if this were the true explanation of the lesions of the small intestine, how is it that the large bowel escapes ; for, according to the theory, we should expect to find that the intestinal lesions would progressively in- crease from the lower third of the ileum downwards, instead of being confined, as is usually the case, to the lower third of the ileum and ceecuni ? The frequent im- munity of the large intestine from any considerable participation in the disease ma}' be explained by supposing that the irritation set up in the lower portion of the ileum, by the vitiated bile, causes such a copious exudation of fluid from this part of the alimentary canal, that the ir- ritating matter is diluted, and at the same time so rapidly carried away through the great intestine, that the lower portion of the alimentary canal usuallj- escapes any severe implication in the intestinal lesion. There can be very little doubt that the dejections in Enteric Fever are chiefly thrown off from that part of the intestinal canal where the inflammatory irritation is greatest — viz. the lower portion of the ileum. The ctccum, where the secretions are necessarilj' retained for a time, is often as gravely affected as the last six inches of the ileum. In some cases, moreover, the large intestine is often severely involved in the disease, and occasionally, as we shall have an opportunity of showing, it is exclusively affected, — a fact quite consis- tent with the theory here advanced. Thirdly : the localization of the intestinal disease may be supposed to arise from de- rangement of that particular part of the sympathetic nervous system, which is dis- tributed to the lower portion of the ileum, just as destruction of the eyeball may fol- low injury of the orbital branches of the fifth nerve. Morbid anatomy fails, how- ever, to reveal such derangement of the sympathetic plexuses : and if it did, there would still remain the difficulty of account- ing for a general febrile condition in such limited defect of nervous action. The question naturally arises to every inquirer, whether the symptoms of Enteric Fever are to be attrifiuted to general blood-poi- soning, or whether they secondarily arise as a consequence of a localized intestinal lesion. From the foregoing observations it will be seen that we are induced to con- clude that the disease arises from a vitia- tion of only a portion of the venous blood, and that the constitutional symptoms are in many cases due to consequent derange- ment of the hepatic function. If we ac- cept this view, we shall be at no loss to account for the great variation in the nervous symptoms observable in this dis- ease. Some patients retain a clear intel- lect to the last hour of their lives (fi. g. cases 5 and 6); others lapse into a state of stupor or coma at a very early period of ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 221 the disease (e. g. case 3); anrl the majority manifest great nervous irritability anil prostration, and at some period or other, more or less delirium. In every case there can be no doubt that the derangement of the digestive, cutaneous, and pulmonary functions results in an impure condition of the blood ; but we consider that in many cases the nervous symptoms are due to nervous exhaustion from inanition, or to active meningeal congestion, rather than to a specific blood-poisoning. The delir- ium partakes very much of the character of delirium tremens, and there is frequent- ly very notable vascular excitement of the cerebral circulation. In those cases in which the cerebral symptoms are predomi- nant, "we are forced to recognize a general blood-poisoning, and then the question arises. Is this due to more or less complete suppression of the hepatic function, or to the admission of a specific poison into the general circulation '? Probably it may be clue to both of these causes. If the poison be arrested by and thrown out from the liver, no general blood-poisoning, and, therefore, no grave nervous symptoms, may ensue. If the liver be unequal to the arrest and elimination of the poison, it passes unaltered from the portal into the general circulation, and symptoms of general blood-poisoning at once appear ; and if the gland be so far deranged in the process of elimination as to become almost paralyzed in its functions, more or less complete suppression of bile would be an additional cause of the cerebral symptoms. Associated Pathoi-ogy of Enteric Pevbe. Pneumonia. — The lungs and the intesti- nal and mesenteric glands manifest very great sympathy in morbid action. In two, at least, out of every three of the many 1^ cases of pulmonary phthisis which I have examined, I have found the solitary and agminated glands of the lower portion of the ileum and the mesenteric glands more or less infiltrated with tubercle, and the former often very gravely ulcerated. The same sympathy is observed when the lungs are the seat of conmion inflamma- tion, and in pneumonia we shall very often find corresponding inflammation of the solitary and Peyerian glands of the ileum. Eeciprocally, of all the complica- tions of Enteric Fever, pneumonia is the most common. In some stage or degree, I believe it is very rarely absent. In many cases the inflammation does not proceed beyond active congestion, the post-mortem evidences of which are engorgement with some friability, and the so-called "spleni- zation or carnification. " ' According to ' M. Louis does not consider " spU^nization M oaruifioation" as the result of inttaminatiou, the observations of Louis, inflammation of the lungs is more frequent in Enteric Fever than in any other acute disease. He found that splenization, simple or com- plicated with partial inflammation of the lung in the first or second degree, existed in twenty out of forty-six cases of Enteric Fever, and in seventeen there was actual inflammation. In only fifteen cases were the lungs healthy, or their alterations slight, little extended and consisting chief- ly of change of color, due apparently to diffuse or partial congestions. Thirty- eight of his forty-six patients had cough at some period or other of the disease. (Louis, Eecher. Pievre Typhoido, vol. i. p. 330 et seq.) These observations of Louis are in accordance with those of every other observer. In upwards of thirty cases examined by myself I have found the lungs free from the eflfects of more or less extensive inflammation only twice. [Such a frequency of pneumonia in Ty- phoid Fever is not observed either in pri- vate or in hospital practice in Philadelphia. Bronchitis, of moderate grade, is a usual symptom, beginning during the first week. Hypostatic congestion of the lungs occurs, in some cases, when the patient is allowed to lie continuously in one position, on the back. It affects the posterior lobes of both lungs ; and may proceed to splenization or hepatization, sometimes with fatal result.— H.] The following case shows the intimate association of the two dis- eases. It is given by M. Forget as an ex- ample of "Follicular Entorite of the inflammatory form :" — Case 7. — ''A strong woman, aged 23, after exposure to hard work in the open air, experienced a sense of painful weari- ness, headache, nausea, vomiting, thirst, shiverings followed by heat, &c. Tliird day: diarrhaa. Fourth day : face flushed ; skin hot and dry, pulse frequent, large, resisting ; respiration frequent, without cough or pain ; tongue, white at the cen- tre, red at the edges ; abdomen indolent ; two liquid stools to-day. Fifth day : tongue red, denuded ; meteorism ; a liquid stool in the night. Sixth day : pulse 120, a little nocturnal delirium, dyspnrea, thoracic sibilance. Seventh to the twentieth day : continued in a typhous condition, with purging, dyspnoea, and more or less delirium." 'Tirenty -first day: delirium, groanincs during the whole night, deglu- tition difficult, several liquid stools, pulse frequent, thready : dyspnoea extreme ; death. . "JVecroRcop?/.—7i('«'^'— notable injection ot meninges. CTfst— old pleuritic adhesions; both lungs engorged— a condition which but such a condition developed during a fren- eral and continued febrile action cannot be regarded as being wholly independent of the inflammatory process. 222 ENTERIC OR TYPHOID FEVER. appeared to have existed for some time — indurated, friable beliind aud at tlie bases. Ahdotiien — partial injeetiou of the mucous membrane of the stomach and intestines. Towards the crecum were met with, at first fine reticulated and swollen Peyer's glands, then rounded ulcerations, which became confluent, confused, fungous in the neighborhood of tlie ileo-cajcal valve and upon it : large intestine also presented traces of inflammation and numerous ul- cerations ; smaller, but more numerous than in the small intestine, and occupying almost its whole length. Mesenteric glands engorged, brownish. Spleen slightly enlarged,"friable. Walls of the mouth and pharynx covered with a white pultaceous matter." (Trait6 de I'Enterite foUicu- leuse. Obs. Iv. p. 414.) In this case diarrhoea and dyspnoea appear to have commenced simultane- ously. The patient died of pneumonia. Take away disease from the one lung, and truly we have, as far as the symptoms and morbid changes are concerned, a typical case of Enteric Fever. Are we, therefore, to attribute the lung disease in this case to a specific typhoid poison, the presence of which must be assumed to be proved by the intestinal lesion ? Or may we not regard the pneumonia and enteric disease as mere local manifestations of one common inflammatorj- condition, prob- ably produced by cold ? We are inclined to adopt the latter view. In the outbreak of Enteric Fever in the two companies of soldiers under Dr. Grossheim's care, this acute observer could find no other cause for the disease, but " the violence and con- tinuance of the military exercises, and the necessary exposure to great cold after being overheated by violent and laborious corporeal exertions." (Edin. Med. and Surg. Jour., vol. xlviii. p. 1S7.) For the association of pneumonia and Enteric Fever, see also cases 6 and 19. Pleurisy is almost as often present in Enteric Fever as pneumonia. Dr. Mur- chison observed recent adhesions, or effu- sion of lymph, in six out of nineteen cases ; Sir W. Jenner, in six out of fifteen; and ]NI. Louis, in two out of forty-six ; but he found a greater or less amount of red- dish, serous effusion in the pleural cavi- ties in nineteen other cases. (Murchison, p. o(50.) Cioe 8. — Julia Hatch, aged about .SO, died of pleuro-pneumonia on tha forty-fifth day of the disease. She was adniitted'into the hospital on the fourth day, when the following note was made : — Pulse 120, tongue moist and furred, skin cool and moist, face flushed, respiration accele- rated, slight dulness on percussion, and pleuritic friction sound at the base of the right lung behind ; bowels regular. She iniproved, and took food with a relish until the twenty fourth day, when the pleurisy attacked the left side ; the felTile symp- toms increased, respiration became hur- ried and oppressive. A second_ blister and mustard poultice, were applied to the chest, and on the thirty-sixth day pulse was 144, feeble ; respiration much easier ; face less livid ; tongue clean ; mucous crepitation and friction sound still heard, both before and behind, on both sides. Eats mutton-chops well. After this date she continues to get worse. On the forty- first daj', pulse 144 ; respirations 50, la- bored ; skin hot and very dusky ; dulness, crepitation, and friction sound still heard. She continued in the same state till the day of her death. The condition of the skin, tongue, and abdomen was carefully noted from day to day, but, throughout, the digestive function was most regularly performed, the bowels acted naturally every day, and the motions were perfectly healthy. Considering her febrile con- dition, her appetite for food was unusuai. On the thirty-Jifth day she asked for meat, and enjoyed it. The abdomen was flat and natural, and there was never any appear- ance of rash. Autopsy. — liody considerably emaci- ated ; alj'domen flat. Chest— costal carti- lages partially ossified ; extensive pleuritic adhesions on both sides, some of which were old, others evidently the result of the last illness ; lower lobe of right lung ad- herent to the diaphragm and side of chest, soft, friable, and slightly crepitant, evi- dently recoverinsr from recr"t inflamma- tion. No trace of tubercle in any part of the lungs. Heart healthy, containing soft, yellow clots in the right cavities. Neck — fibrinous and serous exudation in the are- olar tissue, around the trachea, and be- tween the nmscles in front of it. Slight wdema of the mucous membrane above the glottis, and redness of the trachea. Follicular glands at the base of the tongue much enlarged, with violet, swollen, everted margins and gaping orifices. Ton- sils a little enlarged. Uvula much swol- len. Abdomen — intestines undistended and undisturbed ; the coils of the small intes- tine dark purple. The whole of the ileum was intensely inflamed, and every Pey- erian gland swollen and prominent. Those in the lower three feet of the bowel, and also the intervening solitary glands, were greatly swollen and ulcerated — whole patches being excavated into ragged ul- cers, with rounded, everted, intensely vas- cular borders, overlying the contiguous mucous membrane ; the irregularl3'-exca- vated centres were deeply stained with i bile. One ulcer, two inches from the ileo- caecal valve, alone extended to the mus- cular coat, exposing a smooth surface, I half an inch in diameter, of soft, swol- I len, muscular fibres. The non-ulcerated patches formed elevated fungous-like ex- pansions. Many of the enlarged sohtary Associated pathology of enteric fever. 223 glands were deeplj' excavated at the cen- tre. The intervening mucous membrane was excessively vascular. The civcum was congested, the large intestine healthy, and contained well-formed, solid, bright, yellowish-brown feces. Mesenteric glands much enlarged, congested, and soft. The spleen, liver, kidneys, supra-renal ca]i- sules, and organs of generation were per- fectly healthy. The gall bladder was full of healthy, green, viscid bile. Although the patient was subjected every day to close scrutiny, there was no suspicion of intestinal mischief at any time ; there was not the faintest external indication of it, but the reverse. I examined the case chiefly with the view of ascertaining how far Peyer's glands are affected in acute disease, and I was surprised to find rav- ages much more extensive than are seen in ordinary cases of Enteric Fever, and such as would be considered to be. emi- nently typical of the disease. Laryngitis is a rare complication of En- teric Fever. I have noted it in two cases. In one it occurred during the height of the disease, and yielded to leeching and blistering. In the other it came on dur- ing convalescence. Suffocation impended for two days, but the patient escaped by the ejection of fragments of a tough, or- ganized membrane. [Eronchitis has been already mentioned as, in the United States, one of the usual symptomatic conditions, most marked during the first ten days. — li.] Scarlatina and Diphtheria.- — A very close relationship appears to exist between these diseases and one variety at least of Enteric Fever. All are, for the most part, autumnal diseases, and they may be observed to increase and decrease to- gether, and all appear to arise spontane- ously out of the same conditions. Stober, Loschner, and Frit'dleben maintain that scarlatina and Enteric Fever prevail epi- demically in an inverse ratio to each other, the one prevailing in proportion as the other declines. (Brit, and For. Med.- Chir. Rev., July, ISoS, p. 162.) I have known several instano s of scarlatina or diphtheria, affecting one member of a family and Enteric Fever another, simul- taneously. The day Ijefore C. B. (case 1) came into the hospital, her brother, aged 14, was admitted with ' ' scarlatina in its most marked form." Sore throat, accom- panied by the exudation of white pulta- ceous matter upon the nuicous membrane of the fauces, frequently accompanies the early symptoms of Enteric Fever (e. g., cases 4 and 7). Diarrhoea is often a severe complication in scarlatina, and in almost every fatal case of this disease inflamma- tory swelling of the solitary and agminated and of the mesenteric glands will be found. After most careful microscopical exami- nation of these swollen glands, I have failed to distinguish the slightest differ- ence between them and those of the first period of Enteric Fever. Scarlatina, I have reason to believe, often lapses into Enteric Fever, and such appears to have happened in the case of Julia Hatch (case 8). 1 have described this case under Pleurisy, but it is probable that its appro- priate place would be under Scarlatina. I failed to get information as to her pre- vious history, but the condition of the glands at the root of the tongue, and the neighboring inflammatory ettusions, cor- respond exactly to the effects of scarla- tina. Dr. Murchison noted the co-exist- ence of scarlatina and Enteric Fever in eight cases, and the appearance of scarlet rash without sore throat in five other cases (pp. 518, 473). Other observers have frequently noticed the same fixcts. Barthez and Billiet noted the co-existence of diphtheria and Enteric Fever in six cases. Forget in two, Louis in three, and Murchison in one. The following case of "malignant scar- latina," associated with the anatomical lesions of Enteric Fever, is related by M. Forget : — Case 9. — A strong man, aged 20, after his usual work, was seized with shivering; during the night, sensation of constriction in the throat, headache, fever, &c. Third day : carried to the hospital ; hands, fore- arms, thighs, and chest "offrent une belle coloration scarlatineuse ;" skin burning hot ; pulse 140, small ; tongue red, and covered, as well as the mouth, with a white pultaccous coating ; throat painful; deglutition very painful; no diarrhwa; chest normal. Fourth day : partial stupor; eyes injected ; coloration of skin persists ; sudamina; pulse 1(50, thready ; pultaceous coating of mouth diminished ; back of throat very red, swollen ; deglutition al- most impossible ; epigastrium tender ; death. JVecj-oscopj/.^JJeacZ^meninges injected. Chest — lungs engorged throughout, a little friable at the summit ; heart filled with white clots. Abd/micn — gastric and duo- denal mucous membrane red, manifestly inflamed ; small intestines presented, on approaching the cfficura, numerous Pej'- er's glands, of which some were simply dotted black, others were reticulated ; the majority were red, swollen, firm, elastic, and prominent (gaufrees) ; an abundant miliary eruption (psorenterie) in a great extent of the small and large intestine, including the rectum. "Ces caracteres anatomiques sont tous ceux de I'enterite foUiculeuse tros devel- oppee, avant la periode de gangrene et d'ulceration." (Forget, Obs. xix. p. 144.) On the next page bvit one, the same ob- server gives the history of a case of " scar- latina suive d'enterite folliculcuse." Such is the association which subsists 224 ENTERIC OK TYPHOID botween scarlatinn and Enteric Fever — a a associaLiuii ciosur and niurc frequent taaa is observed between the former and any other acute disease, and one which compels us to aelcnowledge some closer connection than mere accidental intercur- rence. Tracing the connection still further, we observe that the phjsio.nnomy, the cha- racter of the febrile action and delirium, and the condition of the tongue, are the same in both diseases. In both there is a tendency to epistaxis, cracking of the lips, desquamation of the cuticle, and dropsy (see Anasarca). In the other dis- ease, the solitary and agminated glands of the upper part of the alimentary canal (the tonsils and intervening follicular glands pf the tongue), and the neighbor- ing lymphatic glands, are affected ; in the other we find the corresponding parts (the solitary and agminated glands of the ileum, and mesenteric glands) of the lower portion of the alimentary canal diseased. Whether, therefore, we consider these two diseases in reference to their origin, their mode of development, or their physiolo- gical anatomy, we still find in cither case a resemblance between them. It is only in their subsequent progress that we re- cognize a clear distinction. This distinction has reference, _/?rst, to the nature of the contagious poison — scarlatina tends to spread as scarlatina,, and contagious Enteric Ei'ver as Enteric Fever; and secondly, to the progress of the two diseases— the one falls upon the cutaneous surface, the other upon the mu- cous. With regard to the first point, there is nothing in the history of the contagious diseases — at least of the diseases here compared — to dissuade us from the as- sumption that the contagious animal poi- sons are developed within the body, and derive their specific characters from the particular actions to which they may happen to be there subjected. Thus, for example, putrescent substances admitted, on the one hand, in a volatile form by the respiratory surface into the arierinl blood, may be conceived to undergo, during the process of absorption, some special and definite change, whereby a specific poison is formed : and, on the other hand, if the same deleterious agent be taken in a liquid or soUd form into the alimentary canal, and thereby admitted into that limited portion of the venoits system— the portal circulation — we may reasonably assume that it may be peculiarly modified by the agency of the digestive secretions, so as to constitute, upon its admission into the blood, a poison different from that formed in the lungs, but somewhat related to it in its action. But even assuming that the septic agent be not so diversely modified in the process of absorption, we may still find an expla- nation of the differences which ultimately distinguish the two diseases if we coni^iiier that, in the one case, the liver, a most po- tent converting agent, intervenes betAiceu the portal and systematic circulations, and that by its agency the skin and kid- neys — the arterial organs most affected in scarlatina — may be in a great measure protected from a poison introduced by the alimentary canal. If the septic poison be simultaneously admitted into the blood by the lungs and intestinal surface, a mixed disease — scarlatina complicated with En- teric Fever, or the converse — may upon this theory result. Those who have seen most of these two diseases, and have studied them side by side, will, we feel sure, be most ready to acknowledge how soon their distinctive characters become lott in the intermediate modifications which are observed to occur between them. The alhed affection, croup, is also an oc- casional associate of Enteric Fever. The following case is taken from M. Louis's work on Typhoid Fever : — Cane 10. — Croiqj. — A powerful man, aged 23, was attacked with slight pain in the throat, preceded by fatigue, lownc ss of spirits, anorexia, thirst, diarrhoea, and slight epigastric pains. Third day : shivering, heat, and sweating ; diarrhaa each day very considerable ; no sensible increase in the pains in the throat. Fourth day : considerable diarrha?a. Seventh day : considerable epistaxis ; pains in the throat ; soft palate red, without swelling ; deglutition difficult and often excited ; a sense of pricking and heat in the affected part. Eighth day : pain in throat continued ; a shining semi-opaque false membrane upon the tonsils, sides of the uvula, which is in- flamed, and upon the pharj-nx ; voice a little changed ; pain and difficulty of de- glutition ; four stools and copious sweats during the night ; some lenticular rose spots upon the abdomen. J^irdh day : false membrane more opaque, voice angi- nose, larj'nx a little tender, respiration a little accelerated. Tenth day : false mem- brane extending ; deglutition causes in- supportable anguish. Eleventh day : very fetid breath ; croupal voice ; deglutition impossible. Twelfth day : delirium and death. Necroscopy. — Cervical glands enlarged to thrice their size and inflamed ; false membrane upon the pharynx, the uvula, the soft palate, the epiglottis, and larynx ; oesophagus healthy ; mucous membrane of stomach and small intestine thickened and softened, and elevated by a kind of white granulations, miliary in the neigh- borhood of the duodenum, then propor- tionately larger as the caecum was nearer ; Peyer's patches more or less red and thickened in the ileum, their thickening ASSOCIATED PATHOLOfiY OF ENTERIC FEVER. 225 being due to swelling of the mucous mem- brane and subjacent cellular tissue ; me- senteric glands large, of an amaranth red, especially near the Cfecum, where they were softened ; spleen thrice its natural volume. "As to the symptoms peculiar to Ty- phoid Fever, if they were little marked, they announced, nevertheless, from their commencement, that the seat of the dis- ease was in the abdomen." (Louis, Obs. XX. p. 187.) Erysipelas is not frequently associated with Enteric Fever. Out of 199 cases of Enteric Fever, observed by Louis, Cho- mel, and Jenner, erysipelas was noticed in twenty. The following is given by Forget as a case of Enteric Fever. We would rather regard it as a case of ery- sipelas and phlebitis. Case 11. — A strong man, aged 38, was under treatment in the surgical wards for erysipelas of the left hand, and on a cer- tam day, when the inflammation was in process of resolution, he was seized, with- out known cause, with shivering, followed by heat, headache, vertigo, nausea, thirst, diarrhoea, and considerable prostration. He was transferred the same evening to the medical wards ; expression stupid, sub-icteric tinge, abdomen tympanitic, gurgling, tenderness in right iliac fossa. ISecmid day : same state : five liquid stools. Third day : pulse 100 ; six liquid stools. Fourth day : same state ; diarrhoea ; trem- bling of hands. The patient had been bled on the first olay, and to-day one of the punctures is found gaping and exud- ing a puriform fluid, and the forearm and arm invaded by an inflammatory oedema- tous swelling very painful on pressure. Fifth day : pulse 120 ; prostration and stupor increasing ; several liquid stools ; cough ; disseminated rales ; sub-delirium, and death the same evening. J Necroscopy. — Jaundiced tinge of skin, L right arm is considerably swollen ; pus f exudes on pressure from the gaping wound , in the vein ; vein thickened for length of two inches above the wound. CJiest — lungs healthy, except a little posterior en- gorgement. Abdomen — alimentary canal I healthy to within two feet of the ileo-cse- f cal_ valve ; Peyer's glands are met with reticulated and swollen ; in the intervals a slight psorentary ; nearer the valve, and ,; upon it, several patches are in the same state, but redder, more swollen, evidently inflamed, as were the surrounding parts of the intestine ; mesentery contained glands swollen and reddish ; spleen very large and friable, and no trace of purulent ■ absorption anywhere. I " Voila, certainement, une enterite fol- liouleuse bien constatee, au cinquieme jour." (Forget, Obs. xi. p. 119.) We ; coafess that we cannot see more than the participation of delicate cellular organs — = vox.. I.— 15 the solitary and agminated glands, the mesenteric glands and the spleen — in a general febrile condition. Had Peyer's patches been found in an ulcerated condi- tion, the erysipelas, which is clearly the primary disease in this case, would prob- ably have been considered to be a sec- ondary complication of latent Enteric Fever. The following case shows such implica- tion of the solitary and agminated glands in a general inflammatory condition, as is very common in acute disease. Vase 12. — Mary W., aged 40, came un- der my care for erysipelas of the head and face, August 12, 1865. She had continued pyrexia and muttering delirium. Pulse 110 to 136 ; the urine was often retained, and the bowels were confined; tongue dry and brown; evacuations sometimes passed involuntarily; urine contained a little al- bumen; the stools were solid and nai-ural; she died on the tenth day after admission. Head — brain healthy, but the vessels con- gested ; two ounces of serum in the ven- tricles. Chest — lungs congested and car- nified below and behind; healthy in front; heart normal. Abdomen — stomach, save a little finely dotted patch of ecchymosis, duodenum, and jejunum, healthy. Lower portion of the ileum and commencement of the large intestine injected. Peyer's glands in the last three feet of the ileum a little swollen and prominent ; the inter- vening mucous membrane strewn with enlarged solitary glands the size of hemp- seeds, giving to the finger, as it passed over the inflamed membrane, a granular sensation. The mucous membrane of the transverse colon, corresponding to one of the longitudinal bands, was highly in- flamed. Some Peyer's glands, hif^her up in the intestine, were stained with sul- phide of iron, and were dotted with black. Here and there the contiguous mucous membrane was also stained black. She had taken perchloride of iron. The colon contained solid natural feces. Spleen weighed five ounces, and both it and the mesenteric glands were natural in size, color, and consistence. Kidneys and pancreas congested. Liver weighed two pounds fourteen ounces; it was pale, soft, and greasy; bile pale yellow. iSrysipelatous (edema of the glottis has oc- casionally caused death in Enteric Fever. Several cases are recorded by Jenner and Trousseau. Case l^.— Myelitis. — "A delicate wo- man, aged 32, was seized at the cata- menial period with sharp pains in the loins, the sides, and lower extremities. Menstruation continued the usual time, but the pains persisted and increased. Fifteenth day: dorsal decubitus, headache, prostration; face expressive of pain; moans and cries ; the least movement is painful; the patient cannot be made to sit 226 ENTERIC OR TYPHOID FEVER. for the examination of the spine, which is the seat of sliarp pains in its whole ex- tent ; tlie joints are equally painful ; the muscles and skin are everywhere ex- tremely sensitive ; prickling sensations in the hands and soles of the feet ; she can- not stand; skin hot; pulse 100, small and hard ; tongue furred ; mouth clammy ; anorexia ; thirst ; abdomen, like all the rest of the surface, tender ; one stool a day. We diagnose a cerebro-spinal affec- tion. Seventeenth day : acute pains ; the patient says she cannot feel her limbs, but when they are touched she complains of extreme sensitiveness ; spine painful on pressure throughout its whole extent ; bowels confined. Eighteenth day: general pains ; the patient cannot move. Nine- teenth day: delirium, plaints; acute gene- ral pains ; stools and urine involuntary ; skin hot ; sweating ; pulse 112, large and supple. Twentieth day : same state ; dia- phoresis, sudamina, vomitings, and nu- merous stools. Twenty-seconcl day: vom- iting ceased; numerous involuntary stools; abdominal gurgling ; immobility ; acute pains provoked by movement ; pulse 120. Twenty-third day : continued delirium ; involuntary stools. Tixenty-fourth day : the patient is pale, almost pulseless, and bathed in cold sweats ; died this day." Necropsy twenty-two hours after death. — JEZend— meninges slightly injected; brain of natural appearance and consistency; a little serum in the ventricles ; coverings of the cord much injected ; a great quan- tity of serum flowed from the spinal canal. The spinal marrow " est ramollie dans une grande etendue, sans changement de cou- ieur ; ce phenomene est evidemment ca- daverique. " Abdomen — stomach inflamed in patches. Small intestines present only some vascular ramifications to within two feet from the cfecum ; then granulations { psorenterie) appear, then reticulated Peyer's patches, others ulcerated very numerous; some appear to be cicatrizing, and some already cicatrized ; in the large intestine some isolated follicles appear to be affected; mesenteric glands engorged; spleen and liver present nothing'of im- portance ; the bladder contains turbid fetid urine, and its mucous membrane is strongly injected and dotted. (Obs. xxviii. p. 286. — Forget.) M. Forget had headed this case "En- terite folliculeuse latente, prise pour une affection cerebrb-spinale. Forme, rheu- matismale." And after he has detailed the symptoms and post-mortem appear- ances transcribed above, he asks, " Where is the practitioner who would not have been deceived, as we have been, by ap- pearances so fallacious ? How recognize a case of follicular enteritis under such a predominance of sensitive nervous phe- nomena?" Only by regarding lesions of Peyer's patches so long and so exclu- sively that no other pathological condi- tion can be conceived possible, we an- swer. M. Forget attributes the softening of the cord to post-mortem changes, but the cord is not softer than the circumferential parts of the brain ; it is equallj' well pro- tected from maceration by its vascular coverings, and, from its situation in the axis of the body, it is less liable to post- mortem changes than the brain itself, which, in this case, is described "de con- sistance et d 'aspect naturels. " We know of no symptoms, or post-mortem appear- ances, which could more positively assure us of the existence of inflammatory soft- ening of the cord, than those which the eminent Strasburg professor here places before us. Phthisis. — In order to illustrate the similarity between the symptoms of tu- bercular ulceration of the intestines, asso- ciated with pulmonary tuberculosis, and those of Enteric Fever, I will here trans- late two cases from JI. Louis's work on Typhoid Fever, and which this eminent author gives as examples, the one of or- dinary Enteric Fever, accompanied by delirium, and the other of latent Enteric Fever, but which, with due deference to so great an authority on both phthisis and Typhoid Fever, we feel bound, from our own observations, to regard as cases of tubercular disease. We might have adduced instances in which the lungs were most extensively diseased, from our own practice, but we prefer to place be- fore the reader the description and con- clusions of some other author. The reader will form his own opinion on the nature of these two cases, bearing in mind the frequent co-existence of tubercular disease of Peyer's and the solitary glands in pul- monary phthisis, and the difficulty which exists in distinguishing acute tubercular inflammation and ulceration of the glands of the ileum, from the corresponding le- sions of ordinary Enteric Fever. Case 14.— A young woman, aged 17, "d'un embonpoint mediocre," had had cough for four weeks, and in consequence of afflicting intelligence suffered headache, loss of appetite and strength, thirst, in- creased heat, constipation ; the headache was reheved by leeches, the other symp- toms continued to the eicjhth day. She took some ipecacuanha, which produced blHous vomiting and purging, with pains in the hypogastrium ; cough a little in- creased. Ninth day: sleepy; slight de- lirium at night ; belly everywhere tender on pressure, supple ; no tympanites ; one stool ; pulse 105 ; intense dry heat ; some lenticular rose spots on the back and an- terior and lateral parts of the chest ; cough moderately frequent ; oppression of the chest, mucous rales ; in the evening tran- quil but profound delirium. Tenth day : ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 227 partly recovered consciousness ; tongue rod and moist ; abdomen tympanitic, a little tender on pressure ; heat considera- ble ; startings continue. Thirtetnth daj^ : pulse weak ; mucous sputa, some streaked with blood ; a little crepitation at base of right lung behind ; continuation of the involuntary movements and meteorism ; continued drowsiness during the day, and delirium at night. Fourteenth day : me- teorism decreased, three or four involun- tary stools ; crepitant rales heard over the sides of the chest. Fifteenth to nine- teenth day : profound drowsiness and de- lirium at night ; on the evening of the nineteenth day respirations much embar- rassed, 60. Twentieth day : delirium and ineffectual efforts to put the arms out of bed ; death. Kvcroscopy. — Head — brain and meninges apparently normal, only moderately in- jected. Chest — lungs free, filling the cav- ity of the chest, of a tender rose-color in front, a little engorged behind for some extent, strewn internally with a great number of gray semi-transparent granula- tions ; bronchi injected, their last divi- sions covered with a puriform secretion. Abdomen — mucous membrane of the small intestine very soft, of an obscure red near the caecum ; Peyer's patches were only visible in the ileum ; those nearest the jejunum were pale and obscure, the rest red and successively more developed, larger, and more thickened in proportion as they were nearer the ileo-ccecal valve ; those in the last foot of the ileum were ulcerated, their mucous membrane more or less destroyed, and in some the muscu- lar fibres, which were red and thickened, were discovered. The non-ulcerated plates were about a line in thickness. Between Peypr's patches were others much smaller, irregular, and otherwise resembling them, and some yellow, miliary granulations. The last two inches of the mucous mem- brane were entirely destroyed around nearly the whole of its circumference, and tlie submucous cellular tissue was more or less red and thickened. Large intes- tine; mucous membrane thickened and very soft, and presented a considerable number of grayish, lenticular spots, marked with a black point in their cen- tre. All the mesenteric glands were red and livid, and those near the caecum very large and soft. The mesocolic glands were in the same condition. The spleen was nearly double its volume. (Louis : i Obs. xxxiv. p. 25, vol. ii.) It is strange that Louis, of all other ob- servers, should consider the foregoing to be a case of Typhoid Fever, when the history and anatomical characters are so plainly those of acute tuberculosis. The L nature of the other case is still more ap- " parent. Case 15. — A spare man, aged 25, hav- ing short breath from the age of ten years, is taV^-n with the following symptoms : Disgust of food, thirst, cough, shiveriugs followed by heat. These symptoms con- tinued, with constipation, until the twenty- first day, when he ^^'as admitted into the hospital of La Charite. He presented the same symptoms with a slight oppression at the epigastrium ; constipation still ; heat of skin a little exalted, general mois- ture ; pulse large and moderately full ; cough infrequent ; some mucous expec- toration ; natural respiratory murmur ; moderate weakness. Tiventy-flfth day : some lenticular rose spots on the abdomen and chest; pulse 86. Up to the thirty- seventh day the patient continued station- ary, then for the first time he had spon- taneous diarrhi.ea, and grew paler and weaker. Thirty-eighth day : a sudden and violent pain in right testicle and cor- responding part of hypogastrium, accom- panied by a little shivering. The pain came on again in the night, and his slen- der body was covered with large drops of sweat ; he had neither nausea, nor vomit- ing, nor tympanites ; pulse 104. Thirty- ninth day: oOijiousdiarrhcEa ; several vom- itings of green bile ; sweats and pain continued all day. These symptoms con- tinued up to the fcniy-fifth day, when there was great abdominal pain and vom- iting. He died this day. Kecroscopy. — Considerable emaciation. Head — slight sub-arachnoid effusion. Chest — the summit of the left lung presented some cellular adhesions, was a little hard and unequal, and offered for the depth of two inches a considerable number of gray, semi-transparent granulations, in the midst of which a tuberculous excavation was found, the size of a nut, partly empty, and communicating with the bronchi. Below, the pulmonary tissue was in the normal condition. The right lung was in the same condition. Abdomen — general peritonitis from perforation of the small intestine about five inches from the cae- cum ; red patches, due to injection of the peritoneum upon the external surface of the small intestine ; internally, this part of the bowel presented, at about twenty- four inches from the caecum, a transverse ulceration about f ths of an inch in extent, opposite the mesentery, having the at- tenuated muscular coat for its base, and the edges were not very prominent, and slightly grayish. Six similar ulcerations existed in the last six inches of the ileum, and in the centre of the first of them the perforation, measuring about a fourth of an inch in diameter, was found. The edges of this ulcer were very thin, and partly formed by the peritoneumalone. The mesenteric glands were a little red, and three or four times their natural vol- ume, and had only half their usual con- sistence ; liver a little pale and soft ; 228 ENTERIC OR TYPHOID FEVER. spleen twice its natural volume, a little pale and soft. "The thirst, anorexia, pains in the head, and the shiveriugs clearly indicate the commencement of the illness in this case. It was only after three weeks that the pains in the belly were experienced. Diarrlicea came on as late as the thirty- seventh daJ^ The ulcerations of the in- testine being the most profound and with- out doubt the oldest lesions observed, to these ought to be attributed, in great part at least, the febrile sj'mptoms present at the commencement. It is requisite, how- ever, to remark that the tuberculous aflfec- tion commenced, according to all appear- ance, with the principal disease ; yet as ulcerations of the small intestine had the characters of those which occur in the course of the typhoid affection, and as the state of the mesenteric glands' could only be referred to that condition, this disease has evidently had the greatest share in producing the symptoms and lesions ob- served, and we can only place this case in the chapter upon the latent typhoid affec- tion." (Louis, Obs. xliii. p. 232, et seq.) Endemic Intermittent and liemiitent Fe- vers. — One of the most general facts observed in reference to Enteric Fever, is the frequent occurrence of iutermittence in the pyrexial condition. The commis- sioners appointed to investigate the French epidemics of Enteric Fever, "call attention to the fact that a more or less pernicious intermittent or at least remit- tent character, was manifested under a great variety of circumstances." (De Claubry, Meni. de I'Acad. de Med., tome xiv. p. 71.) "A great number of cases of Tj'phoid Fever presented, either at the commencement of the disease, transient symptoms of simple intermittent fever, or during its further progress, intermittent or at least remittent phenomena, which rendered the employment of quinine ne- cessary." (Ibid. p. 11.) M. Trousseau (Clinique Medicale) records cases to show that "Enteric Fever may simulate at first intermittent fever, and reciprocally, an intermittent fever may assume at the commencement the characters of Typhoid Fever." (P. 247, 2d Edition.) "It is especially in countries where marsh inter- mittent fevers are endemic, and with in- dividuals who have recently left their own country, that we see Enteric Fever as- sume at its commencement an intermit- tent type." (P. 250.) ' Louis appears to regard a vascular, swol- len, and softened condition of the mesenteric glands as being inconsistent with the exist- ence of tubercular disease. We have fre- quently seen tlie mesenteric glands purple, soft, and swollen in oases of advanced phthisis in ivhich both lungs and intestinal glands have been affected. (See Diagnosis.) Intermittent fevor is, in the present day, nearly extinct in England. Its last strongholds are to be found in the north part of Kent. There, about the Isle of Sheppey, and on the marshy banks of the Swale, it still lingers. At Milton, for ex- ample, ague is still common in the autumn. "The drinking water is obtained from wells, and the general sanitary condition, as regards drainage and the non-removal of nuisances, is unsatisfactory, and there has been a considerable amount of Ty- phoid Fever at times, and scarlatina in a severe form was prevalent at the time of the inspection." (Rep. by Dr. G. Whit- lej', as to quantity of ague now prevailing in England. Sixth Rep. Privy Council, 1863, p. 432.) At Holbeach and Long Sutton, Ague and Enteric Fever were both prevalent. The drainage of these places is bad, and the water supply bad, being from pits (p. 441). "Very nearly all the medical men who had had opportunities of forming an opinion concerning the co-existence of ague and typhoid fever in the same dis- tricts, were of opinion that the local con- ditions which produced the former are favorable to the development of the latter. Thus, Mr. Keddeil, with foi-ty years' ex- perience in Sheppej', believed that when ague, from certain conditions of surface, is rife in summer, bilious, remittent, and typhoid fevers prevail in autumn." (Ibid. p. 452.) My friend ]Mr. Charles Maj^o informs me, from extensive personal observation, that the "camp fever" of the army of the Potomac was generally recognized as a " typho-malarious fever," in which the symptoms of typhoid fever, diarrhoea, rose rash, &c. were associated with those of intermittent fever. The typhoid symp- toms occasionally predominated, and post- mortem examination revealed lesions of Peyer's glands. [See, on a subsequent page, a fariher account of American Ty- pho-malarial Fever. — II.] It is evident from the foregoing obser- vation that an investigation into the na- ture of Enteric Fever would be very incomplete without a brief consideration of the symptoms and morbid anatomy of the severer forms of intermittent fever. The AValcheren fever offers itself as a standard of comparison. Dr. Davis' has given a very clear and minute description of this disease. " The Walcheren fever," he says, " assumed the quotidian, tertian, double-tertian, and even remitting type. It did not uniformly declare itself with the same type, being one while continued, then remittent or intermittent, and chanc- ing its type again from these to the con- ' View of the Fever of Walcheren and its consequences, by J. B. Davis, M.D. 8vo. Lond. 1810. ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 229 tinned character. I believe the Walcheren fever in many instances would have ceased but for the derangement it had occasioned in the abdominal viscera, be- coming in some measure a secondary dis- ease." (P. 12, et seq. ) The premonitory symptoms were weakness, nausea, head- ache, universal languor, dejection of spi- rits, always combined with a vitiated state, suppression or diminution of the intestinal and biliary secretions. After the paroxysms, headache, confused intellect for two or three days, ending in coma and stupor. At other times con- tinued pyrexia, whiteness of the tongue, distension and uneasiness of the epigastric region, and anorexia. Then the bowels became painful, and there were diarrhoea, discharge of mucus, or much blood inter- mingled with feces, &c. &c. These symp- toms would be obscured by the paroxysm, to reappear after it was over (p. 18). "All the patients with the quartan type under my care were very prone to diarrhoea and dysentery, thirst, pyrexia, emaciation, daily exacerbations of hectic, local pains, and general irritation, constituting an un- manageable disease which wore away the patient's strength, and utterly exhausted him" (p. 17). Delirium was seldom for- midable ; epistaxis frequently occurred. Hectic was almost uniformly the character of the pyrexia. Gray, clay-colored watery stools, and rapid marasmus, were common in cases tending to a fatal termination. Such were the symptoms of " the con- tinued fever or long-continued paroxysm, ' ' [Fig. 11. lip 1 g iBh 1 SI Stfomi: Bemitting lysis In enterlo fever.] when the order of the periods became so completely overturned that it was difflcult to bring the fever to its proper type again (p. 21). ' "^ -"^ "^ If we now turn to the morbid anatomy of the disease, wo shall find positive evi- dence of lesion of the solitary and agminate Rlands of the small intestines, in at least sis of the cases recorded by Dr. Davis. Usually both the small and large intestine were involved in the disease, and its rav- ages greatest in the latter. Thus, in case ti'J, we have a description of the post-mor- tem appearances of dysentery implicating the small intestine : — Colon ulcerated throughout its whole extent. Eectum much ulcerated and had sloughed near its termination. Jejunum and ileum "inter- spersed with black spots internally; the intervening spaces red, and raised up into little protuberances, resembling granula- tions of flesh, not unhke a cock's comb." Liver large, black, and soft. Spleen soft, of enormous size. Mesenteric glands en- larged (p. 173). In case 32 the large and small intestines appear to have been pretty equally affected. " The small intestines were of a deep pur- ple color, and interspersed on their inner side with tubercles and small ulcers, re- sembling chancres. The colon and rectum had numerous tubercles and ulcerations." Spleen weighed four pounds, and was uni- formly soft throughout. Mesenteric glands enlarged (p. 175). In case 34 the lesions were more appar- ent in the small than in the large intes- tine. The convolutions of the small intes- tines were united together by condensed coagulable lymph. They were of a red- dish color, and interspersed with small red eminences on their inner surface. The coats of the colon were thickened. Liver large and black. Spleen firm and dark, weighed four pounds. The particular characters of the intesti- nal lesions are thus clearly described by Dr. Davis. The ileum and jeju- num were frequently interspersed with "tubercles inflamed and ulcer- ated in different parts. Here and there small eminences of the size of a pin's head, or round bodies with an ulcer at the point, or little ragged ulcers, excavated in the middle, re- sembling chancres, or one large, or a succession of small ulcers spreading wide upon, and deep into, the coats of the intestines. Color of these tu- bercles various, consistence firm. While their points were yellow their edges were hard, and their bases al- most black, like a lump of decayed flesh. They did not come fairly to suppuration, but appeared gradually to crumble away and degenerate into a scabrous ulcer. These bodies had their origin beneath the villous coat of the intestine." (P. 191.) Prom the above description we may in- fer that the morbid condition of the solid and agminate glands of the intestine in these fatal cases of intermittent fever is identical with that which is assumed to be characteristic of Enteric Fever. We have already seen that both forms of fever are developed amidst the same conditions, and 230 ENTERIC OR TYPHOID FRA'ER. we therefore unhesitatingly conclude that Enteric Fever is often a part of intermit- tent fever, and the converse. Dysentery. — After the foregoing observa- tions it may appear superriuous to call special attention to the relation between Dysentery and Enteric Pever. But the connection between these two diseases is too important to receive only a cursory notice. Even in reference to Enteric Fe- ver alone, it is important to observe that the ulceration sometimes spreads to the large intestines, when the lesions of the small intestine are in process of repara- tion. The following isolated case recorded by F'orget, may be briefly mentioned to show how the enteric disease may be pro- longed by subsequent lesion of the large intestine. Case 16. — A patient was laid up with the usual symptoms of Enteric Fever for a month, then, after a few days' intermis- sion, profuse dysenteric diarrhoea, tenes- mus, and colic pains set in, and after con- tinuing for about twenty days killed the patient. In the last two feet of the ileum, "numerous white shining spots, of varia- ble extent, smaller than the ulcerated Peyer's patches, and evidently cicatrices, were found. The ileo-caseal intestine was profoundly altered in all its extent from the great valve to the anus ; it was brown, black, hypertrophicd, vegetant, and soft- ened, presenting ulcerations of various depth." (Forget, Obs. xhi. p. 3.51.) Rokitansky describes " the typhous pro- cess in the mucous membrane of the small intestine," as distinct from "the dysen- teric process" observed in the large intes- tine. But this distinction is purely artifi- cial. In the following well-marked case of Enteric Fever which lately died under my care, the large intestine was the more extensively ulcerated, and the ulcers in both small and large intestine were indis- tinguishable from the so-called "dysen- teric ulcers." Case 17.— Catherine M., aged 2.3, resid- ing at Stanmore, near London, was taken ill this autumn with headache, much shivering, pain in the back, and diarrhoea. Fever and diarrhcea continued ; rose spots appeared on the abdomen from the tenth to the twenty-second day. Diarrhoja per- sisted, and there was much hectic. On the tiventy -fourth day there was marked abdominal tenderness. The diarrhcBa con- tinued unchecked, and she died on the twenty-seventh day. Necroscopy. — Chest — lungs congested, friable at apices, weighed thirty-three ounces. Abclomen. — liver enlarged, weigh- ed three pounds five ounces, soft, greasy, and pale. Gall-bladder full of pale, thin, ochre-colored bile. Stomach, duodenum, jejunum, and upper portion of ileum healthy ; last two feet of ileum presented gixteen ulcerations of Peyer's glands, varying from minute vascular abra.sions to three-eighths of an inch in diameter. Four of these pale depressed ulcers were situated immediately above the ileo-ca;cal valve, and were evidently in process of contraction and cicatrization. In the large intestine there were twenty-seven ulcers, twenty of which were in the cae- cum ; several were situated immediately below the ileo-cascal valve, and one of these was as large as a shilling, and deeply excavated the muscular fibres ; an- other, the size of a sixpence, was placed at the bottom of the caecal pouch, and it lay upon the peritoneum, which presented externally a corresponding patch of opacity with vascular ramifications. Seven other ulcers occurred at intervals in the ascend- ing and transverse colon, the last one oc- curring at a distance of two feet from the ileo-csecal valve. All these ulcers were pale, with ashy or smooth bases lying upon the muscular fibres ; their edges were not elevated, and often perpendicu- lar. The solitary glands of the large in- testine were enlarged, the central parts of many were eroded and in a state of inci- pient ulceration. The mesenteric and raesocolic glands were purple, much en- larged, and soft. The spleen weighed six and a half ounces, and was of normal color and consistence. Kidneys, pancreas, and the other organs healthy. The day after this j'oung woman died, a patient in the same ward, under the care of my colleague. Dr. Murchison, also died ; and as the case illustrates very well how extensively the large intestine may be ulcerated by Enteric Fever, I have availed myself of Dr. Murchison's kind- ness in allowing me to make my observa- tions of the case, and briefly detail them here. Case 18. — Ehza H., aged 26, was ad- mitted on the tenth day of her illness with fully developed Enteric Fever. She was taken ill with headache, heats and chills, and diarrhoea, and these sj'mptoms con- tinued to the time of her admission. Rose spots appeared on the abdomen from the tenth to the eighteenth day. The bowels continued very loose, and the stools were of a light yellow color. Medi- cines failed to restrain the diarrhoea, the abdomen became distended and tender, and the patient died exhausted on the twenty -seventh day of her illness. Necroscopy. — Cliest — lungs healthy, with only a little hypostatic congestion. Heart contained firm fibrinous clots in all its cavities. Abdomen — stomach, duodenum, jejunum, and upper portion of ileum per- fectly healthy. In the last two feet of the ileum there were a dozen pale non-ele- vated ulcerations of Peyer's glands ; six of them were in the immediate neighbor- hood of the ileo-ca;cal valve, and the largest did not exceed three-eighths of an ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 231 iivli ill diameter. All were evidently in prjuess of healing. Tlie large intestine was in a state of ragged ulceration fmm the under surface of the ileo-C£ecal valve to within an inch of the rectum. In the transverse and descending colon there were two rows of ulcers, each about a foot long ; these ulcers were deeply exca- vated, and for the most part coutluent, or only separated by narrow bands of hyper- trophied mucous membrane. Each ulcer, or coutluent patch, was about an inch wide. The edges were two or three lines thick, irregular and very vascular, and often black ; the surface of the ulcer was chiefly formed of ashy sloughs of areolar tissue, or disintegrated muscular fibres. In the interval between these rows of ragged ulcers were a great many circular ulcers, and swollen solitary glands advan- cing to this condition. Nearer the csecum and rectum the uk:ers were fewer and more discrete. The mesocolie glands were greatly enlarged, purple, and soft. The spleen weighed eight and a half ounces, and was pulpy. The liver was very soft and greasy ; it weighed forty-four and a half ounces. The gall-bladder contained half an ounce of pale yellow watery bile, which did not affect turmeric paper, but changed blue litmus to red. The other organs were quite healthy. In the following case of Enteric Eever and pneumonia, the intestinal lesion was almost entirely confined to the colon : — Case 19. — Phcebe Poole, aged 14, was admitted into the London Fever Hospital on the 8th of September, 1865, on the /o«r- teentk day of her illness. She had had cough, quick breathing, and diarrhcea, ac- companied by high fever. At this date the pulse was 150, tongue dry, brown, and cracked, skin pungently hot, respira- tions 58, cough, dulncss with crepitation and bronchophony over the lower lobe of the right lung behind ; there was reten- tion of urine, the abdomen was tympanitic and tender, there were two rose spots upon its surface, and the bowels were very loose. The pulmonary and enteric inflammation progressed, tubular breath- ing was heard over almost the whole of the right side of the chest, and the bowels continued very loose. A few fresh rose spots appeared up to the nineteenth day. On the tioenty-ninth day the respirations were 60, short and snatchy, the pulse 160, and the diarrhoea profuse. On the thirty- fiflh day she died. Autopsy.— Chest — right lung completely solid and firm, gray and gangrenous. Left lung a little engorged. Heart healthy. Ahdr)men—i)\& last Peyer's patch near the ileo-csecal valve had two minute ulcera- tions, but the rest of the gland, and all the other agminated and solitary glands, were perfectly healthy. The colic side of the csecum, and the first five inches of the ascending colon, were in a state of ragged ulceration— long clean, transverse ulcers, laj^ing bare and dissecting the muscular fibres, were repeatedly confluent in this part of the bowel, and were inter- spersed with islands of soft, greatly-swol- len, mucous membrane. Lower down, were ulcerated solitary glands, and there were six more in the sigmoid flexure. The solitary glands and the mucous mem- brane of the rest of the large intestine were generally healthy. The mesenteric glands corresponding to the small intes- tine were quite healthy ; the mesocolie glands in the neighborhood of the ca3cum were purple, soft, and much enlarged. The rest of the viscera appeared healthy. The spleen was of natural size. Such cases as the foregoing afford typi- cal examples of acute dysenteric ulcera- tion, and we may question whether the distinction between Dysentery and En- teric Fever is not somewhat artificial. Cholera. — "In the delta of the Ganges, the Nile, and the Mississippi the three forms of disease called cholera, plague, and yellow fever, are constantly seen pre- ceding, accompanying, and following in- termittent fever, and constitute there the reigning endemic diseases ; and one is forced to recognize a very great analogy, not to say an identity, of origin between marsh fever and the three great scourges above mentioned." (Traite des Fievres interrnittentes, remittentes, et continues, par J. C. M. Boudin, p. 161.) A pro- tracted attack of cholera bears a close re- semblance to Enteric Fever ; the intesti- nal lesions of the two diseases, moreover, are indistinguishable from each other. "The most frequent of all the abnormal conditions of the mucous membrane of the intestines was prominence of the intestinal glands, both aggregate and solitary, but especially the latter. This condition, the psorenterie of some French writers, was found in about two-thirds of the eighty- nine fatal cases examined." (W. T. Gairdner, M.D., Month. Journ. Med. Sci- ence, 1849.) M. Pirogoff examined 500 fatal cases of cholera. He observed, in the earlier periods of the disease, "thick- ening and swelling of the mucous mem- brane most often accompanied by swelling of Peyer's and the solitary glands, as well as swelling of the mesenteric glands. In the typhoid period, ulceration of these glands." (Anatomic Pathologique du Cholera Morbus. Folio, St. Petersburg, 1849.) Scurvy is sometimes accompanied by ulceration of the solitary and agminate glands, with all the symptoms of Enteric Fever. An outbreak of scurvy occurred in the Milbank Penitentiary, in London, in the years 1822-23. An account of it was published by P. M. Latham, M.D. (8vo. Loud. 1825.) "In addition to the 232 ENTERIC OR TYPHOID FEVER. ordinary symptoms of scurvy — purpura htemorrhagica, spongy and even bleeding gums, &c. — there was every degree and species of flux ever seen or described. Tliere were cases which corresponded with tlie descriptions of the Indian cholera, and there were some which corresponded ■with the common autumnal cholera of this country, except that they were accom- panied by intractable diarrhoea. There was every kind and degree of dysentery." (P. 32, 33.) In some cases the abdomen was soft and natural ; in others tympa- nitic. Post-mortem examinations re- vealed lesions of the intestines, which, from the descriptions at pp. 46-49, are clearly to be attributed to swelling and ulceration, even to perforation, of the solitary and agminated glands. Varieties. — After the foregoing re- view of the associated pathology of En- teric Fever, can we adopt the dogma of Chomel? — "Quand nous trouverons dans les auteurs, soit anciens, soit modernes, des observations de maladies aigues k la suite dcsquelles on aura rencontre des ul- ceres a la fin de I'intestine grele, nous aurons le droit de les considerer comme des cas d'aftection typhoide." (Fievre Typho'ide, p. 113.) Or, going to the other extreme, shall we deny the exist- ence of Enteric Fever as a specific dis- ease, and regard the intestinal lesions merely as the result of an accidental but severe local complication which may arise in any general febrile condition of the body? If we accept the first proposition, we must include Tuberculosis under En- teric Fever. If we adopt the second, we Taay, with almost equal reason, deny the existence of scarlatina as a distinct dis- ease. We can only a"\'oid the dilemma by admitting that the enteric disease, and all its attendant phenomena, may occa- sionally become a part of some other more general inflammatory condition, and then, I think, it can hardly be denied that in other cases the disease is due to some poison or poisons introduced from witli- out, in the elimination of which, the di- gestive organs especially are deranged. In order to include all the phenomena of Enteric Fever, I find it necessary to divide it into these three varieties : (1) Simple Inflammatory Enteric Fever ; (2) Conta- gious Enteric Fever ; (3) Paludal Enteric Fever. It may seem paradoxical and unphilo- sophical to include under one kind conta- gious and non-contagious diseases ; but since the question of contagion is still an open one with many, and neither symp- toms nor anatomical lesions mark a dis- tinction, we must be content thus to clas- sify the disease for the present. 1. Simple Inflammatory Enteric Fever. — This variety is non-contagious, due to no ! specific cause, and may arise in any in- flammatory condition of the body, such as accompanies pneuuionia, erysipelas, py- emia, &c. The common enteritis, which constitutes autumnal diarrhtea, if pro- tracted, often lapses into this variety of Enteric Fever. Cases 6, 7, 11, 19, &c., furnish examples of this variety. The recognition of the intercurrence of enteric inflammation, with ulceration of the glands of the ileum, in acute diseases generally, is of very great importance ; for of all the organs of the body, these delicate glands, from their situation with- in the thin and vascular intestinal waU, are less capable than similarly constituted parts elsewhere situated, of endusing pro- longed inflammation, without risk of fatal accidents ; and at any time the intestinal lesion may become much the gravest part of the more general disorder. The fre- quency with which the intestinal glands become implicated in acute disease is probably due to their exposed situation, their delicate corpuscular structure, their great vascularity, and the arrangement of their bloodvessels. A well-developed healthy lad, aged 15, fell from a horse ; the skull was fractured and the corresponding surface of the brain lacerated ; febrile action followed, and he died on the third day. Before the body was cold I examined the small intestine. In the last nine inches of the ileum I found the solitary glands swollen, and of a delicate grayish-pink color, and semi- transparent appearance, forming rounded elevations of the mucous membrane, the .size of hemp-seeds (psorentery). The mesenteric glands were a little increased in vascularity and size. There was no trace of disease in an}' part of the body. Here we recognize a condition of the soli- tary glands, which, under the continuance of the general febrile action, might have passed into the worst form of " typhoid ulceration." " But surely," it will be said, "we can distinguish the true typhoid ulceration from any other at a glance ; moreover, the typhoid ulcer is characterized by the de- posit of a distinct morbid material — a spe- cific ti/phous cell.'''' Plaving shown that the inflammatory swelling isdue, not to the deposit of a specific morbid matter within the glands, but to the rapid growth of their normal corpuscular constituents under the influence of undue vascular excitement, we fail to recognize any character by which one form of inflammatory action in Peyer's glands can be distinguished from any other. Ultimately, we shall have little or no difficulty in distinguishing a tubercular ulcer from any other ; but be- tween the lesions assumed to be charac- teristic of Enteric Fever, and those aris- ing from ordinary inflammation, which, of course, may afiect the intestinal glands VARIETIES. in common with every other part and organ of the body, there is, I conceive, no distinction. As a result of common in- flammatory action in the glands, we may lind Peyer's glands swollen into cock's- comb or fungus-like elevations, and exca- vated into ragged ulcers, with red everted edges, or occupied by sloughy cores. (See case 8. ) In a well-marked case of Enteric Fever, in which the diarrhoea, rose spots, and abdominal pain and swelling call attention to the abdominal lesion, we may, on the other hand, find, as in a case which I examined two days ago, a dozen angry-looking ulcers in the last foot of the ileum, varying in diameter from two lines to three-fourths of an inch, and exposing the red-streaked muscular fibres, each ulcer sharply cut, and the irregular mar- gins not raised above the general level of the intervening dark-red mucous mem- brane. Hio;her up were seen glands level with the inflamed mucous membrane, and presenting sloughy erosions, like an aph- thous ulcer of the mouth. 2. Contagious Enteric Fever. — Of this variety I can say but little. I am not gure that I have seen it ; but that it exists, ap- pears to be an indisputable fact. Eight of the sixty-eight patients referred to be- low came from houses in which other resi- dents were aifected with the fever. The disease may have been propagated by con- tagion in some of the se cases, but in two instances, in eaoli of vvhich three mem- bers of the same family were affected, I found from personal observation that an endemic cause existed in impure drinking water. See also cases 4 and 5, and the observation upon " Contagion. " The as- sociations of this variety appear to be, as I have already pointed out, with scarla- tina and the aUied affections, diphtheria and croup. Exudations upon the faucial and laryngeal mucous membrane appear to be frequent in this variety, and the course of the disease more rapid than in the third variety. 3. Paludal Enteric Fever. — This we be- lieve to be the common form of the dis- ease. It arises from putrescent animal and vegetable substances. It is non-con- tagious, and its course is usually slow. Case 2 may be taken to illustrate this variety of the disease. In thus unreservedly recognizing the connection which I cannot doubt exists between Intermittent and Enteric Fever, it may appear to some that I transgress the facts which have been adduced to Illustrate this view ; but I feel sure that justice has not been done to the numerous observations which abound in medical literature, and which, if collected, would together form irresistible evidence of the direct connection between these two dis- eases. In the low-lying districts on the banks of the Thames, within and about the metropolis, where ague was formerly so rife, Enteric Fever prevails continu- ously, becoming very abundant in the autumn, while the higher situations are comparatively free from it. Of sixty-eight cases of well-developed Enteric Fever which have come under my care during the present autumn (1805), fourteen came from the districts of Stanmore, Chelsea, Lambeth, Southwark, Stepney, Hackney, Bethnal Green ; thirteen from the lowest part of the parish of St. Luke alone, where cesspools and pumps are still in use, and where drainage works are now in progress ; twenty-three from the filth- iest and most crowded parts of the par- ishes of St. Clement Danes, Holborn, and St. Giles ; and only five from the more elevated localities of Soho and Maryle- bone, Islington, HoUoway, &c. The re- mainder resided in Maidstone, Croj'don, Mitcham, Edmonton, and various other country districts near London. AVe find Enteric Fever remarkablj' pre- valent in the spreading outskirts of the suburbs, where new houses and streets are constantly springing up beyond the limits of the drainage works. We acknowledge as modifications of the same disease, that intermittent form to which, when London had its cesspools and pumps, and retained all its filth within its undrained area, James I. fell a victim, and that continued modification which still lingers in a subdued form in the same locality, and to which a good Prince has succumbed in our own generation. [Typho-Malarial Fever. — In the States which were the seat of conflict during the American civil war, and especially in Virginia, in 18(>2, many cases occurred amongst the soldiers of the Union army, for which the above is the most fitting name. '' Chickahominy Fever" was a hospital designation, derived from a local- ity in which hundreds of cases took their oridn during the " peninsular" campaign of McClellan. ' Three morbific elements appeared to comliine in the causation of these cases : malaria, camp or "crowd" poison, and the dietetic deficiency which produces scurvy, and gives the scorljutic taint to other diseases. According to the pre- dominance of one or another of these etiological elements, the resulting malady varied. The following brief account is cited from a record taken by me upon the observation of a large number of these cases in two of the Philadelphia Hospitals. " Of the form in which the malarial element prevailed, the somewhat abrupt commencement, gastric disturbance, and icteroid skin and tongue, with remissions tolerably distinct, were predominant fea- ' See Woodward's "Camp Diseases of the United States Army." 234 ENTERIC OK XYPHOID FEVER. tures. The lenticular spots of typhoid fever, and the sudauiina and tympanites, were often wanting altogether. "A slower onset, less distinct remissions, more cerebral disturbance, and diarrhoea, with epistaxis and bronchitis sometimes, but with both less constantly than in civil life, marked the predominance of the typhoid pathogenetic element. Deafness, under my observation, was less frequent than in civil life, but was sometimes very well marked. The aspect of the counte- nance, and the character of the somno- lence and delirium, were precisely the same as in ordinary tjphoid fever. "The scorbutic complication was recog- nizable, in the third group of cases, by the peculiar mental and bodily prostration which preceded and followed the disease — the remarkable irritability of the heart, the state of the gums, tendency to hemor- rhage, discolorations and petechia, pallid, large and smooth tongue, and extremely protracted convalescence. '■^Morbid Anatomy. — Most important was the intestinal lesion, similar to that of typhoid or ' enteric' fever, though not identical. The following account of this is from Dr. Woodward. ' " 'In the earlier stages there was little to distinguish the intestinal lesion from the corresponding process of ordinary en- teric fever, except, perhaps, the great tendency to the deposit of black pigment in the enlarged follicles. In the latter stages certain peculiarities are often dis- tinctive enough to enable the anatomist to recognize typho-malarial fever by the post-mortem appearances alone. The tumefaction in typho-malarial fever rises very gradually from the surrounding mu- cous membrane, and attains a moderate degree of thickness (three to six lines) on the edges of the ulcer. In this it differs materially from the ordinary tjphoid ulcer, in which the enlarged patch rises abruptly from the mucous membrane in such a way that the summit is often larger than the constricted base, giving rise to the com- parison made by Eokitansky, who likens the shape of the tumefaction to that of flat sessile fungi. The umbilicated de- pression, so frequent in the ordinary typhoid patches prior to ulceration, has never been observed in typho-malarial fever. The ulcer itself presents ragged, irregular edges, which are often exten- sively undermined in consequence of the erosion extending more \videly in the sub- mucous connective tissue tlian in the glandular tissue of the mucous membrane. This characteristic undermining of the edges is much more extensive in these than in ordinary typhous ulcers. ' '■'■ Pathol n(pj. — Doubting not at all the presence of the malarial element, the ques- ' Op. citat., pp. 102-3. tion occurs, was the modifying ' febrile' cause of the typhous or of the typhoid cha- racter ? Granting, that is, that these are pathogenetically distinct, we should ex- pect that the typhus or 'crowd-poison' element must result from the circum- stances, as from those which made typhus or ' camp fever' the scourge of armies in Europe. Only, against this, we have the local lesion, of the glands of Peyer and mucous membrane of the bowels, recall- ing enteric or typhoid fever. "But — as, where typho-malarial fever occurred, causes of intestinal irritation (bad water, deficient food, &c. ) were pres- ent — I am not satisfied that such an ap- pearance (not, as we have seen, identical with that of typhoid fever) should exclude the idea of the zymotic action being that of the typhous cause. In that opinion, as a probability, not, of course, now demon- strable, I rest. " Treatment — From the above view of the hybrid and threefold nature of the dis- ease, came its rational treatment. More quinine than in typhus, more alcohol than in remittent, more fresh vegetable food, and fruit than in either. Experience Justified this plan. In our hospitals in Philadel- phia, few died from fever who were not moribund on their arrival from the seat of war.'"— H.] DiSTBiBUTiON. — Enteric Eever pre- vails in every inhabited part of the world. No situation is secure from it. In the re- port of the epidemics which have occurred in France from 1841 to 1846, De Claubry (M6ni. de 1' Academic de Med., tome xiv.) observes: "The situation of the twenty- eight departments which have been the frequent theatre of destructive epidemics of typhoid fever, was such that it ap- peared impossible to conclude that it had any influence whatever in the production of these epidemics." (P. 4.) "If one finds typhoid fever on the one hand in vil- lages situated in deep valleys, in narrow gorges ; in lowlands, where the water- courses frequently overflow, making the submerged soil, upon which the miserable dwellings are built, extremely damp : one sees it, on the other hand, in villages situ- ated, one upon the most elevated points of a high chain of mountains, and constantly exposed to every wind, and having no un- healthy condition in its neighborhood ; another situated 600 feet above a little flowing stream, commanding an extensive view of perfectly cultivated fields ; a third, in a very salubrious position, upon an un- dulating soil, where the flow of water is perfect.''" (P. 8.) Enteric Fever, moreover, attacks every class of society indifferently. On one [' Essentials of Practical Medicine, 4tU ed., pp. 367-9.] CAUSES. 235 hand, we find it associated with the most abject povcrtjf, damp, filth, overcrowding, and detective ventilation ; and, on the other, we witness tlie disease making liavoc amongst the wealtliy residents of spacious, dry, well-built liouscs, isolated, or united to form wide open streets, or elevated terraces. Causes : (a) Predisposing. — Of the causes wliicli predispose to Enteric Fever, youth is usually considered to be one ; but young people are not more liable to this than they are to other inflammatory dis- eases. Dr. Murchison states (page 409), that slightly more than half of the cases of Enteric Eever admitted during ten years into the London Eever Hospital were between fifteen and twenty - five years of age ; one-fifth were under fifteen; loss than one-seventh above thirty : and only one - sixty - eighth exceeded fifty. Similar statistical results may probably be found in many other acute diseases. [More than one attack in the same indi- vidual is rare ; but instances of recurrence do occur. — H.] Seasons have a marked influence on the increase and diminution of Enteric Eever. " Out of 100 times in which an exact indi- cation of the epoch when the epidemics of typhoid fever commenced, the reports of the years 1841 to 184G give the following results : — Eirst yearly quarter, twenty epidemics ; second quarter, twenty-one ; third quarter, twenty-nine; fourth, thirty- six: or, summer (April to September) sixty; winter (October to March) fifty-six. Seventy epidemics commenced in the four months of August, September, October, and November ; while only forty-six com- menced in the other eight months of the year, from December to July." (De Claubry, op. cit. p. 8.) " In New England Enteric Fever is not infrequently called the autumnal or fall fever." (Bartlett on Fevers, p. 101.) On examining the accompanying Table (vide Table) of "the cases which have oc- curred at the London Fever Hospital dur- ing the last 18 years, the following facts appear : — First, that the greater number of cases occur during the autumn and winter months, and the average of 17 complete years' shows that more than twice as many cases, or a proportion of 2'1 to 1, occur during these periods, as compared with those happening during the other six months of the year. Second, that of all the seasons autumn is the one in which Enteric Fever is most prevalent. In fourteen out of the seventeen years, the number of autumnal cases exceeded that of any other season. In one of the three remaining years, 1851, an equal number of cases occurred in the summer ' From 1848 to 1864 inclusive. and autumn respectively. In the other two years, ISGU and 18U2, the greatest number of cases occurred during the win- ter, exceeding the autumnal cases by six- teen. Third, that the disease is least of all prevalent in the spring. Excepting- the years 1852, '56, '59, '00, '61, and '63, the least number of cases occurred in spring, and in all these exceptional years there were only thirty-four spring cases in excess of the summer ones. It appears from these general facts, and from a little closer examination of the table, that Enteric Fever obtains its maxi- mum development in the months of Sep- tember, October, and November, declines slowly during the winter and spring, and reacliing its minimum in May, then be- gins to increase progressively with the ad- vance of summer. Let us now go a step further, and en- deavor to find out the conditions which, prevailing most in autumn, render this season most favorable to the existence of Enteric Fever. Temperature. — In every year but 1852, tlie combined temperature of the autumn and winter was less than the combined temperature of spring and summer, and in this exceptional year the mean tem- peratures were as SO'^'S to 50°'9. And in every year but 1851, '54, '55, '56, and '61, the temperature of autumn was less than that of summer, and in no year did the autumnal temperature exceed that of summer more than l^'l. Again, if we except the years 1851, '55, ^ii^i, and '61, October — the month when Enteric Fever is most rife — was cooler than May, when the disease is at its lowest ebb. It has been already stated that in five of the years, the number of cases occurring in the spring of those years was in excess of the number which happened in the warmer summers. Apart from any other cause, it cannot, therefore, be concluded that temperature has any influence on the increase of En- teric Fever. Bainfcdl— In considering the influence of rain upon the quantity of Enteric Fever, attention must be given, not so much to the total yearly amount, as to the quanti- ty which falls in each month. The ave- rage amount of rain for each of the seven- teen years is 23-1 inches. If only one inch fall during a period of two months, that must be regarded as a season of drought. Of these seventeen years the most ram, 34-4 inches, fell in 1852, and in this year there were 140 cases of Enteric Fever. Next stands the year 1860, when there was a rainfall of thirty-two inches, and only ninety-five cases— a total consider- ably smaller than that of any other year. But on further comparison we find that in 1800 the rain was not only abundant, 236 ENTERIC OR TVPIIOID FEVER. I- — ' ■ 07 i> O d O a "" • Q « £ M ^ ITS t- M H "" § S ^2 " <» qj aj ® a p*=j doe's as-" I; i; « S'o "1 . d es d '-' rt n cj d ^ !■ 1 S « p* m ? ?^ ■^ „ ^:^ *^ 'a I'SS S S fe i ?. = ■2 S iTS ■S -i- £ o 0-.2 s pi o ^ bo ^•8 «M =■ 1S '-■•-1 = •£ S ^ 1 8 ■^ 1^ '='^-i»S <1 ^T3§a H r-i t— 1 Ph rn >}^1 O _lO SgJd w "^ ■°sgs OS » W SJ3 S'O > 00 :!=§ n fe o rag^' fe5 s "■SgS o >5 >>a2g <-) , 1 = 5" ST3 2 » -< •ID e-S^H 3 i 5 fl gS ■^ ci o a ■ E o — o ■a a £a ® -d t*- o — m rd 1* I > ?.a lit 3 to ~ ■- ^ 03 H -J = C3 ^ S S "- a.c>j3 •niBjj Cl T* F^t CO ■p o Cl 'I' O ^1 CO ro o s 1 '0 9 CD (p i Cl Cl ■ojtiisioi^r Oi £ CM 00 -t* t^ en Cl 'J^ o a CO C-, CO CO g Ol CO Cl CO Oct CO o co 1 '? '? rH CD A< CO CO CO (N o o o s Cl 6 Cl CO CD CO c ■* f 1 ■BSS-BO c-i o CO cc „ t- ^ s ■* o CO >o s W '-0 'O o; CO •ui^a 9 ^ o o CO ^- 1^ 6 o ^ 7^ CO Cl p P3 o w >o CO 7* • e.niisioi\[ OJ en CO 00 s s: S g g 03 Cl 1-1 00 CO s CO g -BJ9duiex CO p5 CO 00 OJ (» CD i i ^ CT eo CO t^ s 9 CO Cl 9 •S9SB0 to Ol ■o CO o r- o o s ci Cl Si ^ O) CD 3 ■ui^a ^ o o o CO o o CD Cl tM -y o Cl CD Cl CD I- M ■ejn:t9iOK Cj -^ t- IJ s 00 r- s CB t^ o c« e iO C Cl o s OJ ^ CO CD Cl CO Ol -^jaduiax o Cm o CO Cl If o CD CD CD CD Cl o ^ cp Cl o 9 Cl CD CD ■PSST30 o Cl CO ■- a o •rf Cl C31 Cl Cl CO V^ a S § ? •niy^i: 1^- 1?^ ■* CO O CO CD O 6 OT CD o CD 00 9 9 CO J! •ejnisioi\i a QO CO CO CO CO i; CO CD CO Cl CO OO o Ol o> Ol -Baediuej, 1 5! en o 6 o CO CT CD Cl CD Cl Cl CO o Cl 9 01 •sas^O CO «3 :i^ CO cc c^ f « E:^ Cl g a s CD Cl t6 3 •ni-ea ^ ^ o CI c 6 c- Cl Cl p CO "T Cl CO 9 CO Cl CD 9 p cii ■sjnjstojii g s c- s o 1^ C-1 CO s Cl c: 'J-. CJl «= l-H «5 •ojni -■Biodaiox Cm CO -* CO 0- ■r. o CE Cl 6 CD CD o CD 6 CO s 3 Cl 6 1 •ses-E^ <= >o •a f- :=; - :3 S 2 s t- ;l S o CO 00 1 •ni-BjI fp 6 CI CO Cl o Cl Cl -cf CO CO Cl 'O Cl 9 p CO "Ojn^STojif g •- >o r^ -f " -~r S s o 2 CO 'i^ Cl g T '0 :o , , •ni-eii Cl 'yi d = c>. CO : : : : I ■ejn^sioj^ s «3 CO CO o ^ OO ^ :| : -■Ejadiuai CO -+ 3 CO CO •r CO o 9' . 1 -s©s^3 => C3 - CO CO h- o c Ol .a e o 1 o CO CO g 8 Cl -* -* d d .3 1^ ft > > 3 ■• be d to 'E, 2 d d s d d d "3 o Eh CAUSES. 237 "^ 5^ IH CO •m-G^ CO en O) 9 6 6 4" CI CO o 6 CI CO CI CD o CI CI O) c CI CI CO CO w o ■9annsioj\[ s (M CO f2 CO o t^ § CO CO o •9.1 m -■Bioduiej, CO CO CO to to CO CI CO CO s 1 CD -1' o 'p CO -p g CO CO C?l ■B9SB3 -f en CO o lO c^ CO CI ^ s '.O CTj § ^ •o - g CI 'b i ■ni^H o CO o 1;^ o o CO CO o lb <-o o CO ■ses-BQ CO s Oi -f J_, CI 2 o CI CO CI o ?r. -f CI CO o s i ■ni^H to 6 6 "7* « o o CO CO t^ CO ^ !_■- CD CO 'O o o o •9jn?sioK s g 00 CO s s t^ r: CO 28 CO g >o E o CI ■9jrn -Bjedoigj, CO CO "* o CI -i c» o CO CD ^ -i' 9 '--J CI 6 •B98BQ o s >o ■^ O) 00 't* CI CI M ^ en o s •o s i2 i •m-Ba O) 6 CO M CO CI CO ■c- o A o 9 ^ 9 CO CD 9 tp CI ■ejTl?gTOj\[ s -H o CO CO t- CO CO CO C/S C-j s 1 s Ci CO CO CO s ■9.1 n:^ --B.ioduiax o oil CO ^ -t< -r lb co o c« to CO 'i CO ■o o hi ■898-50 s p CI 6 CI 9 9 9 CO 9 6 ■9in')Stoj\[ CO Oi o s -J* CO s CD t- fe £ £ en K o g CI ■9.in'j -■EJt9dlII9X en ^ cc CO CO g 9 6 CO CI CO 7* o o 6 o CO CO ~T ii 7* p «1 9 CI •9jn?stoi\[ CO CO CO OJ t^ R E: o ?^ 'O CO 'J'J CO CO CJ -^ 00 t^ t- -^J0dtII91 06 s to CO CO CO CO kO g CI CI CO 9 to 9 6 9 CO s •flgs'Eo CO o CI U3 .-, « s s s CO £^ s CI s CO s CD i •Tirejl o ^ 6 CO CI CO ^ o o 9 OS lb CO CI r-( ■oan:}sioj\[ s ■!f CO CD t^ CD fj o £ s o - I^- 'o.tn:j -'EJ9dtU9X CO "? ^ CI 1 i o CI CO g CO 6 =p o 6 a. CO 9 •sos-BO s t- 2 .o O) - 3 CI CI CI s ^ « s C-J r:: 1:1 i i •niBa; CO o 6 -r 6 !M r; CO r CI cp '? 1 6 CI -*< CI 6 CO 9jn}sioi\[ CI CO CO c- IT rr r- c CO CD CI g CO CI CO '9Jn? -'Bjedra9x c6 CO CI CO 9 CD •p >o CO C) s 9 o ■* 9 to -*' 1 9 'O CI 9 >o CI ■S9S'B0 CO o ^ ■^ - Cl o CI -f CO CO c- CI 1 ^~ s Cft o a d s at <5 Pi e to ^1 a « CO 1 M a (S o S 1 a 1 i .9 a a s a -1 2. 238 EXTEKIC OR TYPHOID FEVER. but that each month had a due share, while in 1802 tlie still more abundant rain was unequally distributed throughout the year, the spring and early part of summer being unusually dry. If now, on the other hand, we regard the influence of drought, we find that the largest number of cases, 249, occurred in the driest year, 18G4, when only I'rl inches of rain fell. The next driest year was 1858 ; there were only 17' 2 inches of rain in this year, and one -third of it fell in the summer months ; the winter was the season of drought, and this was associated with an unusual increase of Enteric Fever in January. "With the same amount of rain in the years 1850 and 1851, there is a difference of ninety-one cases of fever, and this may be attributed to the inequality of the dis- tribution of rain throughout the year, which may possibly be greater than is in- dicated in the Table. Thus, for example, the Table is not sufliciently detailed to show that, in 1854, the inch of rain for June did not fall on the first day of that month, and the 1"7 inch on the last day of July, lea-\-ing a long interval of drought between — as may have been the case. Mr. Glaisher's laborious and valuable ob- servations are deserving of more detailed study in the elucidation of these ques- tions. The dry winters of 1851, '53, '55, '58, and "02, were associated with an increase of Enteric Fever. The opposite effects of drought and rain haya lieen well illustrated during the pres- ent summer (1865). Towards the end of July there was a great want of rain, but from the 30th of this month and through- out August there was an unusual amount, larger quantities having fallen almost every day. As shown by the admissions into the London Fever Hospital, Enteric Fever was very prevalent during the dry season, but after a fortnight's heavy rain its further progress received a sudden check, which continued until the effects of the succeeding drought became manifest. It appears clearly from the foregoing observations that the absence of rain fur- nishes conditions most favorable to the increase of Enteric Fever; and since drought is necessarily associated with dry- ness of the air and exalted temperature, we must consider it, thus combined, as t!io one predisposing cause of Enteric Fever. Other Atmosiilieric Conditions. — Too little is at present known respecting the influence of ozone in the production of disease ; but as this body has been ob- served to be absent, or nearly so, from the air during the prevalence of cholera and other intestinal affections, the following general statements made hj Dr. Iiloffatt (GJemical News, September, 1861) may be borne in mind. The quantity of ozone varies according to the time of year, the direction of the wind, temperature, atmo- spheric pressure, and the pressure of de- composing substances. Kain, a south_ wind, fall of the barometer, and increase' of temperature, separately or combined, are associated with an increase of ozone, and the reverse conditions with its de- crease. "Ozone periods terminate with increasing barometer readings, decrease of temperature, and wind from N. points of the compass. " Ozone is most abundant in January, February, and March ; less so in April, May, and June ; and least of all in July, August, and September. "The greatest number of ozone d.ays is in April, and the smallest in August and jSTovember. Whatever tends to a deflec- tion in the direction of the wind leads to a corresponding result in ozone observa- tions ; and a town, chemical works, drains and cesspools, &c. deozonize the air, or wind passing over them" (p. 107). Change of Sesiddice, &c. — Both Louis and Chomel have observed that the greater number of the patients who came under their treatment in Paris had resided there only a short time. But change of resi- dence, apart from the excitement and fa- tigue, the irregularity of living, and the distress which very commonly attends it, can hardly bo considered a predisposing cause of Enteric Fever. In the autumn of 1861 a case of Enteric Fever which ter- minated fatally came under my care in Paris. The patient, a robust, newly-mar- ried lady, had been resident there only a few weeks, but during the whole of this time she had voluntarily lived a life of daily excitement and fatigue ; the diges- tive functions were deranged by an unu- sual diet and irregular mode of living, and to these causes the disease was prob- ably attributable. M. Chomel found that one-third of the 115 cases to which special inquiry was di- rected had been exposed to sudden cold, to want of food or to bad diet, to excessive fatigue, to mental depression, and to de- bility produced by other diseases. In his account of the outbreak of En- teric Fever in a garrison of 306 soldiers. Dr. Grossheim says : "It is difflcult, if not impossible, to ascribe any deleterious in- fluence to the food — all shared alike." He attributes the disease to the effect of mihtary exercises in a changeable season, with night bivouac in the open air. (Edin. Med. Jour., vol. xlviii.) (h) Exciting Causes. — Contagion is sup- posed by ]SOr. Leuret, Bretonneau, G-en- dron. Dr. William Budd, and other phy- sicians, to be the means whereby Enteric Fever is propagated. The following ex- amples of the spread of the disease fur- nish the strongest proof that can perhaps be adduced in support of this view : — CAUSES. 239 Five persons were successively attacked witli Enteric Fever in a certain liouse in Greneva. A sixtli inhabitant of tliat tov^n spent two nights with the third patient, soon contracted Enteric Fever, and died of it in the hospital. "At the autopsy, ulcerations of the ileum, and all the other lesions characteristic of dothinentery, were found." A clergyman who visited the third patient — a little girl — took the dis- ease and died with all the symptoms of typhoid fever ; his nurse was also attacked with typhoid fever, and died in the third week. A young lady also paid the third patient a visit, and rendered her some service in the sick-chamber, and this per- son soon fell ill with symptoms of typhoid fever, in another house, in which five other persons were subsequently attacked by the same disease. (M. Lombard, Gaz. Med., 1839, p. 138 : quoted by M. Pied- vache, Mem. de I'Acad. de Med., tome xv. p. -291.) Dr. W. Budd had seventeen cases of Enteric Fever under his care in the ham- let of Nortli Tawton, Devon, and during the prevalence of the disease three per- sons left the hamlet ill of the fever. A went to Morchard and died there, and ten days after his death two of his children had the fever in the same house. B also went to Morchard, and three cases of Enteric Fever afterwards occur- red in the house where he lay ill. C went to Chaffcombe, seven miles from North Tawton, and nine other cases of Enteric Fever appeared in the farmhouses to which he went. One of these nine left Chaffcombe and went four miles away, to Loosebeare, to be nui'scd. Several in- mates of the house into which this patient was received were subsequently attacked with Enteric Fever, and from this house the disease extended over the whole ham- let. An infected .boy also left Chaff- combe, and took the fever to a cottage midway between Bow and North Taw- ton, and five persons subsequently fell ill of Enteric Fever in the house into which he was received, and in the adjoining one. Besides these there was no single case of the sort nearer to Chaffcombe than North Tawton. "There were twenty or thirty hamlets in the neighborhood similar in all respects to Loosebeare. From the soil of all, through month after month of the same fine, dry, autumnal weather, human aud other exuvite exhaled into the air ; and yet, while at Loosebeare a large pro- portion of the inhabitants were lying prostrate with intestinal fever, in not one of the exactly similar places was there a single case." (Dr. W. Budd, Lancet, July 9, 1859, p. 8.) It is reasonable that those who have witnessed such instances as these should be fully persuaded that Enteric Fever is pr<)pagate ject in the early period of the disease should be to keep the diarrhoea within moderate limits, rather than to stop it 248 ENTERIC OR TYPHOID FEVER. altogether. In the early period, chalk and bismuth, with catecliu and opium, is usually all that is needed to check the diarrlicea and allay irritation. As soon, however, as the diarrhosa becomes exces- sive, or we have reason to suspect ulcera- tion, stronger astringents must be given. Some physicians use sulphuric acid with opium — U. Acidisulphuricidiluti, TlXxxx; tincturaj opii, Tllx; decocti cinchonfe, giss; fiat haustus, quartis horis sumendus. We prefer the styptic salts, having found them much more efficacious : indeed, the acid mixture often increases the purging and pain. Acetate of lead, nitrate of sil- ver, and sulphate of copper are employed. The first may be given in the form of mixture — R. Plumlji acetatis, gr. iij-v; acidi acetici, ITliij; morphise acetatis, gr. ^th; aqure cinnamomi, giss; flat haustus, quartis horis sumendus. Acetate of lead is a very suitable and efficacious remedy, but its continued use in Enteric Fever should be avoided, as it may subsequently affect the S3'stem injuriously. Dr. Twee- die and M. Trousseau speak in high terms of nitrate of silver. It may be given com- bined with a grain or two of compound soap-pill in doses of a quarter of a grain to one grain, every three or four hours. Dr. Tweedie saj-s : "I have prescribed it extensively in Enteric Fever, and con- tinued its use for a considerable time, and have never witnessed any approach to discoloration of tlie skin." (Lects. on Continued Fevers, p. 23.3. ) Of all medi- cines, we consider sulphate of copper to be the most efficacious in restraining the diarrha'a of Enteric Fever. We may give it in quarter-grain doses, combined witla two grains of compound soap-pill, to be taken every two, three, or four hours. If need be, the dose may be increased to a grain, a day or two afterwards. For chil- dren, it may be prescribed in doses of the eighth or sixth of a grain. If too large a dose be given at first, it may excite vom- iting. In small doses we have often pre- scribed it wlien tliere lias been considera- ble irritability of the stomach, in which case it appears to act as a sedative. Alum, catechu, tannic and gallic acids, kramcria, hrematoxylon, &c., are of com- paratively little value in the treatment of Enteric Fever. [Oil of turpentine, the use of which in Typhoid Fever was urged by the late Dr. G. B. Wood, of Philadelphia, has some- times an exceedingly good effect, appa- rently as an alterative to the diseased in- testinal mucous membrane and glands of Peyer. It acts most favorably in small doses (ten or twelve drops e^'ery 3 or 4 hours), in mucilage, with a few drops of laudanum. — H.] Starch and opium cnemata — (Mucilagi- nis amyli, giv; tincturoe opii, Ttl xv-xxx; fiat enema, nocte vel nocte maneque inji- ciendum)— are of great value in allaying that irritability of the lo^^'er bowel wliich often induces purging. A\'hen enemata cannot be retained, we may still use sup- positories. (Pilula3 sapouis composite, gr. V to gr. X.) Abdominal pain and tendernesn. — The disease being localized in the right ihac region, we must direct our remedies to this part. Hot sedative fomentations, turpentine stupes, or poultices containing an admixture of mustard, should be fre- quently applied to the abdomen. If there be mucli tenderness four or six leeches should be applied, partly to the right iliac region and partly around the orifice of the bowel. Leeching of the anus is the most effectual mode of relieving the intestinal congestion. If the pain be great, an oc- casional full dose of opium will be needed. Tympanites. — If there be any increased fulness of the abdomen, a flannel or linen bandage sliould be placed around it. In commencing tympanites we regard this as a very important part of tlie treatment, as it at once diminislies the congestion or the inflamed part, and prevents injurious distension. It also gives support to the painful abdomen in the process of respi- ration. Folds of wet cloths maybe inter- posed between the bandage and the ab- domen. If the tj'mpanites be considerable, it becomes a most distressing symptom, and the life of the patient is in great danger from distension of the diseased and atten- uated bowel ; laceration of its ulcerated coats being imminent so long as the dis- tension continues. To relieve this pain- ful and dangerous condition, turpentine stupes should be applied over the whole abdomen, and a gentle support given by means of a thin flannel bandage. An assafoetida enema (,^xij ad gxx enematis assafoetidfe P. B.) often gives much relief. If we should fail, however, to cause ex- pulsion of the air by this means, a long elastic tulje with wide side openings may be passed into the colon and retained there at intervals. Dr. Tweedie speaks well of the use of the stomach pump, per rectum, in the relief of this condition. "I have applied it," he says, " in some cases with happy effects, and withdrawn tlie accumulated air which may be passed through the lower tube of the stomach pump into a basin containing water." (Op. cit., p. 237.) Oil of turpentine (Ttlx-xx), or oil of rue (Tlliii-v), com- liined with opium and given by mouth, are often serviceable in the relief of pain and flatulent distension. Intestinal Hemorrhage. — Moderate ca- pillary hemorrhage from the general mu- cous surface of the bowel must be regard- ed as beneflcial, and we should employ no means to check it, but if the blood lie clotted, in large quantity, and unmixed TREATMENT. 249 with mucus, we must fear the erosion of a large vessel, and treat for such au acci- dent very promptly. A bladder of ice bandaged upon the right side of ihe abdo- men, and the internal administration of gallic acid, solution of perchloride of iron, acetate of lead, or turpentine, are the most hopeful means of arresting it. Sul- phate of copper in combination with soap- pill is a very valuable remedy in this con- dition also, and one upon which we are inclined to place most reliance. If the patient have been previously taking the copper salt, the dose may be increased at once to one or two grains. Turpentine, in doses of ten or fifteen minims, given every half-hour or hour, is often etfectual in stopping the hemorrhage, and is espe- cially useful in cases where there is a tendency to syncope. The solution of perchloride of iron of the British Phar- macopoeia is a very valuable remedy for intestinal hemorrhage ; TTLxx-xxx in a wineglassful of water may be given by mouth every two or three hours. If the hemorrhage be slight and the arterial ac- tion much excited, Tl\xv tincturte digi- talis, with TTLxxx tincturte ferri per- chloridi, giss aquse menthise piperitte, may be given every four hours. This may be administered alone or in combination with thirty minims of dilute sulphuric acid. If we fail to arrest the hemorrhage by these means, the bowel may be injected with one or other of the following ene- mata. R. Plumbi acetatis, gr. x ; acidi acetici, TTLx ; morphise acetatis, gr. ^ ; aquse tepidse, ^iv\ misce. R. Liquoris ferri perchloridi, TTLxv ; morphise hydro- chloratis, gr. ^ ; aquae tepidse, ^iv; misce. Cerebral Bymptmns. — The indications in the treatment of cerebral symptoms are to relieve congestion and procure sleep. If there be much pain and heat of the head, cold water may be applied as an occasional douche, a gallon being poured in a gentle stream upon the head as often as the heat becomes excessive. Eags wetted with water, or spirit and water, may he applied in the intervals. If this treatment fail to restrain the vas- cular excitement, a few leeches should be appUed behind the ears, or a blister upon the nape of the neck. As often as they are required, full doses of opium should be given to procure sleep. In the majority of cases the cerebral affection is mild and re- quires no direct treatment, and the seda- tives given to relieve the abdominal symp- toms are usually sufficient to calm the ner- vous irritability and procure sleep. When the pulse is fast and there is pulmonary in- flammation, we must be careful to avoid large doses of opium. In some cases the delirium makes the patient obstinate, and he persists in refusing food and drink, and keeps the teeth firmly clenched. In such a case, with diarrhoea present or impend- ing, we cannot feed jxrrecJimi; we must therefore gag the patient and use the stoniach-pimip. In such a state, too, we should daily examine the pubic region. Kow and then we are painfully reminded of the negligence of those in close attention upon the patient, by discovering, after death, the bladder distended almost to the umbilicus, and with its attenuated coats inttamed and softened. Fuhnoiiury Syniptoins. —B^'axing in mind the frequency of pulmonary c( implica- tions, we should carefully regard the breathing, and occasionall}- exaniine the chest. If pain and crepitation be devel- oped in any part of the chest, a blister should be applied and mercurial infric- tions used. Cough and bronchial dys- pua'a may be treated with ipecacuanlia and senega, and the application of mus- tard poultices and turpentine stupes. [Prevention of hypostatic pulmonary con- gestion and splenization may be promoted by care in changing the position of the patient every few hours ; especially not allowing him to he very long at a time on the back. — H.] Food, — AV'hile we are thus combating the disease, the most unwearied atten- tion must be given to the support of the patient. The blood impoverishes, and the body emaciates very rapidly, and our endeavor must be to introduce such food into the stomach as will be most easily digested. All nourishment must be given in a fluid or pultaceous form. Eggs, milk, vermicelli, arrowroot, or ground rice, beef-tea, gelatin — alone, or in various combinations — will be the most appro- priate articles of diet. The eggs must be given in the form of emulsion in a little wine whey, tea, or cocoa. Two or three should be given daily. Milk-arrowroot, containing a little brandy, is a very ap- propriate nutriment. The beef-tea must be' thickened with well-stewed vermicelli, or isinglass. Small quantities of food should be given at a time, and repeated every one or two hours. Stimulants, in any considerable quan- tity, are not needed in the early period of the disease. When required they should be given well diluted. A few ounces of wine in the form of wine whey, or dry port mixed with an equal quantity of water, may be given with a little sponge- cake at intervals. Effervescent wines must of course be avoided. If the heart's action be weak, or the patient tends to lapse into the typhous state, brandy may be freely given, carefully avoiding excess. The following general rules may be ob- served in the administration of alcoholic [' May be, rather ; as, if well made, some patients will prefer it without such addi- tions. — H.] 250 ENTERIC OR TYPHOID FEVER. stimulants in this disease. As long as tlie pulse remains under 120 and retains moderate force, six to eight ounces of wine, or four ounces of brandy, given ^^■ithin twenty-four hours, will be suffi- cient. When the pulse ranges between 120 and 130, and is small, we may double these quantities ; and if the heart does not respond to the stimulant after twelve hours, thrice the original amount may be given. The bulk and force of the pulse must be our chief guides ; and if these notably fail from day to day, we must daily increase the quantity of the stimu- lant until the patient is supplied with as much as half an ounce every half-hour, always diluted with a little milk, tea, water, &c. When there is much hectic, and the pulse is small and sharp, strong stimulants often appear to increase the irritability of the system, and in such a case we should give them sparingly and in the early part of the day, trusting to a dose of quinine, with or without opium, ac- cording to circumstances, in the evening. Excepting a little custard, solid food of all kinds must be absolutely avoided, until a week after the diarrhoea has ceased, and the stools become solid. Then we may venture to order boiled fish with bread. A boiled egg, a little fish, or a ripe pear or plum, taken too early, will almost cer- tainly bring back the diarrha'a with a complete relapse [and danger of intestinal perforation. — II.]. The patient must return very gradually to ordinary diet, and he should be direct- ed to cat slowly and masticate the food thoroughly. At first boiled rice should be taken in place of potatoes. Convalescence is sometimes very slow, and often retarded by the occasional re- currence of diarrhoea. The styptic should be continued a week after the stools have become solid. At first the bowels are usually constipated, and this condition we shall do well to maintain for days. Subse- quently, it will be advisable to relieve the bowels occasionally by a dose of castor oil. As soon as the digestive function is re- stored, we prescribed cod-liver oil as a supplement to the diet, in all cases where there is much emaciation, and if, as is rarely the case, the oil does not digest, we may direct it to be rubbed into the abdo- men. [Amongst physicians in America, of latter years, expeHancy has grown more generally in favor in the treatment of Ty- phoid Fever than in that of almost any other disorder ; as no malady more evi- dently presents a self-limited character. Cases of an ordinary grade are often con- ducted through their whole course to a good convalescence, with no medication, or almost none. Great importance be- longs, under such management, to the regulation of the diet of the patient. This must be liquid and concentrated ; milk and (unfiltered) beef-tea being the chief articles for this use ; these must be given in small quantities at short intervals (a tablespoonful or two every two or three hours), in the more feeble cases, day and night. Also, of course, the bed-clothing must be attended to ; requiring change in the garments next the skin every two or three days, or oftcner, if soiled by perspi- ration or other discharges. The state of the bladder must be watched, to antici- pate prolonged retention of urine. Change of position, from one side to the other, or from the back to the side, should be in- sisted on, to avoid hypostatic pulmonary congestion. Ventilation of the chamber, without direct draughts, must be secured. These, with the quiet always essential to the sick room, and other parts of "good nursing," will suffice in the care of not a few cases of well-marked, uncomplicated Typhoid Fever, without even the addition of alcohol to the food. A large minority of cases, however, will call for this ad- dition. Within a comparatively few years, very positive treatment for fever as such, in all its forms, is advocated by a number of medical authorities. Prominently, cold bathing has been brought forward, by Drasche, Brand, Liebermeistcr, Ziemssen, Wilson Fox, and others. The patient, according to this method, is immersed, for ten minutes or more at a time, in water at about 70° Fahr., to reduce the temper- ature. Ziemsseu's plan is undoubtedly the safest, of placing the ill person in water at 9.50, which is gradually lowered to 80° or 75°, watching the eflect upon the pulse, respiration, and countenance. The indiscriminate use of the sudden cold plunge bath in fever is certainly not free from danger by excessive depression. Quinine is now employed by quite a number of practitioners as a direct antipy- retic. In order to produce a positive effect in lowering the temperature of the body, it has to be given in rather large doses ; ten grains or more, repeated. Salicylic acid acts in a similar manner. It remains to be shown with certainty that this mode of reducing temperature has, on the whole, a favorable etfect upon the progress of Ty- phoid Fever, when it is not complicated by the influence of malaria. — H.l Prophylaxis. — Sufficient evidence has been adduced to prove that Enteric Fever commonly arises from the retention of refuse animal and vegetable substances within an undrained, or imperfectly drained soil. If, therefore, the contami- nation of the soil be prevented by the con- struction of sufficiently inclined sewers with impermeable walls, and the inhabit- ants be provided with abundance of pure water, Enteric Fever may be expected to disappear almost entirely. TYPHUS FEVER: DEFINITION. 251 The requirements for the prevention of the disease are sufficiently simple, but they are not easily fulfilled in every place where living beings are congregated. Na- ture, indeed, has provided these sanitary conditions almost everywhere, and if man would be more mindful of them his life would be rarely sacrificed to Enteric Fe- ver. A house built upon a hillside, with its spring of pure water above the founda- tion, and its cesspool below it, would be free from this disease, as far as external conditions are concerned. But reverse the position of the cesspool and the spring, and the disease may appear at any time. If the dwelling be built upon a low-lying flat, and there is no near spring or flowing stream, these two necessaries — a pump and a cesspool — must needs co-exists side by side. In such a case they should be as widely separated as possible, and the sides of the well should be thickly covered with concrete. Whenever the premises are small, and it can be so contrived, a water- closet should be provided, and the excre- tions carried in an impermeable drain to a distance from the pump. In towns and large villages both pumps and cesspools should be abolished, and every house pro- vided with a water-closet in communica- tion with a sewer. ' The water should be derived from a distant elevated spring or reservoir, preserved from contamination at its source, and conveyed in well-joined iron pipes to its destination. The soil should be well-drained, and during the continuance of dry weather the drains and sewers should be regularly flushed. We cannot positively say that Enteric Fever arises from the ingestion of diseased meat, but there is a strong probability that it does sometimes originate in this cause. "Whether this cause has been in operation during the present year (IStjS), when "contagious typhus" has been so generally prevalent amongst, and destruc- tive of our horned cattle, there is no di- rect evidence to show ; but it is remark- able that, co-iucidently with the spread of the cattle disease, there has been a great increase of Enteric Eever. On turning to the Table at p. 237, it will appear that the number of cases admitted into the Lon- don Fever Hospital in 1805 is more than double that of every preceding year, and more than treble that of the majority. The only efl'ectual way of preventing the admission of diseased meat into the mar- kets would be to establish a limited num- ber of slaughter-houses, where the ani- mals, previous to being slaughtered and afterwards, could be inspected by proper officers. The experience of the present severe epidemic of cattle disease has taught us, that, after death, it is exceed- ingly difficult and, to an inexperienced eye, impossible, to distinguish positively between the flesh of an animal which has died of contagious fever, and that of one slaughtered in perfect health. In the ab- sence of that more general protection which is so urgently required, two precau- tions should be taken : first, flesh of a flabby consistence and of a dusky, dead hue should be avoided ; and secondly, all meat should be so thoroughly cooked that the fibre is quite firm and free from juice, which, on exposure to the air, becomes red. In the treatment of the contagious variety of the disease, the ordinary precau- tions against contagion must be taken, viz., the isolation of the patient and the disinfection of everything that has had contact with him. TYPPIUS FEYER. By George Buchanan, M.D. Definition. — Typhus Fever is an acute specific disease, lasting from four- teen to twenty-one days, characterized by an eruption of its own that appears be- tween the third and sixth day, eminently [' The frequent imperfection of water- closet connections witli sewers, allowing the escape of sewer-gas into houses, has lately been credited with the production of a large number of oases of Typhoid Fever.— H.] contagious, and forming strongly-marked epidemics. Under the name " Typhus," the writer of one of the Hippocratic treatises de- scribes a disease that agrees in its essen- tial features with typhoid fever. But the term was not afterwards used to signify a special disease until the time of Sauvages, in whose nosology it is adapted to certain forms of continued fever, while the name Synochus is used for another class of cases. 252 TYPHUS FEVER. The disease as above defined, and now known as Tj-phus, has been separated from other forms of continued fever with- in tlie la!^t thirty j'uars. Typhus Fever lias received a multitude of names, almost every epidemic having added some fresh one. In English, Spot- ted Fever, Petechial Typhus^ Epidemic or Contagious Fever, Putrid or Malignant Fever, Camp or Jail Fever, are samples of the names that have been conferred on the disease, from various considerations of its nature or cause. Etiology. — The causes that predispose to Tj'phus may be considered as aft'ecting the individual and the community. In the individual, sex and age have no influence in determining an attack. In the writer's experience, at the London Fever Hospital, very nearly equal num- bers of each sex, and persons of every age, from a fortnight to over eighty years, have been attacked. Upon the authority of death registers and hospital statistics, the statement is constantly made that Typhus attacks adults more than children; but the evidence furnished by these data is quite untrustworthy as showing the relative proclivity of diiferent ages to an attack. Typhus, as it appears on the death registers, is indeed incomparably more frequent among adults than children; but that is because children rarely die of it, not because they are rarely attacked. And in hospital records a much greater proportion of adults than of children are seen to be admitted ; but this is because of obvious domestic reasons, because of the slightness of the fever in children, and often because of the rules of the insti- tution. When inquiry as to age is made to include every case of attack, children and adults are found to be quite equally susceptible ; the actual incidence may even be observed to be strongly upon the young, partly because of their greater numbers, and partly because adults are frequently protected l)y previous attack. Depressing mental influences, overwork, and anxiety, appear to be causes that render the system more liable to con- tagion. Fear of contagion is often al- leged, and perhaps justly, to be another such cause. It is especially among per- sons of better rank of life that these influ- ences have been observed to operate. Depressing bodily influences are, however, of far greater moment. With persons temperate and provided with sufficient food, the contagion of Typhus, even though intense, is usually resisted for some time ; but with intemperate and ill- fed persons, contagion is received so readily, and so small a quantity of it pro- duces an attack, that it is constantly diffi- cult to find out whether in the particular case there has been any exposure to con- tagion at all. It is essentially among the poor underfed population of large towns that Typhus epidemics occur. Paupers and the class just aliove paupers are the chief, and except in intense epidemics al- most the only, suflerers from the disease. People whose earnings enable them to get more than the bare necessaries of life from hand to mouth do not suffer from Typhus save in exceptional instances, and usually as a consequence of constant communica- tion with the sick. The most violent epidemics of Typhus have been among communities that were fed more badly than usual, either through social difficulties, or through failure of crops ; special hardships in war, and in civil life, strikes, and commercial distress, have at different times determined an epi- demic prevalence of the fever. The experience of Ireland in 1818 and 1847 illustrates the influence of privation in predisposing a community to Typhus. In each of those years an epidemic of this fever prevailed (along with relapsing fever), as a consequence of the almost complete failure of the potato crop ; and it is estimated that on each occasion an eighth part of the entire population was attacked. But it must not be supposed that serious epidemics of Typhus require exceptional destitution as a necessary condition of their occurrence. A marked instance to the contrary is afforded by a recent intense outbreak at Greenock, where circumstances of special commer- cial prosperity had (by causing exceptional overcrowding) conduced to the epidemic spread of Typhus. The next predisposing cause of Typhus is probably the most important of all, and consists in the association of conditions known as overcrowding, crowd-poisoning, or ochlesis. These conditions are scarcely to be separated from each other, but may be enumerated as overcrowding of dwell- ing-houses upon too limited area, over- crowding of rooms by too many occupants, bad ventilation of streets and houses, domestic and personal dirtiness. It is to the operation of this series of conditions that the special incidence of Typhus upon the laboring population of large towns is to be ascribed. Illustrations of the effect of crowding too many inhabited dwellings upon a limited area might be gathered in abund- ance from the experience of camps, where the superficial space per man has been le.^s than in the densest cities with their tall houses, and where Typhus has carried off large proportions of many armies. But they may equally be drawn from the ex- perience of civil life. The town of Eng- land which habitually has most Typhus, and in which the most serious epidemics occur, is Liverpool. Here the huddhng together of houses with insufficient space ETIOLOGY. 253 ai'ouncl them is carried to a greater degree than in any otlier town in the liingd'om. in Liverpool, a large number of the houses are built back to back, in unventi- lated courts, and the population is so dense that, in some districts, each person gets only eight square yards of superttcial spiice. In these parts it is that fever spe- cially flourishes, and in epidemic periods passes by none but those who are protected by previous attack. Glasgow is another instance of a town in which the packing together of houses reaches an extreme extent, and in which Typhus correspond- ingly prevails ; its distribution following so exactly the degree of density of popula- tion in different parts of the town as to leave no doubt of the connection between the disease and this condition. Overcrowding of the interior of houses by too many occupants, with deficient ventilation of rooms, may be illustrated as a cause of Typhus by the experiences of the common lodging-houses of Eughsh towns. Before the regulation of these by law in 1851, dwellings of this class were in a state of most miserable filth and overcrowding. In London and Liverpool, especially, there is evidence that they were peculiarly infested mth Tj'phus, far more cases of this fever occurring in them than among an equal population residing in poor tenements of another class. Since 1851, the number of fever cases in com- mon lodging-houses has been accurately ascertained, under the same Act of Par- liament that has diminished their over- crowding and improved their cleanliness ; and it is found that in some thousands of such houses in London, hardly any Typhus exists in non-epidemic times, and that in epidemic times they suffer now much less than other houses inhabited by the poor. In Liverpool, it was upon the overcrowded lodging-houses that the chief force of the epidemic of 1847 fell ; the cases of Typhus that occurred in them being numbered by thousands. During the year 1863, when the fever again became epidemic, in a thousand regulated lodging-houses of Liverpool, only twenty-four cases occurred, a quite inappreciable fraction of the whole number of fever cases in the town. Doubtless both sorts of overcrowding act chiefly by facilitating communication between the sick, and contagion from per- son to person. And hence comes one ex- planation of the different degrees in which overcrowding favors Typhus in town and country. In many country cottages, very considerable crowding of rooms, no venti- lation, and habitual dirtiness exist as con- stant conditions, and yet Typhus is prac- tically unknown. Other predisposing cases of Typhus re- quire brief consideration. Persons of all countries and races exposed to its influ- ence contract Typhus with equal readi- ness. But the disease is essentially one of cold and temperate climates. AVilhin such climates there is no country, whose epidemics arc accurately recorded, that does not suffer more or less from Typhus ; and, on the other liand, there is no suffi- cient evidence that this fever occurs within the tropics. Of all countries. Great Britain and Ireland are the chief seats of Typhus, which occurs here more constantly from year to year, and with severer accessions of epidemic force than elsewhere. In the United Kingdom, the large trad- ing ports are especially prone to Typhus ; but this nmst be ascribed less to their posi- tion on seaboard or river than to the greater communication they have with localities from which infection may be de- rived, and the extreme density of popula- tion in such places. By season and meteorological influences Typhus is not known to be very much in- fluenced. It is a very common, though not an invariable occurrence, that the last month or two of the year is the chosen period for an increase in the prevalence of Typhus. In the main this connection appears to be established through the in- fluence of cold upon the vital powers of the individual, and upon the social and domestic conditions of the poor commu- nity. People suffer more from scantiness of food and get less ventilation in their crowded rooms as winter sets in. Drought, again, has sometimes appeared, as recently in Bristol, to predispose to Typhus, through reducing the supply of the ele- ment necessary to cleanliness. Low ele- vation of site, again, is a condition that renders a place less easily purified by cur- rents of air than if it lay higher, and may in some minute degree assist in the de- velopment of an epidemic. But to such atmospheric and climatic conditions as these, and they are the most weighty ones of their kind, an inferior degree of im- portance only is found by experience to attach. As to the exciting causes of Typhus, the great, if not the only one, is the spe- cific poison of the disease transmitted from person to person by contagion or fomites. Evidence of propagation of the fever by communication between the sick is seen in its epidemic spread when it enters a community of susceptible persons, and even more conclusively in the way in which persons exposed to none of its pre- disposing causes catch the fever when they are in close attendance upon cases of Typhus. Nurses in hospitals, where many cases of Typhus are received, invariably get Typhus, no matter under what sani- tary conditions they are placed. There appears to be no exception to this rule, unless, indeed, it be that the nurse is per- sonally insusceptible of the disease from a 251 TYPHUS FEVER. previous attack of it. Medical men and Catholic priests in attendance upon nu- merous Typhus cases are also almost sure, sooner or later, to set the Fever, and that they do not fall ill with so much certainty or rapidity as the nurses appears due only to their contact with the sick being less constant and intimate. The contagious matter of the disease seems peculiarly capable of destruction when it is diluted with air. Thus tolerably close communication with the body of a Typhus patient appears requisite for the reception of contagion from him. Casual visitors to fever wards very seldom get Typhus, and in private houses of the better class the disease rarely spreads to the atten- dants. Extension of Typhus from a hos- pital to the adjacent streets is unknown, even though there should be hundreds of cases congregated within a very short distance of other buildings. In these re- spects Typhus diflfers much from smallpox and some other diseases of its class. There appears reason to believe that Typhus can be communicated apart from actual intercourse with the sick by resi- dence in the house where the fever has recently existed, and by the use of articles of bedding and clothing that have been recently used by Typhus patients. But, as compared with scarlatina, for instance, the degree to which the contagious matter of Typlms can be thus conveyed by fomites is very inconsiderable, and, in fact, it ap- pears to be very seldom thus conveyed if the simplest means of purification by air and water are employed. Great immunity from an attack of Ty- phus is obtained by a person who has once suifered under it. Some, but very few, well-authenticated cases of second attack are on record. There are many instances where Typhus Fever occurs in individuals who cannot be ascertained to have been exposed to any contagion, and where the readiest expla- nation of the occurrence of the fever is that it has originated de noro from the intense operation of its predisposing causes. Cases of this kind, happening in the absence of epidemic influence, and constituting the first instance in a com- munity among whom the disease after- wards spreads by contagion, have been collected by Dr. Murchison, and must be allowed to have weight in favor of the theory advocated by him, that destitution and overcrowding are by themselves ca- pable of generating afresh the contagious matter. If, to this view, the speculative objection be opposed that a specific self- multiplying matter can only be allowed to have a specific origin, the speculative answer may be given that at some time or other there must have been generated a first case of Typhus, and that the same de novo production may therefore occur again. Considerations of this kind, on one or the other side of the argument, are of little importance by the side of Dr. Murchison's actual observations. The most serious obstacle to the reception of this theory arises from the analogy of other specific diseases as to the present production of which by contagion, and contagion alone, there is no question. Thus, in many outbreaks of scarlatina and smallpox, the source of infection in the first instance is often as obscure as in the cases of apparently spontaneous Ty- phus cited by this author, and there are cases even of children's syphilis originat- ing under circumstances that the most experienced investigator has failed to con- nect with exposure to the poison. An- other consideration which weighs some- what against the belief that destitution with overcrowding is the condition re- quired and sufficing for the de novo pro- duction of Typhus, is that outbreaks of Typhus, apparently spontaneous, some- times occur in persons under excellent hygienic circumstances. Thus in a case that came under the notice of the writer, two boys living in an institution where every advantage of diet and lodgment was afforded (as may be held proved by the fact that the fever did not extend) were attacked within a few hours of each other with Typhus, and the most careful inquiry failed to show that either of the boys had had the opportunity of getting the fever by coniagion. Symptomatology.— The period of ?«- ciibation of Typhus is not satisfactorily determined. It is so rare for persons to fall ill of this fever after a single exposure that opportunities of ascertaining the point in this way do not often occur. And in practice it is also extremely diffi- cult to get, with any accuracy, at the limits of the incubation period from the times of first and last exposure. It is probable that this period is not constant, but that it varies from a few hours to several days. The invasion of Typhus is generally marked by headache, more or less severe, loss of appetite and general malaise. For a day or two, and in the absence of in- formation respecting exposure, there is nothing to distinguish the outset of Ty- phus from that of any other fever, unless it be the absence of the positive symp- toms of other specific illness. It is par- ticularly difficult to separate the invasion of Typhus from an attack of acute dys- pepsia. Kigors are of frequent occur- rence, but they are not so definite or so severe as in smallpox, or in the pyrexia accompanying internal inflammation. The sense of chilliness commonly com- plained of along with the early headache may not amount to actual shivering, and SYMPTOMATOLOGY. 255 it is often wholly absent. In slight at- tacks, especially in children, it may not be possible to settle the actual time of invasion. On the other hand, in severer cases the disease begins very suddenly witli shivering, headache, and it may be vomiting. For tln'ee or four days the symptoms of the invasion period get worse, and are accompanied by sleepless- ness and general pyrexial symptoms, thirst, heat of skin, pretty complete an- orexia, and usually a very peculiar pros- tration. In a case of Typhus of any gravity the patient gives in to the disease within the first three days, leaving ofi' his work and commonly taking to his bed by that time. Patients with an actual Ty- phus rash on them, and having been ill live or six days, do indeed sometimes ap- ply as out-patients of dispensaries and hospitals, but this is incomparably of rarer occurrence with Typhus than with typhoid or smallpox patients. Before proceeding to state the symp- toms of a fully developed case of Typhus, under the heads of the organs and sys- tems affected, mention must be made of the general appearance of the patient. This is so peculiar as to constitute to the practised eye a very ready means of diag- nosing Typhus, and frequently even an important element in deciding on the na- ture of a doubtful case. In an average attack the patient lies prostrate on his back with a most weary and dull expres- sion of face, his eyes heavy and with a somewhat dusky flush spread uniformly over his cheeks. In the advanced stages of a severe attack, he lies with his eyes shut or half shut, moaning and too prostrate to answer questions, to protrude his tongue, or to move himself in bed ; or the mouth is clenched, the tongue and hands trem- ble, and the muscles are twitching and half rigid. The dryness of the mouth, the sordes on the teeth and lips, the hot dry skin, and the deafness are other symptoms which strike an observer so immediately as to deserve to be included in the physi- ognomy of the disease. The maximum temperature reached in the course of the disease is rarely less than 104'9 or 105°, and in many cases it reaches 106'o-107°, sometimes even a higher point than this. This high maximum is, as a rule, in favorable cases only attained once or twice throughout the fever, and generally of an evening ; the highest morn- ing temperature very rarely exceeds 106°. The temperature begins to rise at the commencement of the disease, and has been observed as high as 103-8-104-9O the first evening ; it continues rising till the third day, when it often reaches 105-107°. The maximum is generally attained in the middle of the first week, between the fourth and sixth davs and generally on the fourth day, and then a slight though appreciable fall takes place. There is generally a well-marked remission alwut the seventh day. In Typhus, though less than in other forms of fever, there is an exacerbation in tlie evening, and the re- mission about the seventh day is, in some cases, only indicated by the comparative slightness of the evening elevation which then takes place. In the more severe cases there is no trace of remission at this period, but the temperature maintains it- self steadily or even rises a little. The absence of this remission marks the case as likely to be a severe one. In the second week the temperature rises again, but only for a day or two, and rarely reaches the maximum of the first week. The elevation may be from half a degree to two or three degrees, but ave- rages about three-quarters of a degree, often lasts but for one evening, sometimes continues longer. Between the twelfth and fourteenth day there is a remission, in both the mild and severe forms of the disease ; even in cases about to prove fatal, and in those other severe cases which showed no decrease of temperature at the end of the first week. But notwithstanding some remission, the temperature in fatal cases often remains high (rarely, how^ever, above 105'-), and shortly before death a very rapid rise occurs, indicating that the fatal termina- tion is approaching, in some cases the temperature being sometimes higher at this time than at any previous date of the disease. In cases of recovery from an average attack, defervescence generally occurs some time between the thirteenth and seventeenth day, and its approach is sometimes announced by a slight exacer- bation which renders the subsequent fall more conspicuous. The return to the normal temperature takes place very quickly. In the majority of cases it is completed within twenty-four hours, often in twelve hours ; it begins very frequently in the night, and the abrupt manner in which the fever leaves is one of the pecu- liar features of the disease, the tempera- ture sometimes falling as much as three or four degrees in the course of a night. By the end of the second half of the third week the temperature has usually re- turned to its natural standard. The difference between the morning and evening temperature is smaller in the first week and the first half of the second, not amounting to more than one degree or one degree and an eighth ; somewhat more considerable from this time to the termination of the disease, averaging about one degree and a half. The even- ing rise is much less than in cases of typhoid fever, in which disease the great elevation of temperature which precedes the fatal issue of the disease, is not so marked as in Typhus. 256 TYPHUS FEVER. Symptonis refcrrihle to the circulatory sys- tem. — The pulse of Typhus is always ac- celerated ; in a case of medium severitj- in an adult being about 120, in slighter cases not exceeding 80 or 90, while in children (by reason of their age), and in more serious attacks in adults, the pulse reaches up to 140-150, even beyond this to a num- ber which cannot be estimated by the finger. From the time of attack on the one hand to that of improvement or death on the other, the pulse seldom fluctuates or falls ; it rises steadily up to its maxi- mum in favorable cases, maintains the same moderate excess for several days, and then subsides uniformly and rapidly. In graver cases the pulse continues to rise until the crisis of the disease is reached. A fall in the frequency of the pulse indi- cates, in the very great majority of in- stances, the commencement of convales- cence, and a subsequent rise signifies the accession of some local complication. It is said that a sudden fall in the pulse, especially when it has been excessively high, occasionally precedes death. Pro- bably this is sometimes the case when there are obvious symptoms of impending dissolution, but diminution in frequency of the pulse has not been observed to pre- cede other fatal symptoms. The differ- ence between the morning and the evening pulse appears to be only a flight exagger- ation of that which is observed in health. Change from the lying to the sitting pos- ture increases the frequency, but not to any remarkable degree. The character of the pulse is peculiar ; it often strikes the observer as being very large and strong, but very slight compres- sion is ordinarify sufficient to obliterate it altogether. In other cases it is distinctly feeble and small, and when most rapid is often scarcely perceptible to the finger. Irregularity of rhythm is observed in some severe cases. A diehrotous pulse is occa- sionally found, but more rarely than in typhoid. On the other hand, instances are sometimes seen when every second beat of the heart only gives a pulse at the wrist. This circumstance is only tran- sient, and must not be confounded with a real reduction in the heart's frequency. The heart_ sounds in Typhus may be natural, but in severe cases they are weak and distant, the first sound especially, as has been shown by Stokes, being deficient in tone even to the point of being quite inaudible. The capillary system exhibits also im- portant changes in Typhus, showing themselves clinically on the conjunctiva and skin among the external parts, and in congestions of various internal organs. The eyes are often bloodshot, and the skin much injected, symptoms more ob- served in persons below the middle period of life than in old persons whose circula- tion is inactive. The injection of skin is sometimes carried to such a point, that the finger drawn lightly over the surface causes a white stripe to appear in the course of a few moments. Besides this general injection, a special eruption re- sults from congestion and extravasation of blood in the vessels of the skin. This erujition, constituting the measley or mulberry rash of Typhus, is present, at some time or other of the disease, in about 95 per cent, of cases, and forms the principal diagnostic evidence of the fever. It has been described by Jenner and most subsequent writers as consisting of two portions, but between the two every in- termediate link may be found. The one is a faint, irregular, dusky-red, fine mot- tling, looking as if it lay some little dis- tance below the surface of the skin, and were seen through a semi-opaque medium. This appearance is well expressed by the name (which is otherwise inexpressive enough) of " subcuticular" motthng. The other part of the eruption is formed by separate spots of small size and purplish color, scattered over the mottled surface, and looking more or less superficial. These are the "maculfe" of Typhus. They are irregularly roundish in shape, and in color vary from brightish-red to livid, fading into the color of the adjacent portion of skin. At their first appearance, they are often a little elevated, and, exceptionally, are found to be as much so as the spots of typhoid. In the course of a day or two they are no longer felt raised above the surface. The mottling often exists with- out the distinct spots ; the spots rarely without a considerable degree of mottUng. Usually, the two exist together, but in slighter cases (in children especially) the greater part of the eruption is formed by the general mottling, while in old persons it consists mainly of the distinct maculse. As a rule, the eruption of Typhus ap- pears on the fourth or fifth day ; it may, however, be met with as early as the third, and rarely is delayed as late as the seventh day from the onset of fever symp- toms. It comes first on the backs of the wrists, the borders of the axillse, and about the epigastrium ; in many cases it covers the whole trunk, and frequently also the arms and legs. More rarely it is met with on the face and neck, but in children especially it may be so copious on the face as to resemble measles. The eruption takes a variable time, un- der forty-eight hours, for its complete de- velopment, and then undergoes certain changes, which, if life is enough pro- longed, end in its disappearance ; but from the establishment of the eruption in the first week of the disease, no fresh spots are seen. The spots are at tirst wholly obliterated by pressure with the finger, but after a few days there is com- SYMPTOMATOLOGY. 257 monly some little yellow color left when the finger is removed, looking as if the coloring matter of the blood liad stained the skin at the injected spots, and later in severer cases pressure fails to remove the maculae to any considerable extent, owing to an actual escape of blood from the ves- sels. The duration of tlie eruption varies according to the relative amount of mot- tling or maculation, and according to the degree to which the spots become ecchy- motic. In slight cases with few distinct spots, and occurring among children, the mottling may not last more than two days, and the skin be then left quite clear. In cases of medium severity, the greater part of the mottling disappears within a few days, going first from the face and wrists ; the skin of the trunk still showing a crop of the irregular maculae, half ecchy- mosed, and, in their later stages, appa- rently seated at various depths below the surface. In such a case the whole erup- tion lasts till the twelfth or fourteenth day. But in severer cases, especially when the general eruption is livid and the macules immovable by pressure, the typhus spots persist later than this, and the small ecchymoses may not disappear until the twenty-flrst day or even later. Desquamation of the cuticle is not ob- served as a consequence of the eruption. Another lesion, of rare occurrence, con- nected with the circulatory system, is local gangrene. This is more commonly observed in winter than in summer. Tlie toes, the legs, and even the nose may suf- fer. More frequently sloughs on the sa- crum and heels are seen as the result of pressure combined with defective circula- tion. Large, heavy people, much pros- trated, who lie helplessly on their backs day after day, suffer most from these ac- cidents. Other alterations, connected in nature with the circulation, will be considered symptomatically under the headings of the Brain and Lungs. Symptoms referrible to the Digestive Sys- tem. — The tongue of Typhus Fever pre- sents every variety of appearance. In the earlier stages it may be unchanged or covered with a thick white fur. Among adults uniformly, as the disease advances, the tongue becomes dry, the fur forming a rough brown coating over a red mucous membrane. Often the tongue is so hard and the whole of the mouth so dry, that from this cause alone there is difficulty in protruding it. At the end of the second week, in favorable cases, the edges get moist, and the tongue clears, the fur dis- appearing molecularly or else in patches, leaving the mucous membrane shiny and red. In severer forms of Typhus, witli a variable amount of fur, the dry tongue cracks and bleeds, giving rise to black sordes during the disease, and to fissures VOL. I.— 17 of which the remains persist after recov- ery. The tongue may be intensely red and cracked, without there being much fur, and in such cases the characteristic tongue of typhoid is closely simulated. The papillse are rarely enlarged at any period. The mucous membrane of the mouth and throat gets, like the tongue, dry and covered with sticky masses of mucus. The lips, in bad cases, become covered witli black sordes like the tongue. Thirst is a symptom met with very uni- formly, and from the earliest period of Typhus. It does not give way until, as convalescence begins, the natural secre- tion of the mouth suffices to keep the sur- face moist. Extreme loss of appetite is another symptom of equal constaucy. For a few days, indeed, in mild cases, [the patient can be persuaded to take light food, but as a rule refuses everything solid, retaining a desire for stimulants only. These, too, are soon distasteful, and then the only thing relished is cold water. Vomiting is a less uniform symp- tom. It sometimes, indeed, occurs at the outset, and occasionally forms a trouble- some complication in the progress of the fever. Diarrhoea, with tympanitis, is another digestive symptom of not infrequent oc- currence. It appears to have much to do with the regimen under which the patient is put, inasmuch as it certainly occurs more in the practice of some institutions than of others in the same epidemic' It is worth while to insist upon this cause of diarrhoea, since its occurrence at one time, or in one place, might otherwise be mis- taken for a special type of the disease there. Thus in the practice of the Lon- don Fever Hospital, of recent years, diarrhcea has been seen in at least one- third of the cases of Typhus. In the epi- demic of lft50, it was practically absent there ; at Liverpool, during the present epidemic, there has been little of this complication ; and even in the present London epidemic it has been absent in the Typhus treated at some workhouses. The symptom appears to be ascribable in some measure to the greater amount of liquid food that is forced upon the de- ranged stomach in the practice of some physicians. The plan of the London Fever Hospital is to give at short inter- vals as much liquid nourishment as the patient can be made to take. If the oc- currence of diarrhcea do really result from this circumstance, it must be confessed to constitute a slight drawback to a plan of treatment, which for its aggregate results is not the less to be wamily advocated. When diarrhoea is present there is often [' It is quite uncommon in Hospital practice in Philadelphia. — H.] 258 TYPHUS FEVER. considerable tympanites, and some gur- gling may be felt, but it is seldom fine or confined to the coecal region. The abdo- men is in such cases slightly tender on pressure, but svich tenderness is more about the epigastrium tlian elsewhere. On the other hand, in many cases of Typhus the bowels are constipated, but they are readily acted on by purgatives. The stools in this fever difler from those of typhoid, even when diarrhoea is pre- sent. They are usually dark, and are of every consistence, but they do not exhibit the appearance of powdery matter sus- pended in liquid. Their reaction is stated to be acid. There is an obscure connection between dysentery and Typhus, the fever appear- ing under certain circumstances to be generated by persons suflfering from dysen- tery. When this connection has existed, the tenesmus and frequent bloody stools of dysentery have been observed to com- plicate cases of Typhus. The writer has seen peritonitis occur- ring in one instance only among some thousands of cases of Typhus that have come under his notice ; in that case it re- sulted from the rupture of a multiple ab- scess in the spleen following on endo- carditis. Siimptoms referrihle to the respiratory apparatus are so common and so impor- tant that they must be regarded as essen- tial parts of the disease. In most cases of Typhus, during the second week there is some little dry rhonchus found at the posterior bases of the lungs. The chest should be examined daily for this condi- tion, even when there is no objective lung symptom. By care in this respect, the accession of the next series of symptoms may constantly be prevented. These consist in increased duskiness of the face, livid flush on the cheeks (not specially on the malars), dusky color of rash — condi- tions indicating defective aeration of the blood — and these may exist without any cough, but are almost always accompanied by some increase in the frequency of re- spiration. The patient will make no com- plaint, but the smallest degree of any of these symptoms should at once point at- tention especially to the lungs. Often dry rhonchi at the bases will alone be found, but frequently also dulness of one or both bases. About the lower six inches of one base is the amount of dulness usxially reached, but it may extend up to the spine of the scapula on each side. With the dulness are found increased vocal fre- mitus, high-pitched respiration, and at the earlier and later stages of the dulness, coarse muco-crepitation. Tine dry crepi- tation is less frequently heard over the solidified lung. It cannot be too strongly insisted on that, with all these evidences of lung mischief, there may be no cough, and no expectoration, up to the time that redux crepitation begins, and very likely nothing beyond the duskiness that has been mentioned to call attention to the state of the chest. Upon the occurrence of secondary crepitation, cough often be- comes more troublesome, and if there have before been no expectoration it now appears, and consists of a semi-transpa- rent tenacious mucus, scantily aerated, and frequently discolored with varying blood-tints, as in idiopathic pneumonia. Bronchitis and consolidation of the lung in Typhus are very apt to improve about the period when the fever itself reaches its turning-point, which has been stated to be usually about the fourteenth day in adult patients with moderately severe Typhus, and these lung states do not often constitute a superadded disease after the end of the third week. But when they are present they constantly obscure the occurrence of a favorable crisis, and protract the total convalescence of the patient for several days. The phy- sical signs in cases of recovery usually disappear pretty rapidly, but when dul- ness lias been considerable it may not be quite got rid of for some weeks, although the patient be gaining strength, and have no other evidence of chest mischief be- yond this dulness, and a pulse that keeps up above its natural standard. In eases of Typhus fatal from lung complication, the lividity of surface and the physical signs get gradually worse, and generally (but even then not invariably) there is visible embarrassment of respiration. [The origin of pulmonary embarrassment in hypostatic congestion, due to prolonged recumbency without change of position, has an important practical bearing in Typhus as well as in Typhoid Fever. — H.] The nervous symptoms in Typhus are constant and prominent, and it is probably through the nervous system that the poi- son of the disease primarily operates. It is from certain of the nervous symptoms that the name of Typhus was originally conferred upon continued fever. From the very outset of the illness these symptoms occur, consisting in rigor, head- ache, and weariness of body and mind. The amount of head symptoms is greater in proportion to the severity of the attack and the age of the patient. Kestlessness and loss of sleep are, even in the slight attacks of children, pretty constant from the first. Sleeplessness often continues up to the time of crisis, and constitutes one of the most distressing parts of the illness to the patient ; and even if he gets a good deal of intermitting sleep, he will fre- quently protest, with many complaints, that he has not slept a wink. The head- ache is often intense, but is a dull and heavy, and not a sharp pain, and is ac- companied with some giddiness and with SYMPTOMATOLOGY. 259 noise in the ears. It gets worse through the first week, and then gradually disap- pears, rarely lasting longer than the tenth day. Before the cessation of headache, the intellect is heavy, the faculty of appre- ciating dates and intervals of time being notably confused. In a large proportion of cases, delirium is a symptom of Typhus. It supervenes usually between the fourth and eighth days, the headaches going ofi" as the mind begins to wander. Subjectively, as learnt from the statements of convalescents, the delirium is formed by utter confusion about time and place and people, and even about personal identity. The pa- tient often has fancied that he is two or three people, and is undergoing several sets of miseries and horrors. Objectively delirium is of very various amount, and in character may be active and maniacal, or low and muttering. Much active ex- citement is rare in Typhus, but extreme degrees of it are occasionally seen, the pa- tient praying, bawling, blaspheming, ac- cording to his habitual turn of mind, or leaving his bed to escape from imaginary ill-treatment. Suspiciousness is a not in- frequent form of delirium, and the obsti- nate refusal of food that comes of this mental state may be carried to a degree that itself is fatal to the chance of recover}'. Acute delirium commonly passes after some days into the low muttering form, the form which is more usually the cha- racter of the delirium from the first. In this the patient lies talking quietly to him- self about matters that interested him at the time of his seizure, or on subjects sug- gested by what is going on, or he supposes to be going on around him. In severer Typhus, the muttering delirium passes into a heavy stupor, and tremulousness of the tongue and hands, with twitching of the muscles {suhstdtus tendinum)^ is then commonly observed. In very bad cases the patient cannot be roused from his coma, or a few days before his death he falls into the state known as coma-vigil, staring vacantly and with fixed eyes while in a state of complete unconsciousness. To the severe coma, rigidity of the mus- cles, fumbling at the bed-clothes, and loss of power of swallowing are added before death. Convulsions are another symptom of occasional occurrence, and of almost certainly fatal augury. They are epilepti- form in their character, lasting a few min- utes only, and giving place t& profound coma, in which the patient dies, with or without a repetition of the convulsion. Convulsions in Typhus are almost always associated with albuminous urine, and, in a few cases where this has been investigat- ed, with urea in the blood. If the head symptoms have been promi- nent, and yet the patient recover, a child- ishness of intellect is often left for a few weeks. In very rare eases, the patient has remained insane for some time, but in such of these cases as have come to the writer's knowledge the previous history of the patient's mind was not satisfactorily made out. As a very rare condition in- deed, softening of the brain, proving fatal, shortly after the fever has subsided, has been witnessed. All cerebral symptoms are severe, and the delirium is commonly earlier and more active in persons of the better class of life, when they happen to contract Ty- phus, probably on account of the habitu- ally greater activity of their brains. Of the special senses, that of hearing is chiefly affected ; besides noises in tlie head, deafness is of very frequent occur- rence, beginning at the end of the first week, being slight, or nearly total in amount, and persisting even after the advent of convalescence. Nothing is to be seen in the ear to account for it. The eyes are suffused, and the conjunctival vessels injected. The sight is rarely af- fected, but much light increases the head- ache. The pupils vary a good deal from a condition of medium dilatation to one of great contraction. Their size has not, in the writer's experience, a very constant relation to the mental state of the patient, nor to the severity of his disease ; but small pupils are the rule when coma is present. Some sluggishness of the pupil to the action of lightls then also frequently observed. Kidneys. — The urine of Typhus has not been sufficiently investigated, and many of the following statements rest wholly upon the writer's own observations. In quantity it directly represents the amount of fluid ingested, regard being had to the other ways in which the body gets rid of water. The quantity has been found greatest in the first week of the fe- ver ; about the same or slightly less, in the second ; and notably less during the third week after the commencement of convales- cence ; the mean of several cases and of several days being taken for comparison. A belief exists among good authorities that much ingested water is retained in the body during the whole stage of py- rexia, but of this there appears to the writer to be no evidence that will bear scrutiny. The occurrence of diarrhoea diminishes pro tanto the amount of fluid carried off by the kidneys ; as to the per- spiration, it is not yet demonstrated what alteration in its amount goes along with the increased temperature of the body ; it is commonly assumed, and is probable, that very little water is got rid of by the dry-feehng fever skin. An increased amount of urine is said often to accom- pany the crisis ; this has been observed occasionally by the writer, but with no approach to constancy. 260 TYPHUS FEVER. The color of the urine in Typhus is variable. In most cases it is darker than usual up to the turn of the disease ; it then becomes natural in color, and after the third week it is commonly pale. It is very rarely pale throughout. The reac- tion is acid, probably not more so than in health ; and in a case quantitatively ex- amined by Parkes, the free acid reached to only half the normal standard. The twenty-four hours' urine is often quite free from deposit ; but at some period or other of the disease it is usually turbid from lithates. A deposit of lithates has been said to occur as a critical dis- charge ; but in the cases examined by the writer, this was observed quite as often at earlier as at later periods, and most fre- quently a day or two before convales- cence. The daily amount of uric acid at the height of the fever appears (from one analysis by Dr. Parkes, and one by my- self) not to be in excess of the healthy quantity. In Parkes 's case the sulphuric acid excreted was rather high ; the phos- phoric acid has not been estimated. The chlorides of the urine are greatly reduced during the pyrexial period of Typhus. Tins partly results from salt not being ingested ; but there must be some otlier cause for their disappearance from the urine, since all chlorides may be withdrawn from a person in health, and yet the urine will continue to contain con- siderable quantities for some time after. In pretty severe cases of Typluis the abo- lition of the chlorides may be total ; but usually there is a small amount secreted, estimated volumetrically at from two to three grains in the twenty-four hours, and just giving an opalescence when acid ni- trate of silver is added to the urine. Be- fore the advent of convalescence, the diet remaining the same, the chlorides reap- pear in some quantity, undergoing a grad- ual increase, though the quantity Ingested remains the same from day to day. It is not ascertained how far their previous dimininution is made up for by greater excretion of them during convalescence. Their disappearance is not connected with diarrhoea, nor is it due to the accession of pneumonia. When common salt is taken into the stomach as a medicine in the early days of Typhus, while the natural chlorides are being excreted in diminished quantity, it does not pass out by the urine. When taken at a later period, just before con- valescence, it is found freely in the urine. In fatal cases, it does not appear up to the time of death. In one such case, where twelve drachms of salt were given to a patient on the ninth and tenth days of Typhus, mere traces of it were ex- creted by the kidneys, up to the time of death on the seventeenth day ; and upon examination of the blood, a certain small' excess, but not accounting for one drachm of salt in the whole vohime of the blood, was detected. It is probable, therefore, that tlie chlorine attaches itself to some solid tissue of the body ; or that the ex- cess is diffused alike through all the tis- sues, and that its retention is intimately connected with the febrile condition. The daily excretion of urea in Typhus, as deduced from sixteen cases accurately observed through the several stages of the disease, is at first considerably above the normal amount. Taking one case with another, the daily quantity during the first week — the patient being fed on low diet, milk and beef-tea — may be stated as about double that of the fourth week, when he is sitting up and eating his fill of meat. The increase is found at the earliest day at which the urine has been examined. In three fatal cases, it did not diminish in quantity during the time that the urine could be procured. In cases of recovery the amount of urea gets gradually less, sometimes, but not always, showing a special decrease about the time of crisis.' The urine of Typhus is occasionally al- buminous. In fifteen male cases of vari- ous severity, examined throughout their course (some as early as the third or fourth day, and most as late as the fourth week), albumen was found in two cases. One of these was fatal on the tenth day without complication, and the urine con- tained much albumen on the fourth, fifth, and sixth days, the only occasions when it could be collected. In the other case, a trace was found on the eleventh day, but none before or after ; here the patient died on the twenty-fifth day, from one of the rarer sequelee of the disease. Albu- men is only found in Typhus of consider- able severity ; but in some of the cases examined, though the fever proved fatal, there was none m the urine at any stage. The proportion of cases here stated to have exhibited albumen is below that which is reported as the experience of most observers. A trace of sugar was observed at one time or another in nine cases out of four- teen, when it was sought for. It appeared at any period between the sixth and ' It must not be forgotten that some portion of the excess is due to gelatine taken in beef- tea. In one case it was attempted to esti- mate the influence of this element. For two periods the patient was fed on milk, and no gelatine, and between these periods he was fed upon three pints daily of the strongest beef-tea ("so strong it was quite a jelly when cold"), and nothing else. The mean of the two milk periods was compared with the beef- tea period, and an average daily excess of 11-5 grammes (1V4 grains) of urea was found in the latter. The writer would also like to see the influence of alcohol excluded in cer- tain observations on the urines of fevers. DURATION — TERMINATION AND SEQUELS. 261 twenty-seventh days, and only lasted a day or two. It was probably no more than often occurs in health, and was clearly of no clinical significance. Convulsions, as connected with kidney disease, have already been considered under Brain Symptoms. Retention or else involuntary passage of urine is fre- quent in severe cases. Generative System. — The catamenia are sometimes present in patients on their admission to the London Tever Hospital ; occasionally to a considerable degree. If not present at the earlier stages, the cata- menia do not usually appear during the progress of the fever nor during the por- tion of convalescence that the patient passes in hospital. When pregnant women get Typhus, if they are past their sixth month, they frequently miscarry, but this accident adds very little to the danger of the case, Typhus Fever herein differing much from typhoid or scarlatina. Duration.— The duration of Typhus Fever may be measured by the fading of the eruption, by the fall in the pulse, by the decrease of temperature, and by the general improvement in the aspect and condition of the patient. As a rule, amendment begins in all these ways pret- ty simultaneously, the fall in pulse and temperature being, however, the most re- Uable indication of approaching convales- cence. Measured by these tests, the dura- tion of the uncomplicated fever varies from twelve to twenty-one days, in mild cases (among children particularly) being sometimes less than twelve days, but only in very rare instances reaching twenty- two or twenty-three days. When the fever is complicated, for instance with ery- sipelas or parotid swelling, the pulse and temperature may keep up beyond this lat- ter date. In about half the cases, they fall on the thirteenth or the fourteenth day. Except when petechise on the skin have been very distinct and irremovable, the eruption usually fades about the same time, and, with very rare exceptions, is altogether gone by the end of the third week. Relapse in cases of Typhus, meaning by the word recurrence of the specific disease after apparent convalescence, is of exces- sively rare occurrence. Once only has it happened to the writer to see a true Ty- phus rash recur, and this was in the case of a woman who lost the eruption on the fourteenth day, and appeared to be get- ting rapidly well, when, after a few days' ailing, the eruption reappeared copiously on the twenty-fifth day and remained visible for more than a week, the patient passing through a second and very severe attack of the fever. The duration of fatal cases of Typhus extends from two or three days to twenty- one days, which appears to be the limit of risk in cases of uncomplicated Typhus. In civil practice it is uncommon for the fever to prove fatal before the seventh day ; but in certain epidemics that have occurred during warfare, death has fre- quently occurred at an early period, be- fore the development of the eruption. The ordinary duration of fatal cases is twelve or fourteen days. When parotid swelling or other complication appears as the cause of death, the fatal result may be postponed to the thirtieth day, or even later, but it is not then due to the direct influence of the Typhus poison. Termination and SBQUBLiE.— The terrninati'ni of Typhus in recovery occurs often with great rapidity ; the patient who the day before lay prostrate, stupid, and wandering, with only a slight fall in pulse and fever-heat to hint at the commence- ment of cliange, becoming conscious, looking comparatively intelligent, chang- ing his position (though now feeling for the first time his utter weakness), and almost suddenly regaining his appetite. This improvement is more usually spread over two or three days, the lividity of the face gradually getting less, the tongue cleaning, the thirst disappearing, the pulse falling ten or twelve beats a day. The fall of temperature takes place pretty rapidly in almost all eases ; and if it be retarded, while the patient appears to im- prove in other respects, the accession of some complication is commonly imminent. Occasionally the pulse does not fall below 90-100 for many days after manifest im- provement in other respects. This is commonly due to some thickening of the lung remaining behind, and probably in other cases to the weakness of the heart being extreme. On the other hand, a fall in the pulse to a point much below the healthy standard is not infrequent in the early days of convalescence ; the natural frequency being resumed in a short time as the patient gains strength. From the time when the patient begins to mend, he commonly goes on getting appetite and strength from day to day. Any lung symptoms improve at the same time and rapidly disappear. Emaciation, which is seen towards the end of the acute stage, often continues to increase for some little time after the cessation of the febrile condition, but soon the convales- cent regains what ho has lost and returns to a state of unimpaired health. Fre- quently he finds himself after a month or two stronger and better than before his illness. In cases of Tvphus terminating fatally through the inte"nsity of the disease itself, prostration, subsultus, and carphology in- crease, and low delirium passes into com- plete coma. The pulse and temperature 262 TYPHUS FEVER. continue to rise ; stools and urine are passed involuntarily ; food is often obsti- nately refused, and there is much diffi- culty in swallowing for a day or so before death. When there is much bronchitis or congestion of the lung, mcreased livid- ity of face with quickened breathing and flapping nostrils are observed, but these conditions are often less noticed through the great prominence of the nervous symp- toms. A patient ill with Typhus does not alwajs convalesce immediately upon the cessation of the specific fever. The sequelce of the fever are indeed few and rare, espe- cially when it is compared with typhoid or scarlet fever, and very seldom does it leave behind it any permanent impair- ment of health. These sequelae consist either in the persistence of some of the local complications that have been enu- merated in the description of the disease, or in the advent about the period of con- valescence of certain conditions of an erysipelatous nature. The complications that occasionally continue are consolidation of the lung, which occasionally goes on to gangrene, but generally mends in the course of a week or two ; weakness of the heart, leav- ing the pulse feeble, with a tendency to palpitation for some short time : bedsores and gangrene of the toes of course have also to be repaired, or may cause death at a late period ; and occasionally a patient dies shortly after the twenty-first day from the kidney disease that has been set up in the course of the fever. When erysipelatous afliections make their aj)pearance, it is usually somewhat late in the fever, convalescence being re- tarded by their approach. But they may also occur during the earlier stages of the disease ; and, although for practical pur- poses they may be regarded as sequelae, it is probable they have an intimate con- nection in nature with the specific disease. Erysipelas itself, following the usual course of idiopathic erysipelas, occasion- ally occurs about the time of convales- cence. It begins at the root of the nose, the fauces being at the same time red, and may spread over the face and head more or less widelj^, often causing suppuration in the eyelids. In three cases lately ob- served at the London Fever Hospital, rapidly developed o!dema of the glottis had supervened in patients suffering from erysipelas after Typhus. Swelling "of the extremities — sometimes consisting in in- flammatory exudation into the cellular tissue, at other times connected with phlebitis^and pytemic affections of the joints, always ending fatally, are other rare conditions of the same sort. Of this group of sequelae, the common- est is swelling, or bubo, of the salivary glands, which are liable to become affect- ed at any period of Typhus, but especially in the third week ; at any age, but mostly in the adult. In a few hours a swelling forms that is extremely tender, increases rapidly, and, in the majority of cases, goes on to suppuration. The parotid is the gland most commonly affected, and it is not uncommon for both sides to suffer. Kext, but at a long interval in frequency, the submaxillary gland is liable to be af- fected, while the sublingual gland is very rarely attacked, in the only two cases seen by the writer, becoming involved after others of the salivary glands had swollen. Sometimes, more often in the child than the adult, parotid buboes sub- side without suppuration, but, usually, they go on increasing ; in three or four days fluctuation is detected, and if the swelling be not evacuated artificially, it bursts in the mouth, or the meatus of the ear, or upon the external surface. These swellings appear to occur more in some epidemics than in others, and they add much to the fatality of the disease. If they are at all capable of spreading from • one patient to another, it is to a very slight degree that this occurs, at any rate in hospital practice. Upon examination of all the evidence bearing' on their nature, Murchison regards these buboes as form- ing a connecting link between Typhus and Oriental plague. Inflammatory swellings and abscesses in other parts of the body are occasionally observed after Typhus. Commonly these accompany Typhus only as they accom- pany smallpox, or other acute specific diseases, but there have been some epi- demics in which the lymphatic glands of the groin and axillae have been observed to swell, again appearing to show an af- finity of the disease with plague. Diagnosis. — The diseases from which it is most often required to distinguish Typhus, are measles and typhoid lever, pneumonia, and certain brain diseases. The eruption of Typhus is sometimes, though not commonly, a good deal like that of measles, and it appears about the same day after invasion. If it should happen that a child is attacked, and the source of contagion is unknown, there may be real difficulty in distinguishing the two diseases. Coryza, when present and distinct, points to measles. The erup- tion of Typhus is of a smaller pattern than in measles and scarcely ever has any crescentic shape. The occurrence of spots on the face by no means excludes Typhus. Much elevation of the rash is in favor of measles. If the diagnosis have remained difficult up to the sixth day, it may then usually be made 'with certainty, by noting the sudden fall of temperature that then characterizes measles, and that does not DIAGNOSIS — PATHOLOGY. 263 occur so early or so completely in Typhus. Still even this means is only available for cases uncomplicated with pneumonia. From typhoid fever, Typhus is usually pretty easy of diagnosis. Minor elements of distinction are, the nature of the fever prevailing in the same house and neigh- borhood, and the comparatixe immunity of old people from typhoid. In typhoid, the invasion symptoms are far more insidious than in Typhus ; rigor and headache are less marked. In the early stages of typhoid, epistaxis is sometimes observed, a symptom very rare in Typhus, compli- cated with scurvy. [The same may be said of bronchitis. — H.] The eruption of typhoid appears later than that of Typhus, rarely being met with before the seventh day in typhoid, while in Typhus its ap- pearance is very seldom postponed so late as this. The mottled, dull-red eruption of Typhus, with its irregular, non-elevated (at least after the first day), and often persistent spots, is not often closely simu- lated by the scantier eruption of lenticular, rose-colored spots of typhoid. But the most essential distinction between the two eruptions is, that of Typhus comes out in one single crop, while in typhoid fresh sets of spots appear day after day, and each spot lasts only three to four days. Diarrhoea is a much more frequent symptom in typhoid than in Typhus ; but in the particular case, the presence or ab- sence of diarrhosa is not much to be relied on for distinguishing the two fevers. The character of the stools is more distinctive; in Typhus they are natural or dark in color, and, if loose, of muddy consistence ; while in typhoid they are yellow, and consist of powdery-looking matter sus- pended in liquid. In typhoid, the stools are alkaline, and contain crystals of triple phosphate ; but the stools of Typhus come to resemble them in these respects when there is diarrhoea. The tongue does not give much help in diagnosis; for, though the typical tongue of Typhus — hard, thick, and with much dry brown fur, — resembles little the typical tongue of typhoid, flat, red, dry, and cracked, with little or thin fur ; yet either of these descriptions of tongue, and every variety of them, may occasionally be found in either disease. That the tongue should be persistently moist, is a circumstance pointing much to typhoid. Considerable fluctuations of the pulse, and great evening rise of tem- perature, are points in which typhoid dift'ers from Typhus, but to which appeal can rarely be wanted to guide diagnosis. The duration of the two fevers will com- monly aiford a point of distinction, if a case should by possibility have remained doubtful throughout. Typhus does not last more than three weeks, and in the attacks with obscure rash (where confu- sion with Typhoid is most possible), gen- erally a fortnight only ; while, in typhoid, the fever, as evidenced )jy the pyrexia and the eruption, goes on to a fourth week, and may go on to the thirtieth 'day, er even later. In referring to duration, as distinguishing the two diseases, it is, of course, necessary to exclude complica- tions that may be keeping the patient ill, after the specific fever has left him. With idiopathic pneumonia, it will ea- sily be understood that Typhus may be confused, since a species of pneumonia is one of the commonest conditions compli- cating Typhus. The compressible pulse, the great prostration, and the brown tongue of Typhus are simulated by cer- tain forms of pneumonia, in which, more- over, the signs that point to the chest may be no more prominent than they are in the lung-consolidation of Typhus. The presence of a Typhus rash is the essential means of separating the fever from the idiopathic local disease, and, without it, the diagnosis cannot certainly be made. In the same way, the existence of Typhus eruption is the only way in which cases of this fever, complicated with other local lesions, can be distinguished from those local lesions occurring idiopathically — from ursemia or erysipelas, for instance. In many cases of Typlius, especially when occurring among drunkards, the patient, without much apparent prostra- tion, has active, suspecting delirium, there is total sleeplessness, the muscles tremble, and there is considerable resem- blance to delirium tremens. But the moist tongue and skin, and the absence of eruption, usually separate this disease from Typhus, from which it also difiers in the manner of its commencement. We have often to make a diagnosis be- tween Typhus and acute idiopathic or tubercular meningitis. Headache is of a sharper character in meningitis, making the patient cry out with pain, and it per- sists after delirium has set in, which it never does in Typhus. Instead of the senses being obtuse, as in Typhus, they are usually painfully acute in meningitis, and the countenance has not the look or intense prostration that it commonly has in Typhus. Unilateral symptoms, such as inequality of the pupils, or ptosis, may be seen in meningitis. And in this diag- nosis, again, we are guided by the erup- tion, if it be present, more surely than by any other consideration. Pathology. — It has been stated that Typhus is the result of a specific poison having the power of reproducing itself in a healthy person submitted to its influ- ence in sufficient quantity and for a suffi- cient time. An account of the pathology of the disease should explain what this poison is, how it enters the body, and is given off to infect other persons, and how 26-4 TYPHUS FEVER. it operates upon each organ and sj'stem to produce the clinical results that have been described. Our knowledge goes but a very little way towards such an expla- nation. The views of Virchow, Parkes, and Kichardson upon the subject aftbrd the most suggestive data, and may be combined into some such account as the following : — ■ The Typhus poison is a complex or- ganic substance, probably itself in process of decomposition, and capable of produc- ing chemical changes in the albuminous tis'sues and fluids of the body. Upon these changes the symptoms of the disease depend, and in the course of them a fresh amount of the specific poison is produced. The nature of these chemical changes is not known, but the evidence of their oc- currence in the albuminous tissues and fluids comes from the changes observed in the blood and urine, and the alterations seen in the structure of the muscles in fatal cases. The immediate efTect of the mechanical change that is brought about by the poi- son of Typhus appears to consist in an alteration of the osmotic properties of the blood. Through this alteration many of the phenomena of fever are evolved. The interchange of material between the blood and the alimentary canal is interfered with — an interchange which in health is represented by several pints of fluid daily, and which is of as much consequence to the maintenance of the body as the inter- change of gases in the lungs. From this interference arise the dryness of the mu- cous membrane, the arrested secretion of saliva and gastric fluid, the diminished secretion of chlorine from the body, and probably the febrile phenomena. Another consequence of the chemical change in the albuminous substances of the body is altered metamorphosis of tis- sue, firstly, in the way of increase, as we see in the great excretion of urea ; and secondly, in point of quality, the altera- tion of the albuminous substances giving rise to new products in the secretions. In the urine Frerichs shows two abnormal albuminous products. In the skin and mucous membrane the peculiar odor of Typhus, in the absence of chemical proof, serves as evidence of some similar change. And the self-producing poison of Typhus may itself be one of these abnormal ele- ments of secretion. It has been suggested that ammonia, or a compound related to it, is the actual poison of Typhus. To the writer it ap- pears probable that the matter of this poison is of an organic nature less ad- vanced in decomposition than the stage of ammonia, and that the evidence ad- duced to support the ammonia theory (even if the fallacy of decomposing matter about the mouth have been sufficiently excluded in the experiments upon which this theory is chiefiy based) points rather to the production of ammonia as one of the subsequent changes, excretory in na- ture, of the altered albuminous com- pounds. Morbid Anatomy. — The anatomical changes that can be appreciated in Ty- phus are few, and the only one that is quite constant is a change in the blood. But changes from the healthy standard are seen in the muscles, in the mucous membranes and glands, in the kidneys, in the lungs, and in the brain, and in other organs. The body of a Typhus patient is not much emaciated, if the patient die at the time usually fatal, at the end of the sec- ond or in the third week. The Typhus maculfe, but not the subcuticular mot- tling, often persist on the skin after death. Decomposition is generally rapid. The blood in Typhus is particulars liquid. Drawn from the veins during life it coagulates rapidly, but very imperfectly, the coagulum being large, dark, and soft. Under the microscope it is stated that the corpuscles are crenate and misshapen, and do not adhere into rolls, but run into amorphous heaps. After death the same appearances are observed in the blood. It is either not coagulated at all, or forms in the heart and great vessels large, very soft clots, and rapidly becomes putrid. Chemical analysis of the blood is as yet extremely imperfect. The proportion of fibrine is stated to be diminished and that of the red corpuscles to be increased, while urea and ammonia are said to have been found in the blood. Lehmann's account is that the fibrine corpuscles and albumen are all in excess at first, but that the amount of corpuscles diminishes in the latter stages, causing the blood to have a lower specific gravity. As to the abnormal elements of the blood and the chlorides in it, no sufficient observations have yet been made. Morbid changes in the muscles of Ty- phus have been long observed in the heart's tissue. The organ is soft and flabby, and under the microscope the fibres are seen in a state of fatty degene- ration, probably identical with that ob- served in other striated muscles. Although softening of the voluntary muscles was long ago pointed out by Laennec, and they are known to be often darker and softer than natural, researches into their pathological changes have not been followed out. The elaborate re- searches of Zenker on the muscles in ty- phoid were not extended by him to Typhus Fever ; but in cases examined by the writer the characteristic changes which were described by Zenker have been seve- ral times observed ; the granular and PROGNOSIS AND MORTALITY. 265 waxen degeneration having been well marked in fibres taken from the rectus abdominis and adductor magnus femoris muscles. When the cases examined had been rapidly fatal, the changes were not seen; but when death had occurred in the third week, or later than this, from some complication, the degeneration was well marked. Several instances are on record of hemorrhages into the voluntary muscles, an occurrence which further points to a muscular change in Typhus similar to that demonstrated by Zenker in typhoid. The mucous membrane of the stomach is occasionally injected and softened. That of the intestines, particularly of the colon, is not uncommonly inflamed, its vessels being intensely engorged, and soft lymph being sometimes exuded on its sur- face. This condition is met with when during life there has been much diarrhoea. The agminated glands, and the solitary glands of both large and small intestines, may be found enlarged, especially in chil- dren, who have them naturally very visi- ble. But under no circumstances is there any deposit in these glands, nor does the ulceration of them which is so constant in typhoid ever happen in Typhus Fever. In those epidemics where dysentery has complicated the fever, the characteristic lesions of that disease have been observed. Of the glands, the liver and spleen are frequently hypersemic, large, and softened. The spleen is sometimes pulpy in consis- tence and enlarged to twice its natural volume ; this is seen more when the dis- ease has been fatal at a late period. "When the salivary glands have been swollen iu Typhus, inflammation and softening of the gland tissue itself is the lesion usually observed ; and if the disease is advanced, suppuration and sloughing of the gland substance and the interstitial areolar tis- sue. Some authors have insisted that the pathological changes in these glands be- gin in the areolar tissue between the lobules, but in the writer's experience this is not the rule. Under the microscope abundance of oil-globules and of granules, and of pus cells are found, and the gland cells are fuh of oil-globules. The pancreas is frequently injected, but is not known to suffer any change resembling that of the salivary glands. The kidneys are not much or often affected by Typhus. Their commonest deviation from health is congestion, the organs being large and somewhat friable. In the rare cases that prove fatal by con- vulsions, the kidneys are either found the seat of old disease, or they are in some stage of recent engorgement up to actual acute nephritis, or there may be no lesion whatever detected in them. The bronchitis that is so very common a condition in fatal Typhus offers no ap- pearances after death requiring special comment. The consolidation of the 1 uncjs, often met with in most fatal cases, con- sists either of true pneumonia or (more usually) of hypostatic congestion. In the latter the posterior parts of the lung are dark, non-aerated, friable, with a section that is not granular, as in pneumonia, and from which much dark serosity exudes. The nervous system commonly shows after death no lesion whatever to account even for intense head symptoms. The utmost change that is usually observed is some fulness of the sinuses, coarse injec- tion of the meninges, and increased vas- cularity of the brain substance, and none of these conditions reach any intense de- gree. Occasionally a film of hemorrhage is seen iu the cavity of the arachnoid, and the amount of serum in the sulci and ven- tricles is greater than usual, but neither of these conditions appears to have any connection with the brain symptoms dur- ing life. Actual meningitis has, however, been observed in Typhus, in such a way as suggests its occurrence more in some epidemics than in others. It is described by the physicians of the London Fever Hospital in their w-orks, published in 18.30, as of no infrequent occurrence ; but in the course of the last ten years, menin- gitis has certainly been very seldom seen there as a post-mortem appearance in Ty- phus. But in the last few years, a form of fever, akin to Typhus, if not actually identical with it, has been observed in America to be often complicated with meningitis of the brain and spinal cord. And in the present year (1865) a Russian physician, Dr. Kremiansky, describes a hemorrhagic inflammation of the dura mater as a frequent occurrence in persons dying of Typhus in St. Petersburg. Prognosis and Moktalitt. — In Ty- phus, these are affected by nothing so much as by age ; but to some degree by temperament and habit, by social position and nature of previous occupation, and also by the characters of the prevailing epidemic. The rate of mortality from Typhus in a community attacked by it is usually stated much too high, the experience of hos- pitals, into which few children are re- ceived, being taken as a basis of calcula- tion. When every attack, in persons of all ages, is included, the mortality of Ty- phus is about 10 per cent. But when such cases only as are ordinarily sent to liospitals are considered, the mortality is about 20 per cent. When age is com- pared strictly with age, however, this dif- ference, either wholly or for the most part, disappears. Between one hospital and another, or between hospitals and cases treated at their homes, there are in- deed some apparent differences of mor- 266 TYPHUS FEVER. fality, but the causes of such differences (when real and not dependent merely upon age or accident) are not of a nature that any general statement of them can be made. The death-rate of children under ten years of age, attacked by Typhus, is about 5 per cent. ; that of persons over sixty years is 66 per cent, or upwards, of those seized by the disease. Between the two there is a regular gradation of fatality. For example, at Greenock, the death- rate, at seven periods of life, was recently found to be, under ten years, 5 per cent, between ten and twent}^, 8 '6 per cent, between twenty and thirty, 15 '6 per cent, between thirty and forty, 21 -5 per cent, between forty and fifty, 42 per cent. ; and over fifty years, 66'6 per cent. ; the mor- tality increasing with each decade of age that the patient had reached. The death- rates of the London Fever Hospital, ana- lyzed in detail by Murchison, gave figures corresponding in the main with these, but all of them slightly higher through the se- verity of the cases that are presented to that institution. The difference in mor- tality, according to age, is so great and so universal, that the caution may well be given that no comparison between differ- ent methods of managing Typhus can have the slightest value which does not accurately allow for this overshadowing influence. Bulky, lymphatic, and fat people are more likely to die than those of a different conformation when they are attacked with Typhus. Negroes, treated in the London Fever Hospital, have been observed to have the fever more severely than whites. People of a better class of life, though sel- domer attacked, are believed to experi- ence a larger mortality than the poor. Habits of intemperance very seriously add to the unfavorable prognosis. Occupational differences only affect the prognosis of Typhus in so far as they have involved extreme exhaustion and fatigue, persons who are attacked under circum- stances of that kind usually having a high mortality. Overworked soldiers, doctors and nurses, for example, get the disease with peculiar severity. And if the pa- tient try to keep about, going on with his work until he takes to his bed from sheer inability to stand, he materially dimin- ishes his chance of recovery. The conditions occurring in an attack of Typhus, which gives especial gravity of prognosis, are as follow :— Very abun- dant rash, with spots scarcely affected by pressure ; considerable duskiness of sur- face ; a high maximum temperature, as 107° or above ; continuous rise of temper- ature up to the end of the first week, a sudden great rise of temperature in the third week, this being, it is stated, of fatal significance ; very weak pulse, with inau- dible first sound of the heart ; very rapid pulse, death being almost certain if in the adult the pulse exceed 150 ; lung compli- cations of all kinds make the prognosis bad according to their amount ; early de- lirium ; severe and active delirium, with complete sleeplessness ; profound coma, and especially coma vigil ; intense pros- tration and subsultus ; convulsions, which are almost certainly fatal ; albumen in the urine ; obstinate refusal of food ; vomit- ing ; uncontrollable diarrhffia. Any of the erysipelatous conditions noted as oc- curring towards the end of the disease contribute to reduce the patient's chances of recovery. Therapeutics.— Typhus Fever, like other diseases of its class, cannot be cured nor its duration shortened by any means at present known to medical science. Its symptoms may be combated, and its com- plications may be treated, while the pa- tient's strength is supported through the time of the fever, but we know of no .way of encountering the specific disease. Upon a full recognition of this truth, the treat- ment of a case of Typhus will be most sat- isfactorily based. If we propose to our- selves to give the patient the best possible opportunities of recovery, our treatment will be more successful, than if we direct our efforts to cutting the disease short by any supposed methods of cure. In a disease which lasts two or three weeks, in which the metamorphosis of tis- sue is increased, and in which ordinary food cannot be taken, the patient must be kept up by nourishment appropriate to his new condition, or he will die, as a healthy person deprived of food for the same length of time would die. The es- sential part of the management of Typhus consists in giving this appropriate nour- ishment, and in preventing the patient dying from the want of it while the cura- tive processes of nature are going on. The character of the nourishment to be given requires some detailed considera- tion. In the early stages of the fever, if the patient have appetite, he may be al- lowed anything not positively noxious that he has a fancy for. As his dislike for food increases, he will still consent to take liquids and sick-room delicacies. But soon there comes a time, in every severe case of fever, when everything but cold water is distasteful, and when food has to be administered like so much medicine to the unwilling patient. At this time, the digestive functions are in more or less complete abeyance, and the nutriment given must be such as requires the sim- plest processes for its assimilation. Fore- most among nutriments of this kind, ex- perience has put beef-tea and broths, milk, THERAPEUTICS. 267 eggs, and alcoholic drinks.' Bread, ar- rowroot, jellies, are other suitable articles; and the nurse who can manage a good deal of variety in the choice and combina- tion of such things as these, does much for her patient's chance of recovery. Samples of such variety are Gillon's meat- juice ; vermicelli in beef-tea ; chicken or veal broth ; mutton broth with rice or bits of toast ; eggs in custards or beaten up with milk or with wine ; blancmange of isinglass or ground rice; syllabubs or wine- whey; barley-water or thin arrowroot with milk ; weak tea or coffee with milk. For drinks, lemonade, soda-water, cur- rant-water, cold weak tea without sugar or milk, or any of these iced, may be al- lowed at the patient's choice. Often food is taken cold when hot is refused. But even of this light diet a little only can be taken at once, and it therefore becomes desirable that it should be given frequent- ly. Every two or three hours the patient should be fed, and if he be in a drowsy state he should even be roused up to take his nourishment. But of these means of giving support, there is none more important than alco- holic drinks judiciously used. It is not every patient that requires alcohol ; chil- dren rarely do, and about half the adult cases admitted into hospital may be treated without any. But it is especially in two classes of patients that we need to give stimulants: those who cannot take a sufficient quantity of other kinds of nour- ishment, and those who are in health habituated to the use of strong drinks. Besides the use of alcohol as an aliment, it has also a medicinal effect upon the nervous and circulatory systems, and its full employment will much depend upon whether this effect is desirable. The cases in which alcoholic stimulants are most serviceable are (1), in old people al- most universally ; (2), cases of great pros- tration, with low delirium and coma; (3), ' The writer has no intention to side in the controversy concerning the food character of alcohol. He accepts the evidence that much ingested alcohol is got rid of by the excre- tory organs, or is retained for some time in ! the tissues after tlie manner of many medi- cines. But witli food in its widest sense, as what keeps up the vital functions, the phy- sician will have little hesitation in classing alcohol, who has observed the common ease of an habitual tippler maintaining for years a fair standard of bodily health upon a quan- tity of other nutriment wholly insufficient by ■ itself to maintain such health. And to such a case a fever patient offers some resemblance. He, too, may not be able to take enough of ether food to maintain him, but alcoholic drinks will help him not to starve. And thus , ^M writer judges them to have a food value apart from their medicinal action. cases where the pulse is very compressi- ble and the first sound of the heart feeble also when the pulse intermits and usually when it exceeds 120 in frequency; (4), cases where the extremities are cold and the surface is Uvid ; (5), where there is much congestion of the lungs ; (6), whore there is any erysipelatous complication. In a great many cases of Typhus alcohol is unnecessary, and appears to do actual harm when there is violent maniacal ex- citement at an early stage, and also with young people in whom, without notable depression, there is much bronchitis, or in whom true pneumonia can be diag- nosed. Alcohol is rarely wanted before the appearance of the eruption, and is most needful in the second or third week, as the patient is approaching the crisis of his disease. For ordinary cases requiring alcohol, the strong wines are best adapted, while lighter wines with water form ex- cellent drinks. Beer is a very good form of giving alcohol with other nourishing principles, and it is often craved for by the patient. Severe cases, particularly in old persons and in drunkards, require spirits, which may be given mixed with beef-tea, with milk, or with eggs. A moderate allowance to an adult, suffering under pretty severe Typhus, with dry tongue, moderate delirium, and weak pulse of 120, would be a bottle of claret or half a bottle of sherry daily. A bad case, with livid features, tremulous muscles, much low delirium, with coma, and a very weak pulse of 140 or 150, may often have 12-20 ounces oi' brandy or whisky daih' distributed in hourly doses. It of- ten happens that in such cases a patient for whom there might otherwise be a chance, obstinately clenches his javs>s against his nourishment, or is made sick by it ; it is then sometimes possible to tide him over the time of crisis by frequent enemata of beef-tea and brandy, which are usually well retained, even if there have been some tendency to diarrhoea. [The nicmner of administration of food and stimulants in typhus is very impor- tant. After the first few days, if not from the start, milk, beef-tea, or some other concentrated nutriment, should be given in small quantities every two or tliree hours; in cases of extreme prostra- tion, every hour, day and night. Having had experience of an attack of typhus, when resident in a Hospital, I very well remember the distressing sense of sinking felt on awakening after a couple of hours of sleep ; reUeved for the time by a table- spoonful or two of concentrated liquid food. But for watchfulness with this kind of care of the patient (especially through the weakest time of the twenty-four hours, between midnight and morning), not a few will, as it were, slip through the fingers. 268 TYPHUS FEVEK. "When alcohol is needed, it does the most wood t^iven in milk ; say one tablespoonful of whisky to two of milk, or, in very feeble cases, half and half. — H.] But though what has been said is, in the writer's experience, the essential part of the treatment of fever, there are many symptoms and complications that can be met by medicinal agents. The thirst is best relieved by acidulous draughts, and there is no better medicine for slight cases of fever than twenty drops of dilute hy- drochloric acid in an ounce of water. The headache, sleeplessness, and delirium are very frequently lessened, even though there should be a good deal of suffusion of the eyes, by opium ; the writer has constantly given five minims of laudanum every four hours, or else a night dose of fifteen minims, with considerable advan- tage to these symptoms. He has avoided opium when the pupils are very small, when there is coma, and when there are serious lung complications; but with these exceptions, he finds no contra-indications to the use of the drug. ' If opium be given with the object of soothing violent de- lirium, it should be in full doses at night, and not in small frequent doses : but if possible it is better not then to use opium. Combined with a small quantity of tartar emetic, opium has an increased power of relieving headache and of inducing sleep. When it is desired to use a sedative, but to avoid opium, good results have often followed from a grain or more of extract of cannabis indica given at night. Strong coffee is said to have relieved headache ; the writer has seen no effect from it, either upon headache or coma, in the few cases where he has employed it. Cold lotions to the shaven ihead and blisters to the forehead are each of use in many cases of severe headache, and they are means that are especially applicable in the cases just mentioned where opium must not be used. In early furious delirium, two or three ounces of blood have been taken from the temples with good results ; doubtless if meningitis were diagnosed, this would be right practice then also. When the pa- tient's delirium causes him to leave the bed, there is no means of restraining him equal to the care of an experienced nurse, but there is no objection to mechanical restraint, for if it be effectually applied the patient often ceases to struggle and so saves his strength. From deep coma pa- tients may sometimes be roused by blis- ters to the forehead and nape or to the shaven scalp. Subsultus and tremors are said to be peculiarly controlled by cam- phor and musk. Among stimulating remedies that may be used, along with much alcohol in cases of great prostration, spirit of chloroform and turpentine are the most valuable. The bowels had best be kept open once a day, but slightly confined rather than purged. Any but very gentle laxatives are apt to cause weakening diarrhoea. Should this from any cause be present, draughts of sulphuric acid or of chalk and catechu may be given ; and when diar- rhcea is severe or obstinate, acetate of lead in draughts ; or sulphate of copper in pill, are most useful, along with small doses of opium, if there be no reason against it. Starch and opium (fifteen minims of lauda- num) injections are also of great use. Vomiting is best checked by ice, lime wa- ter, or soda water, and by bismuth ; some- times by a sinapism to the epigastrium ; if it persist in spite of these remedies, it is well to let the stomach have complete rest for a while, supporting the patient by nutritive injections. For lung complications of all kinds, one of our most valuable remedies in Typhus is carbonate of ammonia. The bicarbon- ate (formed by exposing powdered sesqui- carbonate to the air till its pungency is gone) is less irritating to the parched mouth, and can be given in larger doses than the monocarbonate. Senega assists the expectorant action of ammonia, and may be given, except for its nastiness, in all cases complicated with bronchitis or with consolidation of the lungs. Another extremely useful remedy for congestion of the lungs, especially in old people, is tur- pentine, fifteen drops in mucilage. And with these internal remedies it is always right to use counter-irritants ; mustard poultices, often repeated, to the back and sides of the chest, being the best form of them. As for the urinary organs, it is import- ant to be on the watch against retention of urine, and to relieve the bladder duly by catheter. Slight albuminuria itself calls for no special treatment, beyond contra-indicating opium, and being, it is thought by some, a reason for not giving alcohol very freely. When there is much albumen in the urine, or when convulsions have occurred, it is right to give gentle saline purgatives that may act also as diuretics, to use mustard or dry cups to the loins, and to get the skin to act by means of the hot-air bath. Where swelling of the salivary glands occurs, the chance of their resolving with- out suppuration has seemed to be in- creased by blisters over them at an early stage. Cotton-wool may be applied over the swelling, and when the formation of pus cannot be avoided the abscess should be poulticed continuously and opened as early as ever fluctuation can be detected in it. It is of great consequence to give extra food to the patient as soon as a salivary gland is observed to swell. Eggs, fish, panada, and more stimulants should be given without any limit but his abifity to swallow them. Erysipelas supervening RELAPSING fever: DEFINITION. 269 on Typhus is best treated by extra food and stimulants, by tlie tiucturo of iron in- ternally, and by wrapping the affected parts in cotton-wool. In the management of a case of Typhus it is of great consequence to place the pa- tient in the best hygienic conditions, and if he has been attacked in the close crowd- ed rooms where the disease mostly occurs, his removal to a properly constructed hos- pital should be insisted on. An ample supply of fresh air of even temperature, of clean linen, of soft but cool bedding, and the services of an experienced nurse, are parts of the treatment as essential as the prescriptions of the doctor. Of hy- gienic treatment, quiet, cleanUness, fre- quent sponging, and occasional changes of posture to avoid lung congestion and bed-sores, are the most worthy of men- tion. As soon as the patient passes the crisis of the fever, and regains his appetite, he may be allowed any article of food that is good for him in health, and may eat and drink Uberally. It often happens that, with a tongue still dry and brown, and only just moistening at the edges, the pa- tient asks for meat, and if it is given him finds no ill effects from it. But as a rule it is certainly safer to keep him on light puddings and fish until his tongue has got pretty clean and moist. Beer is generally relished in convalescence more than wine, of which the palate is tired, and good ale or stout may be substituted for a great part or for the whole of the other stimu- lants. The amount of stimulants must be brought to the standard required in health by degrees, and not suddenly. When during convalescence the patient remains childish in intellect, or wanderino- in his mind, it is a reason for giving plenty of food and wine, not for diminishing his allowance. Of the prophylactic measures to be used against Typhus httle need be said, as they consist almost entirely in an avoidance of the predisposing causes that have been enumerated. Persons in attendance on the sick should not be overworked, or de- prived too much of their natural rest and exercise, and they may be further guarded against the reception of the fever by the use of disinfectants, of which fresh air and cleanliness are incomparably the most important. Lime whiting and repapering (after lime whiting) of infected rooms, stoving the bed and bedding, boiling the patient's linen, or soaking it in water im- pregnated with chloride of lime, and the use of this substance or carbolic acid in the water employed for sponging his body, are other means that should be employed for avoiding contagion. Varieties.— The varieties of Typhus are few, and consist chiefly in different degrees of severity. One epidemic may differ from another in its liability to spe- cial complications, to dysentery, or to cerebral inflammation, for example ; or in intensity, in this respect being affected by the average age of the community in which it occurs, and by the degree to which the predisposing causes of the diseases are in operation. But of such varieties no fur- ther consideration is here required. EELAPSING FEYER. By J. Warbitrton Begbie, M.D. \ This, its familiar name, has been ap- plied to one of the forms of continued fe- ver, on account of its most characteristic and pecuhar feature. The disease may be defined as follows : — DEFEsriTioisr. — A contagious" disease, rarely appearing, except as an epidemic ; marked by its sudden invasion, the pyrec- tic symptoms continuing till about the fifth or seventh day, when, after the oc- [' The application of tbis term is questioned by some, at least, of those who have studied the disease. — H.] currcnce of a critical evacuation, their abrupt cessation occurs. There succeeds an interval of complete freedom from fe- ver, followed by sudden relapse on the fourteenth day from the commencement of the original attack. The condition of pyrexia is again terminated by a crisis on or about the third day of the relapse, and for the most part convalescence ensues. Not very infrequently a second, with in- creasing rarity a third, fourth, and even a fifth relapse, has been noticed. History, Nomenclature, and Bib- liography.— In 1843 an epidemic of fe- 270 RELAPSING FEVER. ver appeared In Edinburgh, Glasgow, and other of the largei towns of (Scotland, which, although at first believed to pre- sent characters previously undescribed, was soon recognized as being similar to the fe\er which had prevailed in the for- mer city during the years 1S17-18, and likei\'ise to the fever which during these years and the one subsequent, 1819, as well as many previous years, had occurred iu Ireland. Carefully observed in 1843, and very aljly described by several Scotch physicians, this same fever during a later, though by no means so extensive preva- lence, in 1847-48, attracted the attention of other accurate observers, both in Scot- land and England. Since the disappear- ance of the last-named epidemic the dis- ease has been very little seen. In 1851 Dr. jNIurehison informs us that in London, as well as in Glasgow, there was a con- siderable increase of Belapsing Fever ; but since 1855, this excellent writer on fever remarks, he has reason to believe that not a single case of Relapsing Fever has been obst^rved in either of these cities.' As re- gards Edinburgh, a very competent au- thority. Dr. W. T. Gairdner, has stated that he has not seen a single case distinct- ly rcferrible to this type since 1855." The writer is able to otier an abundant con- firmation of the latter statement, for, dur- ing his ton years' service as physician in the Royal Infirmary, dating from May 1855, while having at all times charge of fever-patients, he has never once encoun- tered a case bearing any resemblance whatever to the Relapsing Fever. Several of the physicians who have en- joyed the most extensive opportunities of observing the more recent epidemics of Relapsing Fever, have occupied them- selves with an inquiry into its history ; it may therefore be expedient here, before entering on the consideration of the phe- nomena presented by the disease, to make a few observations on the former subject, while indicating at the same time the different names by which it has been de- scribed, as well as the sources from which the most reliable information regarding Relapsing Fever is to be drawn. In one of the important discussions which took place in the Medico- Chirurgical Society of Edinburgh during the prevalence of fever in 1844, the late Dr. Robert Spittal called attention to the interesting fact " that the present epidemic seems to be exactly the same in all its important features as an epidemic described by Hippocrates as having occurred in the island of Thasus, off the coast of Thrace." The chief fea- tures of resemblance between the ancient ' A Treatise on the Continued Fevers of Great Britain, by Cliarles Murchison, M.D. London, 1862. P. 298. 2 Clinical Medicine, by W. T. Gairdner. Edinburgh, 1862. P. 158. and the modern epidemics are the invari- able occurrence of relapses, the marked character of the crisis, and the frequent association with the more ordinary events in the disease, of copious perspirations,' hemorrhages, particularly epistaxis,°jaun- dice,'' splenic enlargements," and in women the tendency to miscarry.'' A simple mention of the occurrence of one or more relapses in the progress of continued fever has been made by many writers in their descriptions of different epidemics. This circumstance alone, it is scarcely necessary to observe, does not admit of such cases — which were merely excep- tional in these visitations of fever — being considered examples of the form of fever now under consideration. Thus, Dr. Srother, in his account of a fatal fever which prevailed for two years in London, mentions the occurrence of relapses as frequent. "Perhaps," he remarks, " we may find reason to lay some blame on the air for the frequent relapses."" Dr, Lind," also, in treating of the contagious Ty]ihus of the fleet, alludes to the same. "Many." he says, "relapsed." Joseph Frank, iu his learned account of adynamic fevers, refers to the occurrence of relapses, but that these were not often witnessed, may be gathered from his words, " raro recidiva morbi timenda. "^ These quota- tions will suffice to establish, firstly, the circumstance that occasional relapses in cases of continued fever had long been observed and described ; and secondly, that the fevers thus indicated were cer- tainly not the disease we are now discuss- ing, for in it relapses are not merely occasional, nor even frequent, but invari- able. We come then to the well-known work of Dr. Rutty,^ and in it there is ' The London and Edinburgh Monthly Journal of Medical Science, vol. iv. for 1844, p. 177. Ka! 6i'Jfoti>. •"Eo-ti y ?irt Ik ^ivSv h/xoffiytiri, •'"Eo-ti &' (w-i tx'"l°^ ej^Taimo-i. "AiiTiiea it ^■^r^J» Htrt is ^vve^vpntTS Iv ya, Dr. Dubois reported its occur- rence, also mostly among emigrants, in New York, in 1847-48. During the sum- mer of 1870, several hundred well-marked cases of it were observed, in localities presenting unsanitary conditions, in New York and Philadelphia.' Between April and November of that year, 517 cases were admitted into the Philadelphia Hos- pital ; of which 89 were mortal. The whole number of deaths reported to the Board of Health in Philadelphia was 162 ; of which 107 were of the colored race. 26 per cent, of the latter, affected with this disease, died ; while among white patients, but 5 per cent, of those attacked died. — H.] Etiology. — Relapsing Fever affects persons of both sexes and all ages ; the statistics of the London Fever Hospital, quoted by Dr. Murchison, making it pro- bable "that the proportion of the young to the aged is greater than in the case of typhus. ' " The special season of the year has little, if an}^, influence on the preva- lence of Relapsing Fever, neither is there proof of any particular occupation or em- ployment predisposing to the disease. This much, howe\'cr, has long been known ; and the observation of Relapsing Fever when more recently epidemic in England and Scotland, as well as in Ire- land, has strengthened the belief that this disease is peculiarly the fever of the va- grant and the unemployed. The contagious nature of Relapsing Fever scarcely admits of doubt. Two eminent authorities, and these only, have expressed the opinion that this form of fever is non-contagious. One of them, Dr. Cragie, has, indeed, almost admitted the contagious nature of Relapsing Fever: "This," however, he adds, "is rather a presumption than a well-founded inference." The other non- contagionist is Virchow ; but, as Dr. Murchison has shown, the importance justly attached to the opinion of this emi- nent observer is necessarily diminished from the consideration that his experience of the disease was limited to a single fort- night ; he left BerUn on the 20th Febru- ary, 1848, and returned to it on the 10th ' Clinical Reports on Continued Fever, baised on an Analysis of One Hundred and Sixty-four Cases, &c. &c., by Austin Flint, M.D. Philadelphia, 1855. P. 374. [2 Fevers, &o., by M. Clymer, M.D., Phila- delphia, 1846, p. 99. » Philada. Med. Times, March, 1871.] * Loc. cit. p. 303. of March. An examination thus con- ducted must have been cursory and in- complete. The opinion, moreover, ex- pressed by Virchow, was not shared in by the other medical men of Silesia ; all engaged in practice there believed the epidemic malady to be contagious. In all the epidemic visitations of Relapsing Fe- ver, to which reference has already been made, but more especially in those of 1817, 1818, and 1819, of 1843-44, and 1847-48, precisely the same facts which have been held as sufficient to establish the contagious nature of such diseases as Typhus, Scarlatina, and Morbilli, were ob- served. Physicians engaged in the daily observation of the epidemic fever for many months together, unanimously form- ed the opinion that the Relapsing Fever propagated itself by contagion. Concern- ing the earliest mentioned of these epi- demics, we find Dr. Welsh writing as follows: "When acting as clerk to Dr. Hamilton in the Royal Infirmary, in the course of four months, my three col- leagues, two of the young men in the apothecary shop, two housemaids, and thirteen or fourteen nurses, caught the disease, and the matron and one of the dressers died of it. Since I left the in- firmary, three more of the gentlemen act- ing as clerks, one of the young men in the shop, and many more of the nurses, have caught the infection, but the number I do not know. In this hospital (Queensberry House), since it was opened on the 23d February, 1818, my friends, Messrs. Ste- phenson and Christison, the matron, two apothecaries in succession, the shop-hoy, washerwoman, and thirty-eight nurses have been infected ; four of the nurses have died. With the exception of two or three nurses who have been but a short time in the hospital, I am now the only person in this house who has not caught the disease, either here or at the infirmary, within the last eight or ten months. Sev- eral students, whom curiosity led too near the persons of the patients, might be ad- duced as additional evidence. When it begins in a familj-, we always expect more than one of them to be affected ; I could mention instances of four, five, six, and seven, being sent to the hospital out of one family ; eight, nine, and ten, out of one room ; twenty and thirty out of one stair ; and thirty and forty out of one close ; and this all in the course of a few months."' The contagious nature of the epidemic fever of 1843-44 is thus insisted on by Dr. Wardell : " Most of the medical officers connected with the Edinburgh Royal Infirmary and additional fever hos- pitals were seized with it ; eight of the resident and clinical clerks in quick suc- cession became afliacted, and, out of that ' Welsh, loc. cit. p. 45. ETIOLOGY. 275 number, no less than six were yellow cases, and thus, obviously, in danger of their lives. The majority of the nurses and domestics took tlie disease, and of the former at one time no less than nineteen were laborino; under it. Some of the dis- pensing physicians and other practitioners took the disorder, as also several of the clergy, and visitors of the sick, whose du- ties brought them to the bedsides of the patients. The few cases occurring amongst the higher classes, resident in the new town, were generally to be traced to the influence of contagion, the parties aft'ected having had either immediate or indirect communication with those suttering under the disease.'" And no less decided is the testimony borne by Dr. Corinack : "The disease," he remarks, " is contagious. Of this we have sufficient evidence in the fact that almost all the clerks and others ex- posed to the contagion liave been seized. Dr. Heude and liis successor, Mr. Reid, in tlie new Fever Hospital ; Dr. Bennett, my successor there ; Mr. Cameron and his successor ; Mr. Balfour, in the adjoin- iag fever house ; as well as most of the resident and clinical clerks in the Eoyal Infirmary, have gone through severe at- tacks during tlie last summer and autumn. Hardly any of the nurses, laundry-wo- men, or others, coming in contact either with the patients or their clothes, have escaped ; at one time there were eighteen nurses off duty from the fever; and of those who have recently been engaged for the first time, or of those who have hitherto escaped, one and another is, from time to time, being laid up."^ It is in language closely resembling that employed in the sentence now quoted, that Drs. Paterson, W. Robertson, and other physicians have expressed their belief in the contagious property of the Relapsing Fever of 1847- 48 ; and the writer, whose position as re- sident medical officer in the Fever Hos- pital while under the care of Dr. Robert- son, in the spring months of 1847, afforded him the best opportunity for studying the nature of the epidemic, arrived at the conclusion that the Relapsing Fever, like typhus, is capable of communication from the sick to the healthy ; that, for this pur- pose, actual contact with the sick is not necessary, the subtle poison of this form of continued fever, equally with that of typhus, being readily conveyed through the air surrounding the latter ; and, last- ly, that, by means of fomites or clothes, the disease may readily be propagated. [In the Philadelphia Hospital, with 517 cases of Relapsing Fever admitted in eight months, no instance of its commu- nication to other inmates of the Hospital ' Warden, loc. cit. ' Cormack, loo. cit. p. 115. occurred.— II.'] It appears sufficiently remarkable that, as specially noted by Dr. Cormack in 1843-44, laundry-women engaged in washing the clothes of the sick, though never brought into direct communication with patients themselves, suffered frequently from the disease ; but this, too, was noticed in regard to epi- demic cholera ; and it was an experience of precisely the same nature in regard to that disease, acquired in the same build- ing, the New Fever Hospital of 184.3-44, being in 18.")3-54 used as a cholera hospi- tal, that, more than anything else, con- vinced the writer of the contagious nature of epidemic cholera. ^ Resembling typhus in the mode of its propagation 1 ly conta- gion, there is one particular in which these forms of continued fever remarkably con- trast. An attack of typhus, for the most part, secures the individual who has thus suffered from subsequent attacks. It is otherwise with Relapsing Fever ; no such immunity is by it secured. Welsh no- ticed, in regard to the epidemic of 1817- 18, that " being once affected with the disease seems to afford little, if any, pro- tection against a second, or even a third attack, aad that, too, in the space of a few montlis. I have seen many instances of a second attack within the last twelve- month."^ It is well known to the many personal friends, as well as the profes- sional brethren of Dr. Christison, that he has frequently suffered from attacks of continued fever, and we have his own authority for stating that, during the epi- demic described by Welsh, he experienced three separate attacks within a period of fifteen months. Dr. Wardell, Sir W. Jen- ner and many other writers on Relapsing Fever have noticed the like circumstance. It requires little acquaintance, however, with Relapsing Fever, and but slight familiarity with the remarkable epidemics to which reference has been made, more especially the last two, those of 1843-44 and 1847-48, to feel assured that conta- gion, while undoubtedly explaining in part the progress of the disease, does not do so wholly ,"and stops far short of satisfactorily accounting for any of the phenomena which were observed, and this more espe- cially at the very commencement of the different outbreaks. As assisting the bet- ter understanding of a subject still encom- passed with difficulty, the generation of fever, there is, in regard to Relapsing Fevers at all events, one consideration of [' Philada. Med. Times, March, 1871.— H.] 2 Short account of the Cases treated in the Cholera Hospital, Surgeon's Square, during the late Epidemic, by J. Warburton Begbie, M.D. Edinburgh Medical and Surgical Jour- nal, 1855, p. 253. » Welsh, loc. cit. p. 46. 2T6 RELAPSING FEVER. very considerable importance. It cannot, we think, be denied that an intimate con- nection subsists between this form of fever and destitution. Dr. Alison— who, in all his many writings on fever, as consistently held as he ably supported the doctrine that intercourse with persons already sick of the disease is the only exciting cause of continued fever, of the efficacy of which we are certain — was evidently greatly im- pressed by what he and many other ob- servant physicians had noticed of the con- nection between destitution, or famine, and fever, in the epidemic of 1846-47 more especially ; and he has left it on record as his deliberate opinion regarding the prevalence of the fever at that time, that " although burdening the infirmary more than any other which I recollect, it has not for many mouths spread to any considerable extent among the working classes of the city, but is to be regarded as merely the effect of the unavoidable connection of this country with the desti- tution of Ireland.'" Dr. Murchison has adopted an excellent method of demon- strating the intimacy of the relationship between Kelapsing Fever and destitution; he has examined the records of the Lon- don Fever Hospital and shown that since 1847, 430, or 97-5 per cent, of the patients were paid for by the parochial authorities, and totally destitute. Nine of the remain- ing patients were admitted free, and were also destitute. Not a single patient had been a servant in a private family, and in only one instance was a fee for admission paid by the patient's friends. A large proportion of the patients for some time previous to their attack had been literally starving. Irish writers, with few excep- tions, have insisted on the intimate con- nection which exists between fever and famine. Stokes described the fever of 1826 as "famine fever," and the well- known pamphlet of Dr. Corrigan, con- cerning the fever of 1847, had for its title, "On Famine and Fever, as Cause and Effect in Ireland.'"' These physicians, in their respective accounts, referred to epi- demics largely composed of Relapsing Fever. Again, the expressions, "Die Hungerpesf'and "Famine Fever," clear- ly indicate that by German observers, as well as by physicians among ourselves, this relationship has been noticed. The whole subject of the etiology of Relapsing Fever has been ably treated by Dr. Mur- chison, and the opinion which he has ex- pressed of Relapsing Fever being the ' Observations on the Famine of 1846-47. 2 Dr. Henry Kennedy's Observations on the Connection between Famine and Fever in Ireland and elsewhere (Dublin, 1847), con- tain much important information and ingeni- ous argumentation, but, notwithstanding this admission, we adliere to the statements made in the text. result of destitution, while typhus is pro- duced by overcrowding and destitution combined, will, we are disposed to believe, stand the test of further observation and renewed careful investigation. Reference has already been made to the circumstance that at the commencement of the Epidemic Fever of 1843, the dis- ease was speedily recognized as present- ing remarkable characters. "The present epidemic," wrote Dr. Henderson, to whom is justly due the merit of having first expressed the opinion that Relapsing Fever is a separate and distinct disease from other forms of con- tinued fever, "began to prevail in Feb- ruary last, and the very first cases which fell under my notice I distinguished at once as widely different from every fever that I had formerly seen.'" About the same time other observers, and more par- ticularly Dr. Cormack, from their separate and independent observation, were led to a similar conclusion; and it is indeed im- possible for any one to read attentively the descriptions given by Henderson, Cor- mack, Warden, Halliday Douglas, Wil- liam Robertson, Paterson, Mackenzie, Reid, and more recently, but more par- ticularly. Sir W. Jenner, in which the whole proof is admirably handled and ex- posed — without arriving at the conclusion that Relapsing Fever is a form of con- tinued fever, wholly different from typhus fever, with which it had formerly been confounded. These observers — and all who have had the opportunity of carefully studying the two fevers, must admit the accuracy of their statements — pointed out that the one fever under no circumstances gave rise by communication to the other, and that an attack of typhus never con- ferred immunity from Relapsing Fever, any more than the latter afforded protec- tion from typhus. It cannot be consider- ed as offering any serious objection to the view which has now been expressed, that, as in the experience of Dr. Henry Ken- nedy of Dublin, in 1847-48, cases of Re- lapsing Fever and typhus have been occa- sionally met with among the members of the same family, and in individuals occu- pying at the time of the occurrence the same apartment. Dr. Murchison, indeed, alludes to such, as an occasional expe- rience in the London Fever Hospital, since the well-known observations of Sir W. Jenner were made. The circum- stance of the existing epidemic being composed of both forms of fever, and the further circumstance that both fevers are of an infectious nature, satisfactorily ex- plain these coincidences. And, upon re- ' On some of the Characters which distin- guish the Fever at present epidemic from Ty- phus Fever, by W. Henderson, M.D. Edin- burgh Medical and Surgical Journal, 1844. SYMPTOMATOLOGY. 277 flection, we feel constrained to acknow- ledge that were the one form of fever capable of producing the other, or, in the view of the spontaneous origin of fever, were typhus capable of being originated in the same way, or under precisely the same circumstances as Relapsing Fever ; then the association of the two fevers in the one family, and in the one room among the poor, would have been of infi- nitely more frequent occurrence than it has ever been proved to be. Symptomatology. — The suddenness of its invasion is characteristic of Kclaps- ing Fever. The patient is seized witli coldness and rigors, accompanied by headache, pain in the back, and loss of strength. The muscular feebleness and general prostration, however, are not at the first great ; for, as Dr. Cormack has observed, "manj'' walk long distances from the country to the hospital, espe- cially during the first daj'S of the disease; and a still greater number of the destitute town patients lounge about tlie streets after the seizure, and come in to us on their legs. '" The feverishness gradually increases, while the muscular and articu- lar pains and headache become more se- vere. By the third day, there is visually some amount of epigastric uneasiness, and not unfrequently vomiting. No general abdominal tenderness, however, presents itself, and diarrhosa is of rare occurrence. A perspiration, marked in character, and general over the body, occurs sometimes very early in tlie disease, on the second or third day, bringing with it little or no relief to the headache and other symp- toms. It is from this circumstance, but particularly from the still better marked though more rarely-occurring alternation of rigors and sweating in the earlier daj'S of the illness, that the resemblance to an intermittent fever of irregular character has been remarked by various physicians. On the third or fourth day the fever is at its height, and the case is for the most part characterized as follows : By the greatly augmented temperature of the surface (noted at 102'= by Halliday Doug- las; as high, and this is very high, as 107° by Wardell); a very quick putse (this it was which first struck Dr. Henderson as remarkable, unlike what he had witnessed in typhus), very rarely below 100, often 120 (125 on the fifth day, being the ave- rage frequency in thirty-eight cases noted by Henderson) ; it has, however, been noted at 140, and even 160. It was soon determined that, unlike what holds true of typhus, this rapidity of the pulse did not indicate the existence of danger. [In Philadelphia, in 1870, the tempera- ture was found to rise generally to 104^ or ' Loo. cit., p. 3. 10.50 on the second day, and to reach its maximum on the day before the critical defervescence. On the occurrence of the relapse, about the fourteenth day, it again rose to 104°, lOo'-', or even higher; declin- ing again with convalescence.— IL] With these, the true symptoms of py- rexia, are at the same time associated very slight disturbance about the head, headache frequently, rarely delirium, he- patic and splenic tenderness, with vomit- ing, great restlessness, thirst, and a white condition of the tongue. In a considera- ble proportion of the cases a peculiar yel- lowness of the skin becomes noticeable, best marked in the face, styled by Cor- mack "facial bronzing," and to this a distinct jaundice, with" urgent vomiting, sometimes succeeds. To these symptoms there occurs, usually on the fifth or sev- enth day, an abrupt cessation. Nothing can be more remarkable than the sudden change — usually ushered in by a profuse perspiration, less frequently by an epis- taxis, or other hemorrhage, or by diar- rhoia — effected in the condition of the patient. The frequent pulse and hot skin have in a few hours vanished, there is a normal appearance presented by the tongue, and, as Cormack has described it, "one day we hear the patient moan- ing and groaning in pain, and on the next he is at ease and cheerful, his only com- plaint being of hunger and weakness." The condition of apyrexia established, the patient continues to improve ; he gains strength, often rapidly, and convalescence appears to be altogether satisfactorjr, ex- cept that the pulse sometimes continues remarkably slow. On or about the four- teenth day from the commencement of the original attack the relapse takes place: there occurs a second paroxysm of fever in all points similar to the first ; it may, however, be more severe, or on the con- trary less severe in its symptoms. The duration of the relapse is usually three days ; it may extend to five days, or even longer, and, when usually mild, it may terminate before the third. A second re- lapse, usually occurring about tlie twenty- first day, is far from uncommon. "Not less than five of these accessions or ' re- lapses' have been known to occur."' To some of the more remarkable phe- nomena now briefly alluded to, and to a few other features in the symptomatology, it is proper to direct attention a little fur- ther in detail. Relapsing Fever, properly speaking, is undistinguished by cutaneous eruption. The most careful observers have failed to notice in it the measly rash so characteristic of tjqjhus, no one has described the rose-colored spots {taches roses lenticulaires of Louis) now regarded ' British and Foreign Mcdico-Chirurgical Review, vol. viil. p. 8. 278 RELAPSING FEVEK. as equally characteristic of enteric or ty- phoid fever. The " measly-lookino- efflo- rescence," noted by Welsh in 1819, as occasionally present, may fairly be con- sidered to have occurred alone in the cases of true typhus which constituted a portion of the epidemic he observed. Petechise, hemorrhagic spots, and vibices have all been described as of occasional occurrence, while Dr. Ormerod found a miliary erup- tion (sudamina) so common in the Ke- lapsing Fever of 1847, that in his descrip- tion he gave to the disease the name of ' ' Miliary Fever. ' ' ' Dr. Halliday Douglas found sudamina very rarely in the fever of 1843-44, and the writer can answer for their presence in that of 1847 being like- wise quite exceptional. But another cu- taneous appearance, although variable, is of decided importance — although it is pro- bable that its gravity as a symptom has been unduly estimated by some physicians — namely, a yellowness, or javmdiced hue. "Welsh also noticed this: "a yellowish, dusky state of the skin was not unfre- quently observed." In connection with it lie likewise noticed "that the patient's urine distinctly tinged linen cloth or simi- lar substances immersed in it. "^ In tlie epidemics of 1843 and 1847 jaundice was observed, in the former specially by Cor- niack, "\^^ardell, and Douglass ; in the latter by Jenner, in London ; also, but with greater rarity than during the pre- vious epidemic, in Edinburgh, by William Robertson and B. Paterson. Nausea and vomiting have been de- scribed as common sj'mptoms in Relapsing Fever. The matters vomited have usu- ally been found to consist of the ingesta, frequently tinged with bile. Occasionally an appearance resembling the black vomit of yellow fever was noted, as by Cormack and AVardell, who regarded it as a pecu- liarly unfavorable sign, and by Dr. Arnott, of Dundee, who, looking upon black vomit as quite common in its occurrence, did not find it by any means a fatal indication. Peculiarities, as regards the appearance presented by the tongue, have been noted. It is usually from the commencement coated with a white or yellowish fur, ■4\hile a small triangular space towards the point of the tongue, as well as its edges, is clean, and often redder than natural. In mild cases the tongue con- tinues moist throughout the attack ; but in the more severe, dryness, blackness, and incrustation with sordes, occur. The appetite suffers in Relapsing Fever for the most part, as in other febrile disorders, ' Clinical Observations on the Pathology and Treatment of Continued Fever, from Cases occurring in the Medical Practice of St. Bartholomew's Hospital, bv Edward Latham Ormerod, M.B. London, 1848. P. 216. 2 Loc. cit. p. 21. but many obsen^ers have stated that an unusual and sometimes altogether inordi- nate desire for food has distinguished par- ticular cases. The urine in Relapsing Fever was specially examined by Dr. Henderson and Mr. (shortly afterwards Dr.) Michael Taylor. Occasionally the quantity is reduced, or there may even be suppression of the secretion, while the amount of urea is greatly diminished ; in connection with these changes the occur- rence of serious cerebral symptoms is to be apprehended. Here our knowledge of a very important topic ceases. Dr. Parkes has truly observed tiiat scarcely anything definite is known on the subject.' Dr. Henderson had his atten tion early directed to the condition of the kidneys, and satis- fied himself that the occurrence of con- vulsions, coma, and less serious symp- toms of a nervous nature, were to be as- cribed to interference with the proper function of these organs. In connection with a diminished amount of urea in the urine. Dr. Douglass Maclagan deter- mined, by investigations undertaken at Dr. Henderson's request, the existence of an increased amount of urea in the blood. There are certain complications and sequelas of Relapsing Fever. The inflam- matory aifections within the chest which are known to occur in the course of the other forms of continued fever — at times seriously influencing the mortality which these occasion — are met with also in Re- lapsing Fever, bronchitis, broncho-pneu- monia, pneumonia and pleurisy. Laryn- gitis, requiring tracheotomy, occurred in one case in the experience of Dr. Pater- son. The writer remembers that the pre- sence of a similar inflammation necessi- tating the same operation in at least one other case, was ascribed, at the time of its occurrence in 1848, to the patient hav- ing been peculiarly exposed to cold while under treatment in one of the temporary sheds erected for the accommodation of the fever patients admitted to the Royal Infirmary of Edinburgh. Hemorrhages of various kinds have been noted to occur, for the most part, about the period of crisis. Paralysis of a local nature — of the deltoid muscles, as observed by Cormack — and much more frequently severe mus- cular and articular pains, are among the number of thenervous complications which have been observed. Parotitis, which is familiar to us in typhus and enteiic fever, and other glandular enlargements and suppurations, were certainly of uncom- mon occurrence in the epidemics of Re- lapsing Fever witnessed in this country. In the recent Russian epidemic it would ' The Composition of the Urine in Health and Disease, and under the Action of Reme- dies, by Edmund A. Parkes, M.D. London, 1860. P. 260. SYMPTOMATOLOaY. 279 appear that these buboes are more fre- quent ; and Mr. Simon has no doubt cor- rectly inferred that "from tliis circum- stance tliere arose the rumor of plague.'" Diarrhoea, sometimes taking the place of perspiration, has been described by many observers as the critical evacuation in Ke- lapsing Fever ; with a greater degree of frequency it occurred during the relapse, or after recovery from the relapse. That diarrhoea raised the mortality consider- ably, is evidenced by the statements of various of the Scotch physicians. There are few more interesting circum- stances known in regard to Belapsing Fe- ver than the frequency with which preg- nant women abort or miscarry. By some this accident has indeed been described as invariable ; it is not so, but the excep- tions are infrequent. In relation to this peculiarity, Dr. Murchison has truly ob- served that, ou the supposition that Re- lapsing Fever is but a mild variety of typhus, it would be very remarkable that, in the former, abortion is almost invaria- ble, and the foetus dies ; whereas, in the latter, abortion is the exception, and when it occurs, the child, if near the full time, usually lives. ^ A sudden, wholly unlooked-for, and at times fatal, syncope has distinguished some cases of Relapsing Fever. Dr. Halliday Douglas mentions one such in which the patient was found dead about the period of the first crisis, and only half an hour after she had ex- pressed herself as feeling easy. An oc- currence of this kind, though fortunately not common, may well be considered im- portant in a prognostic point of view. Lastly, an interesting form of ophthalmia presenting two distinct stages, the amau- rotic and the inflammatory, has been met with and specially described by Dr. Mac- kenzie, of Glasgow, as post-febrile oph- thalmia. ' In that city so frequent was the eye affection in 1843, that Dr. Andrew Anderson speaks of multitudes of cases having been treated at one Eye Infirm- ary. ■" When the frequency of the occurrence, either of more than one relapse, or one or other of the complications or sequelas which have been attended to — others less ' See his Letter to the Lord President of the Couiicilj dated Whitehall, April 19, 1865. It may be right to mention here, that in the experience of the writer, parotitis, hitherto a very rarely observed phenomenon by him in fever, has during the last twelve months been seen frequently, botli in typhus and enteric fever. ^ See a confirmation of the last observation in an account published by Dr. Matthews Duncan, of a case which recently fell under the writer's notice. Edinburgh Medical Journal, September, 1863. ' See Mackenzie, in Medical Gazette, 1843. * Lectures on Fever, p. 135. frequent and of less severity it has been thought unnecessary to mention— is con- sidered, it will be understood that Relaps- ing Fever, though happily occasioning a mortality greatly inferior to typhus, is a fever determining— in not a few of the sufferers from it— long-continued bodily weakness ; while in a still larger number convalescence is greatly protracted. The account which has been given of the symptoms and course of Relapsing Fever is sufficient, we think, to establish its separate and distinct nature, and to allow its being readily distinguished from typhus, enteric fever, febricula, remittent, or yellow fever, diseases, with the ma- jority of which it has been at one time or other confounded. The relapse, which is the distinguishing feature of this pyrexia, is, properly speaking, unknown in any other form of fever; and Sir W. Jenner's careful observations, confirmed by the ex- perience of many competent authorities, have proved that Relapsing Fever — a contagious disease, as we have already seen — is capable only of giving rise to a similar disease ; it can engender no other form of fever, and no other form of fever can engender it. What there is in the morbid anatomy of Relapsing Fever, and in the mortality it occasions, to sustain and confirm this opinion, we shall now inquire. As to the former, unlike what holds true of pythogenic or enteric fever, there is then no constant or invariable morbid appearance to be detected. JSTev- erthelcss, there are a few thoroughly as- certained facts in regard to this subject, which, in the not unlikely event of another occurrence of Relapsing Fever, should form the groundwork for renewed and still more extended investigation. The spleen is almost always found altered ; enlargement and softening, nearly in some instances to the extent of diffluence, are the most frequent changes, but in- creased firmness in its structure, and fibrinous deposits in the splenic substance, have likewise been observed. Enlarge- ment and engorgement of the liver, with- out any structural change— even as has specially been stated by Cormack and others— in the best marked "yellow cases," have been generally found. The blood, when subjected to microscopic ex- amination, has revealed the existence of an increased number of white corpuscles, similar to what occurs in the now better understood conditions of leukfemia. [Dr. Hand, of Philadelphia, reported the observation of a granulated and cre- nated appearance of the red corpuscles. Obermeier, of Berhn, discovered minute moving filiform organisms, called spn'illa, in the blood in Relapsing Fever.— H.]_ The mortality occasioned by Relapsing Fever is usually not great, being far in- ferior to what is commonly observed in 280 RELAPSING FEVER. either typhus or enteric fever. In the recent Russian epidemic, Eelapsing Fever is, according to Mr. Simon, "causing more than its usual proportion of deaths;" but that usual proportion does not exceed 4'75 per cent., or one death in every twenty-one persons attacked. Dr. Mur- cliison, on placing together the results noted at the London Fever Hospital, with those detailed by various physicians dur- ing the Scotch and Irish epidemics, has tiven as the total 14,119 cases, with 072 eaths — yielding the rate which has just been quoted. Age and habits influence the mortality in a manner closely resem- bling that which is witnessed in typhus and adynamic fevers generally. The mode of fatal termination is not always alike, the occurrence of a sudden and fatal syncope has already been noticed ; and, as originally indicated by Dr. Hen- derson, the impaired action of the kid- nej'S, leading to the imperfect elimination of urea, causes death by coma. An as- thenic termination, too, may occur in those instances of the disease in which one or other of the complications already adverted to, have manifested themselves. Therapeutics. — If, as we believe, there is an intimate connection between famine — by which is understood poverty and destitution — and Relapsing Fever, then it will readily be conceded that such attention to the wants of the poor, par- ticularly as regards due nourishment, as ameliorates their condition, will tend di- rectly to prevent the origin and to arrest the spread of this disease. It is likewise contagious, and therefore isolation of the sick should, as much as possible, be se- cured. Dr. Welsh, to whose account of the epidemic fever of 1817 and 1818 we have frequently had occasion to refer, conceived tliat blood-letting was the great remedy. Little reliance, however, can be placed upon the therapeutic observa- tions of Welsh, seeing that neither he nor other physicians of his time had distin- guished between typhus and the fever which showed the tendency to relapse. Further, it will, we think, appear to any attentive reader of Welsh's interesting work, that the changes in the condition of the patient, particularly the reduction of the pulse, the diminution of the fever heat, the occurrence of sweating — ascribed to the beneficial operation of the blood- letting—were in reality merely those changes which a subsequent better knowl- edge of the disease has led us to recognize as the essential phenomena of the fever itself, invariably occurring in its course, and uninfluenced by any treatment. All attempts to ward oflf the relapse, and for the most part attempts to postpone it, have signally failed. Those antiperiodic remedies in the use of which we place re- liance, and the virtues of which in the ordinary intermittent and remittent fevers have been incontestably established — such remedies as quinine, arsenic, bebeerine, salieine — have all been faithfully tried, and all have failed. Emetics of ipecacuanha, or of ipecacu- anha with antimony and mild laxatives, exhibited early in the disease, have ap- peared to be useful in the hands of various physicians in relieving portal congestion, and producing freedom from the often- times distressing pain, or at least uneasi- ness experienced in the region of liver, stomach, and spleen. Diuretic remedies — and particularly the salts of potash — were serviceable in relieving the tendency to head symptoms, by which, as we have already stated, some cases of Relapsing Fever 'were distinguished. Those considerations for the proper employment of food, and the administra- tion of stimulants, which should guide the physician in the treatment of the other forms of continued fever, are availa- ble likewise in the instances of Relapsing Fever. It seems unnecessary to enter on an analysis of these here ; and while the complications and sequelse of Relapsing Fever are, as we have seen, sufficiently remarkable, there is only one, the oph- thalmic affection, the treatment of which seems to require a brief description ; this may be given in the words of Dr. Ander- son : "We learned very important lessons from the treatment of this ophthalmia — lessons which tell against some of the the- ories which arc fashionable at the present day. The previous fever and the actual debility of the patients made us at first eschew anything like depletion ; but we found on the failure of other means that bleeding was the most effectual — the only effectual — mode of cutting short this dan- gerous ophthalmia. '" After the abstrac- tion of blood, calomel and opium were administered, until there appeared evi- dence of the system being slightly affected by the mercury. These remedies may be prudently combined with quinine and a generous diet, while it is almost unneces- sary to add that in the treatment of the purely and simply amaurotic affection, ■ altogether unconnected with hypersemia, which occurs as a sequela of Relapsing Fever, only tonic remedies and an invigo- rating diet are required. ' Anderson, op. olt. p. 135. YELLOW FEVER: HISTORY. YELLOW FEYEE. By John Denis Macdonald, M.D., F.R.S. DEriNiTiON. — Infectious continued fever, ushered in with languor, chilliness, and more or less severe lumbar pain and frontal headache ; countenance Hushed ; eyes at first humid, then suffused, and ultimately ferrety ; skin imparting a tin- gling heat to the touch, and as the second stage advances, gradually acquiring a lemon or greenish-yellow tinge ; mind usually disturbed with hallucinations, or more or less violent delirium ; restless watchfulness, or, possibly, drowsiness, even to extreme coma ; epigastric unea- siness ; spontaneous vomiting without effort, first of a clear glairy fluid, but sub- sequently with "coffee-ground" flocculi, or blood itself, often, towards the close, with irrepressible hiccough, and wild shrieking or melancholy wailing ; ten- dency fatal, but the disease generally con- fers an immunity from subsequent attacks. Synonyms. — Yellow Fever, Bulam Fever, Heemagastric Pestilence, Black Vomil;. Latin — Febris Flava, Synochus vel Typhus Icterodes, Synochus Atrabi- liosa. Spanish — Fiebre o Calentura Ama- rilla Vomitonegro 6 Prieto. French — Fievre on Typhus jaune, Fievre Matti- lote, Mai de Siani. Italian — Febbre Gialla. HiSTORY.^From the year 1647, when the first recorded outbreak of Yellow Fever in the West Indies' occurred, to the present time, this disease has been recurring at irregular intervals in the epidemic form, and gradually extending its range. It has, moreover, appeared, in many instances, to borrow new vigor by its importation from one place to another, and though it may be said to be perma- nently present in some localities, e. g. , the islands of St. Thomas and St. Domingo, there is no proof whatever of its spon- taneous development anywhere. Every epidemic seems to have some assignable source, and even where this is not very obvious, there are a priori reasons enough to trust that it would be discoverable, were investigation properly instituted. [The earliest recorded visitation of Yel- low Fever in the United States occurred at New York, in 1668. It appeared destruc- tively in that city also in 1702, 1743, 1795, ' Ligon's History of Barbadoes. 1798,1803,andl822. Philadelphia was first visited by it in 1695 ; also, in 1793, 1797- 98-99_, 1805 ; and, with less severity, sev- eral times in later years. Mobile was the seat of an epidemic of it in 1705 ; New Orleans, for the first time, in 1769. The years of the most serious epidemics in the last-named city have been, 1819, 1847, 1853, 1854, 1855, 1858, 1867, and 1878. The last epidemic extended to many local- ities on both sides of the Mississippi River. Several of the Atlantic cities of the United States have suffered severely from it in different years. — H.] The symptoms ot Yellow Fever mani- festly result from the more or less potent operation of some subtle organic poison upon the system through the medium of the blood ; and the very fatal tendencjr of the malady is probably linked with na- ture's efforts to eliminate the poison by the gastro-intestinal mucous membrane, when both liver and kidney have been rendered ineffective in bringing about this result. The fact may want confirmation, but it has always occurred to the writer, that the liver is especially active in per- sons perpetually exposed to the specific infection of the disease, without, how- ever, yielding to its influence ; as though the elimination of the poison had been effected, in their case, without developing the train of symptoms proper to the dis- ease. Whatever physical conditions— such as increase of temperature, moisture, and subsequent evaporation, and the like^ may be favorable to, or merely coincident with, the development of Yellow Fever on shore, when once communicated to a ship, and isolated by far removal from all local influences, its phenomena are very striking and suggestive. Under such cir- cumstances it Is difficult to witness the spread of the disease from one individual to another, and its virulence becoming more intensified by the unavoidable crowding of the sick, without recognizmg the important part which the emanations and excretions of the human body itself must take in the matter. It may be ob- iectcd that all the most potent of the ter- restrial or atmospheric conditions alluded to are fulfilled in the bilge effluvia ; but as these, per se, have never been known to originate the disease, we are driven to one or other of two positions, either that they 282 TELLOTV FEVER. have nothing to do -n-ith it, being simply coincident liko other things that might be named, or that they form "the nidus for its further development and spread subordi- nate to a specific cause. It must, how- ever, be apparent to a close observer, that the human element far outweighs all other suppositions, and, in this point of view, the refinement and subtlety of the poison may be more easily conceived. If Yellow Fever be referrible to the zymotic class, in support of which idea several cogent arguments might be adduced, its mode oforigin cannot be materially different ; and few nowadays would attempt to trace the whole of the specific virus of rubeola, scarlatina, or other true exanthemata, to any of the common decompositions of cesspools or the effluvia evolved in bad drainage, and such, otherwise, certainly unwholesome conditions. We are in want of proof of the spon- taneous development of Yellow Fever in- dependently of infected places or persons, while a knowledge of the precise nature of its specific cause is still a desideratum to medical science. But that it is en- demic in certain localities, though varying much as to its intensity, and the periods of its manifestation, cannot be doubted ; for under sinular circrimstances, i. e. of latitude, or climate, &c., certain other localities have never been visited by the disease. What has just been said in regard to Yellow Fever very strikingly points to analogous facts in the geographical dis- tribution of plants and animals, and the curious laws that regulate both their prop- agation and decline. But it may be con- sidered probable, however much the human system may modify tlieir composi- tion and manifestation, that the primary zymotic poisons owe their origin to the development of the humbler and more minute, and therefore more subtle, forms of animal and vegetable life ; such being always coincident with a corresponding amount of decomposition, and the evolu- tion of new or simply liberated com- pounds in a gaseous or diffusible form. The presence of offal and filth, or stag- nant water, with infused animal and veg- etable matter, may be regarded as afford- ing something more than predisposing conditions ; and such a state of things is often, though certainly not always, dis- coverable where Yellow Fever is rife, but more particularly in sultry weather, after heavy rains. The periodical occurrence of Yellow Fever, with intervals of immunity, has its parallel in a fact well known to the stu- dents of the diatomacese-and dermidiacese ^namely, that particular species, which are known to exist in a definite pond or pool one season, may be at another re- placed by forms never before detected in the same spot ; while, again, the original species, under fiivorable and often unac- countable circumstances, reappear after the lapse of a certain time.' It is not our intention to make even brief reference to all the views that have been put forward as to the nature of tlie specific cause of Yellow Fever; but it may be remarked that even if they were carefully detailed, our conclusions would probaljly be the same ; for upon this head very little more than what has been above stated is critically known. The infectious nature of Yellow Fever is now not only generally admitted, but it forms one of the most distinctive features of the disease, at once marking it off from those fevers which in nearly every other particular simulate it. It is scarcely necessary to multiply or repeat the "strong proofs" in this place, after the satisfactory evidence lately brought before the Epidemiological So- ciety of London, in the papers of Dr. Bry- son, and the important verbal support of the late lamented Dr. M'William. The tenets of the writer, derived from actual facts, are the following, acknowledging a genealogy to the widely-spread family of Yellow Fever. 1. That the first place or the first per- son, or both, must have become infected, somewhere or somehow. 2. That by veritable, but unknown, or rather untraced, links with this source, places, having become infected, may in- fect persons. .3. That persons infected may infect other persons and places previously pre- sumed to be healthy. 4. That the clothing of infected persons, or of healthy persons having communi- cated with infected places or persons, may impart infection to other places or persons. 5. That if places were movable, hke persons (which is literally true of ships), on being infected, they would impart the virus to other places in suflBciently close proximity. 6. Finally, from the investigation of the history of particular cases, it has been sat- isfactorily shown that the period of incu- bation, or latency, in this disease, i. e. from the imbibition of the poison to the first appearance of symptoms, ranges from one to fourteen or fifteen days. [Of the above account, that which is most evidently beyond controversy is the statement that Yellow Fever is " endemic in certain localities," while, "under simi- lar circumstances, of latitude, climate, &c., certain other localities have never been visited by the disease." This exist- ence of a "true Yellow Fever Zone'" is, 1 Med. Journal of H.M.S. Icarus for 1860, N. A. and W. I. Station. \} See Diagnosis, p. 286.] HISTORY. 283 indeed, the cardinal fact in the natural history of the disease. Its geographical "habitat" is as well marked as that of almost any plant, which is capable of transplantation, but difficult of permanent naturalization. Dr. R. La Eoche, in his exhaustive trea- tise on Yellow Fever,' summing up the results of all the history and literature of the subject, confirmed by personal obser- vation, asserts strongly the non-contagion, as well as the locally infectious character of this disease. Of ships, he says^ that " by them the disease, or its cause, may be, and has been, introduced into healthy places, and communicated to those who have gone on board, or approached suffi- ciently near to be placed under the influ- ence of the effluvia issiiing from them. But such an introduction differs materiallj'- in its consequences from that of a conta- gious poison." AVhile controversy is endless, from the nature of the case, between opposing in- terpretations of the same facts in regard to the extension of disease from place to place, it is important to bear in mind how often the most careful and elaborate in- vestigation, by competent inquirers, has resulted in the conclusion just cited. Thus, the London General' Board of Health, the Superior Council of Health at Paris, the Sanitary Commission of New Orleans, and other such bodies, have from time to time judicially pronounced in favor of the discrimination between contagion of persons and infection of places (including ships) in the causation of Yellow Fever. It is true that, in some of the same places, a similar official expression in a contrary sense has afterwards sometimes been ob- tained, by the urgency of a few, under a "wave" of alarm in regard to contagion and quarantine. But a survey of'the whole history of the disease leaves it still to be concluded, that, at the most, conta- gion is to be admitted as a merely possible supposition, extremely hard even for its advocates to trace with certainty in any definite instances ; while the geographical relations of the disease, and its promotion by local unsanitary conditions, are palpa- ble and overwhelmingly important. No more deliberate and competent con- sideration of this subject was ever given forth than that of the Third National Quarantine and Sanitary Convention, which assembled in New York in 1859. As the result of a full discussion, partici- pated in by nearly all those who by expe- rience and information were entitled to judge of the question as one of American sanitation, the following resolution was adopted, by a vote of 85 yeas to 6 nays :— "Resolved, that in the absence of any [' In two volumes, Philada., 1855.] \} Op. oitat., vol. 11. p. 545.] evidence establishing the conclusion that Yellow Fever has ever been conveyed by one person to another, it is the opinion of this Convention that the personal quaran- tine of cases of Yellow Fever may be safely abolished, provided that fomitts of every kind be rigidly restricted." The majority of this Convention at- tached little importance to the clause in regard to fimiites, except as a part of the general system of local sanitation, Avhicb has been shown to be as indispensable and efficacious in the prevention of Yellow Fe- ver as in that of any other disease what- ever.' The geography of Yellow Fever is cer- tainly remarkable. It is comprised within the borders of the Atlantic Ocean, and the waters (Gulf of Mexico, Western ISIediter- ranean, and the rivers emptying into these) communicating with it, in the zone between 42° north and 35° south lati- tudes. Especially are the West India Islands subject to it. Next after these, in regard to frequency and severity of visitation, have been New Orleans and some other cities of the Southern United States. Barely does it prevail many miles from the sea or from a considerable river. None of the far interior cities of either continent have ever been visited by it. Never, except as, in a very few instances, transiently conveyed by infected ships, has it been seen upon the coasts of the Pa- cific Ocean. The oriental tropical homes of cholera and plague have never known it. How verj' different is all this from the histoiy of an indefinitely portable, truly contagious disease ! It has been a prominent fact in repeated epidemics in different American cities, that the infection of Yellow Fever is, from time to time, localized in certain limited spaces, mostly measurable in fractions of a mile. Many times the removal of the inhabitants of an infected city, in large numbers, has brought them securit}' , while the scattering of those who thus migrated, some of them with the disease in their systems, has not extended it else- where. Thus, from Barcelona, in 1821, 80,000 of the inhabitants escaped by flight; while of those who remained in the city, one-seventh, 10,000, died.^ During the [' At the meeting of the American Public Health Association, at Richmond, Va., in 1878, resolutions were passed pointing in a different direction from the above. But it was evident that this meeting, called under the pressure of public alarm on account of the extended and destructive epidemic of that year in the Soutliwestern States, had not time nor material for doing justice to its subject. This was clearly indicated in a circular issued by the Executive Committee of the Associa- tion, shortly after its adjournment. — H.] [' Second Report on Quarantine, 1852.] 284 YELLOW FEVER. war between the United States and Mex- ico, in 184U-7, Dr. Bennett Dowler re- ported tliat many tliousand instances of sueli removal of individuals proved expe- rimentally its advantage to those who have left infected localities, and its safety to others amongst whom they have gone. Practically, we deduce from these facts the conclusion, that three things are un- questionably needful in the in-oi^kylaxis of Yellow Fever: 1. Complete and persist- ent local sanitation in all places within the "Yellow Fever Zone;" 2. Vigilant in- spection, at sea and river ports, of all ves- sels, so as to detain those found to be un- clean, at a distance from city wharves, until they have been thoroughly purified and disinfected ; 3. Removal of all inhab- itants from every spot ascertained to be infected, to some open and salubrious lo- cality. ' If but a small fraction of the large expenditure provided, by aid of the be- nevolence of the people of the Northern States, in the summer of 1878, for the care of the sick and dying in the stricken cities of the South, had been applied to their early removal, house by house, and ward by ward, as soon as local infection was ascertained, hundreds, perhaps thousands, of liA'cs might have been saved, and much commercial distress averted. Of course part of such a plan must he, the choice of healthy places for accommodation of those removed, and the conservation among them of good sanitary conditions. — H.] ALTITUDIiq^AL AND HORIZONTAL Ranges. — It may be very well to assign an altitudinal limit to the spread of Yel- low Fever — and, roughly speaking, this may be estimated at between 2000 and 3000 feet above the level of the sea — but the local conditions of every country seem to determine a range peculiar to itself. Thus, the disease has been known at Newcastle, Jamaica, at an elevation of 4000 feet ; while in the Valley of the Mis- sissippi its highest recorded range is about 600 feet (admitting the Fever of Gallipolis to be of the genuine type). Humboldt alludes to the Farm of Encero, in Mexico, at an elevation of 3243 feet, as the altitu- dinal limit of Black Vomit. At St. Do- mingo, the mountain encampments of the French in 1792 and of the English in 1796, enjoyed an immunity from the disease, while it was spread far and wide amongst the troops in the low country. Though the West Indian Islands, and the neighboring coasts of North and South America, may be looked upon as the focal area of Yellow Fever, yet taking the out- lying points at which its occurrence in [' What to Do Against Yellow Fever : by H. Hartshorne, M.D. Reports and Papers of American Public Health. Association, vol. i., 1873.] the epidemic form has been recorded, its geographical range must be regarded as very considerable indeed, i. e. between 97° west and 2° east longitude, and be- tween 48° north and 35° south latitude. At least for the space of a century and a half, up to the year 1850, the river Ama- zon, dividing the Brazils from Guiana, limited the extension of Yellow Fever south of the line ; and while the disease was raging at Rio and Bahia at the close of that epoch, the Montevideans flattered themselves that they were without the geographical limit of the pestilence, until it fell to their turn to sustain its visita- tion several years later, when the illusion was dispelled. Similar facts may be ad- duced with regard to the extension of the disease along the shores of the Pacific ; so that, however well we may be ac- quainted with its present range, making all due allowance for temperature, we caniiot tell what the future may bring foi'th. In this connection it may be men- tioned that a temperature of at least 72° is assumed to be essential to the develop- ment of Yellow Fever, though cases ex- ceptional to this rule also may now and then happen. SYMPTOMS.^With or without such pre- monitory symptoms as loss of appetite, costiveness, flatulence, sense of debihty, and the eyes humid and bright, the dis- ease frequently makes its invasion with chills ; but this will greatly depend upon the existing temperature or climate. Thus Jackson maintains that they seldom occur within the tropics, while they are quite usual in more temperate climates. The chills alternate with flushes of heat, and the latter gradually settle down into reg- ular fever, which is often observed to be- come more severe towards evening, with something approaching a remission in the morning. The amount of fever, moreover, bears relation to the severity of the chills preceding it. Frontal headache is also an early .symptom, with shooting pains through the orbits and temples ; but dis- tressing as these may be, they are usually trivial in comparison with the agony of the lumbar pains which frequently seize the patient at this period, and fell him to the ground in a writhing and convulsive state. In some severe cases, however, this symptom is nearly entirely absent. From the very commencement the pa- tient may be troubled with nausea and epigastric tenderness, or they may be de- veloped as the reactive stage advances. The pulse exhibits great diversity of character, being much accelerated, full, and strong, in keeping with the force of the paroxysm or even soft and weak where the febrile reaction is deficient in severe cases— the beats ranging between 90 and 120 in a minute. SYMPTOMS — DIAaNOSIS. 285 Also varying with tlie nature of the paroxysm, the skin may be liot and pun- gent, dry or perspiring, livid, flabby, and even cold. The tongue exhibits a creamy-v^rhite coat on the dorsum, with red tip and edges, and injected papillae, with or with- out soreness of the throat. As the second stage advances irritabil- ity of stomach is added to the nausea, and the epigastric pain and tenderness become more distressing. The patient craves for cold drinks, which are immedi- ately rejected, first with some retching and pain, but subsequently without effort The matters vomited usually have a sus- picious appearance : thus, they are some- times imbued with bile, lightly streaked with blood, or quite serous with small chocolate-colored flocculi, discovering the tendency to hemorrhagic oozing from the lining of the stomach. The urine is scanty, high-colored, and probably albuminous : the stools become gradually more and more deficient of bile; and the bowels are often obstinately con- stipated. The patient begins to be restless and vigilant, and disposed to leave his bed, go into another, or walk about naked if he be permitted. He exhibits an evident de- rangement of intellect, though he may answer questions coherently. In other instances, — with a suffused ferrety eye and a drunken expression of countenance, —wild hallucinations, similar in every re- spect to those of delirium tremens, afflict the victim's mind, and may deceive the practitioner most seriously in sporadic cases. Febrile reaction may continue for an indefinite period between a few hours and two or three days, and its duration is said to be in the inverse ratio of the violence of the attack. "Having run this course," says Dr. La Eoehe, "the fever subsides, never more, or very seldom, to return — the disease be- ing one of a single paroxysm — and is fol- lowed by a state of remission or meta- phosis." The nature of this remission is all important, as regards the fate of the patient. Should all the symptoms be alleviated, the pulse becoming less fre- quent, or even normal, the delirium sub- siding,^ and, above all, if there is no more u'ritability of stomach ; active diaphoresis, epistaxis, or a critical discharge of bile from the bowels, may place him on the highroad to recovery. Should the skin nave assumed its lemon-yellow tint, it will remain all through the convalescence, to- wards the close of which the writer has noticed a desquamation of the cuticle much resembling that of the ordinary ex- anthemata. If, on the other hand, the ferrety eye whitens, the cheek grows pale, and the lips are blanched, while the pulse is weak and compressible, and the delirium is per- sistent with irritable stomach, the appa- rent remission is delusive, and a fatal issue is pending. The patient refuses all medicine and food, lies down very much against his own inclination, cramps gather in the calves of his legs, and while they arc being rubbed by the attendants, his delirium becomes frantic, and is probably retrospective of former impressions. His utterance is supernaturally rapid, keeping pace with a panoramic sequence of idea in which the mind is absorbed, the pulse is imperceptible at the wrist, and just when physical exhaustion has merged into death a final automatic discharge of black vomit closes the tragedy. It is only at this period, in many cases, the lemon-chrome tint of the skin makes its appearance. When it happens in the course of the disease, i. e., third stage, it is observed to spread from the forehead downwards to the face, neck, and chest, and then it becomes general. In another class of cases, the pulse gradually moderates, but thirst increases, and epigastric heat and pain are persist- ent, with irrepressible vomiting and hic- cough, but the mind is calm and coherent to the last, though quite conscious of its tendency to wander. Indeed, the effort of the intellect to correct vagrant ideas, and give them a rational form, is often affectingly observable, more particularly in the case of educated persons. Contrasting remarkably with the class of cases just described, some persons ex- hibit a tendency to drowsiness at a very early period of the disease, and finally settle down into a placid state of coma, not unlike that of severe concussion of the brain, without pressure or organic lesion. This state of things, no doubt, results from urwmic poisoning in connection with the suppression of the urinary secre- tions. It is a fact, worthy of special note, that the heart's action may continue long after the pulse at the wrist has become imper- ceptible, and when all respiratory move- ments have ceased. Death may happen in the course or at the close of any of the three stages of the disease, namely: 1st, the accessionary; 2d, the reactive ; or ,3d, the remissional : and this will of course be in accordance with the type or variety assumed by the mal- ady. Further remarks on the symptomatolo- gy, rendering the ideas here given of it more complete, will be found in the sec- tion on the classification and varieties of the disease; as it is of importance to avoid unnecessary repetition. Diagnosis. — Though a very good gen- eral sketch of Yellow Fever may be given 286 YELLOW FEVER. by any one who has witnessed an epi- demic of the malady, it is not quite so easy to isolate the symptoms that may be fairly assumed to be pathognomonic. In- deed, the whole aspect of the disease is often so diversified, or distinguished by the absence of this or that symptom where the collateral evidence of its identity is indubitable, that it is difficult to say which feature is of most diagnostic im- portance. Add to this the actual occur- rence of the several symptoms of Yellow Fever in some part of the course of other febrile disorders which, after due consid- eration, have been declared to be essen- tially distinct, and the diflaculty will be still more apparent. Inasmuch as yellowness of the skin and eonjunctivse, not merely from the effusion of the hoematine of the blood itself, as in Yellow Pever, sometimes occurs in the paludal remittent fevers of various coun- tries, that character, singly, cannot be pathognomonic of Yellow Fever. Of black vomit also the same thing may be affirmed, so that two of the most impor- tant features of the malady are scarcely available for a satisfactory diagnosis. Much stress has been laid upon the very constant symptom of frontal headache, in connection with the watery and suffiised eye, the white, creamy, or cottony coat of the tongue, and its red tip and edges ; and in particular the early appearance of albumen in the urine ; but none of these characters, nor even all together, can be more definite than the following posi- tions : — 1st. Now that there can be no doubt of the infectious nature of the disease, it may thus at once be distinguished from those disorders with which it is likely to be confounded, for this property is sure to be developed in every epidemic of specific Yellow Fever. 2d. As Yellow Fever is one of a " sin- gle paroxysm," of longer or shorter dura- tion, and divisible into three stages, the disease is continuous in its type, or it runs a definite course without such remis- sion and exacerbation as are seen in the paludal fever. 3d. If Yellow Fever shall have passed through all its stages without destroying life, it in general confers immunity from a second attack.' The first appearance of Yellow Fever not infrequently presents no other symp- toms than those of an ordinary ephemeral fever; for which the writer very naturally mistook the first case of Yellow Fever that ever fell under his observation. The ■ In H.M.S. Icarus, in 1860, only five per- sons out of about 130 escaped an attack of Yellow Fever ; yet not a single case of re- lapse occurred during the whole course of the epidemic. disease, however, declared itself on the second day, and there was no further doubt as to its real nature. There is a still greater possibility of confounding malarial remittents with specific Yellow Fever, and even good observers have re- garded them as identical. In this con- nection, however, we may appropriately quote Dr. Maclean's bold diagnostics, as given by Dr. Aitken.' "I am now my- self a firm convert to the doctrine that Yellow Fever is specially distinct from remittent. To this opinion I have come with a full knowledge of the fact that some cases of remittent fever in India closely resemble some of the forms of Yel- low Fever. But of this I am now certain, that the Yellow Fever of the true yellow fever zone is unknown in India, where true malarial fevers abound. There is in true Yellow Fever, for the most part, an absence of that periodicity which is an unfailing characteristic of true malarial fevers. Then there is the difference, so well insisted upon by Blair, in true mala- rial fevers. Men do not pass from re- covery to health, as is the case in such a marked degree in Yellow Fever, after which there is no, or very little, evidence of the existence of any cachexy. Mala- rial fevers exist and are destructive at a temperature at which Yellow Fever is at once destroyed. Albuminous urine is al- most invariable in Yellow Fever— only occasional in remittent. There is in Yel- low Fever an unexampled range of hem- orrhages; in remittent fever these hemor- rhages are often, indeed generally, absent. Quinine has a power over malarial fevers that is beyond the reach of doubt or cavil; the same is not true of Yellow Fever. jMen suffer from malarial fevers again and again ; second attacks of Yellow Fever are, to say the least, rare." [There is reason to believe that what the late Dr. S. Dickson (formerly of South Carolina) called a "blending of types" sometimes occurs, between Yellow Fever and remittent fever. This will account for the very few instances in which true black vomit is said to have been witnessed in connection with remittent. If it ever is seen in an vincomplicated case of mala- rial fever (" country fever"), it must be one of the rarest of symptoms. — H.] Pathology. — Temperature of the Body. — The writer has observed that when pa- tients previously treated in the open air on board ship were transferred to hospital, the body exhibited a marked increase of temperature, and the febrile symptoms became more active. Moreover, any part of the body exposed more than another soon evidenced a diminution of animal ' Science and Practice of Medicine, vol. i. pp. 479-80. PATHOLOGY. 287 heat. In the axilla the temperature may range from blood heat to 107° Falir. , the maximum observed by Dr. Blair. In the "sthenic form," in comparison with others, Dr. Lyons noticed a general ele- vation of temperature ranging between 3° and 70 Fahr. Coloration of the Skin. — On the first ac- cession of the disease the skin becomes pale and, perhaps, shrivelled to a greater or less extent; but, as the reactive stage sets in, it warms up and grows red, the face in particular appearing animated and flushed. The deptli of tliis redness, of course, bears relation to the intensity of the febrile symptoms, and it is looked upon as pathognomonic from its very con- stant occurrence, whenever reaction is de- veloped at all ; but should the latter be defective, the ' countenance may be pale, livid, or sallow. The so-called jaundicing of the conjunc- tivae and skin is by no means a constant symptom, but may be more or less charac- teristic of particular epidemics or of dif- ferent stages of the same epidemic. It is highly probable that the greenish- yellow hue is often due to the presence of bile. But, as I believe was first suggested by Warren,' and subsequently by Sir G. ' "This yellowishness, I am persuaded, chiefly arises from a more complete colliqua- tion or dissolution of the red globules of the blood into a yellowish serum, which will natu- rally soon give that tincture to the whole skin. The same is also observable on human bodies soon after bites of some poisonous ser- pents, or other venomous animals ; and, in such cases, it cannot with any reason be sup- posed to proceed from a suffusion of bile, but rather from a colliquation, and perhaps a gangrenous diathesis of the sanguineous mass, occasioned by the force of the delete- rious venom that had been infused into it. What is observed every day in all common bruises of the flesh may serve somewhat fur- ther to elucidate the matter : for here, when the texture of the extravasated blood begins to loosen and dissolve into a liquid serous consistence, a very visible yellowness appears in and about the part ; but tliis soon goes off again, when the matter is fully absorbed back into the vessels, where it commits no hurt, but is readily overcome by the force of nature, as the quantity of such dissolved blood is small, and at the same time very innocuous. I do not, however, deny but that, through a great propensity and straining to vomit, some quantity of the bile may be thrown into the blood ; but then I must observe, that the yel- lowness of this distemper I am speaking of very frequently shows itself when there has been no vomiting or retching at all, or scarce any sensible sickness of the stomach ; for the truth of which I can appeal to many." — Trea- Blane and others, the lemon-yellow and orange tints are unquestionably owing to the solution and eflusion of the coloring matter of the blood. M. Guyon regarded it as nothing more than the tinge of con- tusion. They should not be confounded with the nmch darker and more greenish hue of Yellow lieniittent Fever, "depend- ing altogether upon jaundice, and there- fore of a very difterent nature. Though yellowness of tlie skin may set in at any time from the first to the fif- teenth day, or even exhibit itself after death, yet from Dr. Blair's observations, it occurs most frequently on the fourth and fifth days of the disease. It is im- portant to note, however, that it niiikes its appearance coincidently with the black vomit in the generality of eases. The Tongue. — It is only when the febrile reaction is taking place, or even some time after this Iras begun, that the tongue in general assumes its characteristic white coating, with red tip and edges. Pre- viously to this it may be quite normal in appearance, only perhaps bearing the im- pressions of the teetli. Indeed, instances occur in which it remains witliout marked change, even up to the close of the mal- ady, eitlier in recovery or death. Tiie characters of the tongue, therefore, can- not be always said to go hand in hand with the increased heat of skin and accel- eration of pulse. After having first become coated with a white creamy substance this condenses into a thick cottony fur, and the marginal papillse become enlarged. Tlie coating becomes thicker towards the base of the tongue, and more discolored ; moreover, one, two, or more j'ellowish, brown, or black longitudinal bands run down its middle. When hemorrhage arises from the parts about the mouth, the epithelium of the tongue and fauces is soon stripped off, leaving the surface glazed with half- dried blood and sordes. Under such circumstances, the tongue is more pointed and smaller than usual, of a mahogany-red color, and more or less fissured. As might be expected, the de- nuded throat is sore and requires special treatment. The accompanying table, as quoted by Dr. La Eoche, from the records of Eoper Hospital, Charleston, during the sickly season of 1854, gives a good idea of the difference of character presented by the tongue in the three stages of Yellow Fever. tise on the Malignant Fever of Barbadoes, p. 11, as quoted by Dr. La Koche. 288 YELLOW FEVER. Condition of the tongue. 1st stage. 2d stage. Sd stage. Total Swollen 4 29 31 64 Dry . . . 52 23 14 89 Bloody . — 3 31 34 Whitish 44 33 18 95 Brownish 94 53 39 186 Moist . . 109 109 110 328 Red . . . 43 26 33 102 Velvety and white 23 2 3 28 Black . 1 1 19 21 Natural 26 10 7 43 Glazed . 4 2 6 Cracked — 3 — 3 Total number of observations The Pulse. — If the tongue has been ob- served to be variable and inconstant in its character, the same may be said of the pulse, and trusting to it alone a very in- correct prognosis may be formed. Thus, it has been known to preserve an appa- rently normal state, even coincidently with the most portentous symptoms ; and it has been previously noticed that the pulsation of the heart itself may continue some time after all respiratory movements have ceased. It is easy to imagine the evil results that might follow active deple- tory measures in the reactive stage, when the force of the pulse usually gives so false an idea of the stamina of the system (for, naturally, without such means, the pulse diminishes in force and frequency as the third stage sets in) ; but their em- ployment in accordance with primA facie indications may render the ebb fatally low. The pulse in Yellow Fever is usually full ; but it is assumed to be less tense and hard than it may be in other fevers at a corresponding stage, and from a frequency of 100-110 it will rapidly fall to the healthy standard, or even below it, when the period of excitement closes. The Blood. — Accurate observations on the physical characters and chemical pro- perties of the blood in Yellow Fever are much wanting to improve our knowledge of the pathology of the disease. The following facts have been observed from time to time by various authorities : — 1. Blood of a bright scarlet color has sometimes been drawn at the very onset of the malady. 2. It gradually acquires a darker hue as the disease advances. .3. As observed on both sides of the heart, arterial and venous blood exhibit no appreciable difference. 4. It may present the appearance of being composed of two differently colored fluids. 5. It may assume a brighter color as it flows from the arm, or on exposure to the air. 6. It may be of the consistence of mo- lasses, or a thin fluid from the commence- ment, though this is more commonly . 999 observed in the third stage, or only after death. 7. In many instances the blood remains without coagulation, or is very slow in the process. 8. The crassamentum appears as if it were undergoing solution at the base. 9. The serum varies in color from a whitish appearance, through yellow and orange, to a red, which has been compared to the tint of water in which meat had been washed. 10. The amount of serum with respect to the clot is smaller than in other cases, and at the commencement than at tlie close of the malady. 11. In all cases in which yellowness of the skin presents itself, the serum is also found to be yellow from solution of the coloring matters, and the blood globules, broken up from their nummular arrange- ment, are precipitated to the bottom. 12. The morbid discolorations of the blood, of even healthy persons residing within the range of infection, shows the agreement of Yellow Fever in this parti- cular with what has been observed in the case of other zymotic diseases. 13. Dr. Blair has shown that the dark grumous character of the blood in hemor- rhages supports no necessary assumption that the blood within the vessels is of the same nature. 14. Persons who have had much to do with bleeding in Yellow Fever affirm that the odor of the blood, like that of the skin,' is quite characteristic of the disease, dif- fering appreciably from the odor emitted by the blood in other fevers. 15. Dr. Davy has demonstrated the acidity of the blood in Yellow Fever, while alkalinity of that fluid is known to exist in other zymotic diseases. 16. Chassaniol has detected a larger amount of urea in the blood, more parti- cularly in that of the third stage, when the urinary secretion has been more or less suppressed. But Professor Sogers, ' See Barruel's remarkable experiments, in which even sex has been determined by the odor of the blood, so closely resembling that of the cutaneous secretions. PATHOLOGY. 289 who proved an excess of salts, contrary to the views of Stevens, was unable to obtain urea in any of the stages. His specimens, however, were believed to have been in a semi-decomposed state. Chassaniol, with great reason, refers the more important symptoms of the adynamic stage to the presence of urea in the circulation. 17. As in other diseases arising from a specific poison, the proportion of fibrine in the blood is much below the normal stan- dard in Yellow Fever ; and it is probable that whenever buffing and cupping of the blood occurs in this disease the condition Is due to the co-existence of some infiam- matory complication. 18. The destruction of the cell wall of the blood corpuscles, said to have been observed by M. de Bienperthuy, is, in the writer's opinion, a doubtful appearance, and certainly not borne out by the re- searches of Professor Leidy and Dr. Davy. Tendency to Hemorrhage. — As a hemor- rhagic tendency is often developed, more particularly in the third stage of Yellow Fever, it may be well to notice some of its leading features in this place. Active congestion usually precedes the extravasation of blood in the parts affected, and discharges of this kind have happened from all the outlets of the body without exception. But the special seat of the hemorrhage, and the amount of it, will vary with the type or perhaps with the period or locality, of the epidemic. Hemorrhagic oozing from the skin, without abrasion, is known at Martinique under the appellation of " sueur de sang. " Epistaxis, however, is much more com- mon, and usually happens in the third stage, though it has been known at the close of the first. Blood may exude from the inner can- thus of the eyes, and from the auditory passages, but these hemorrhages are of rare occurrence. Bleeding from the cavity of the mouth, tongue, gums, and lips is usual in every epidemic ; and though the blood may be at first well-colored, when it mixes up with the secretions of the mouth its character becomes altered, and it assumes a dirty madder-brown hue, coating tongue and teeth. The menstrual discharge, when not pro- fuse at this period, appears to exert a salutary influence on the disease ; but more active coincident hemorrhage, as in parturition or abortion, is eminently peril- ous. HEematemesis scarcely ever happens Without the passage of blood by stool, which is often critical in its nature. Ecchymotic abscesses occurring in the neck produce distressing symptoms from their pressure on important parts ; and if it be found necessary to relieve them, the Writer would recommend a valvular open- ing. As the patients advance towards VOL. I.— 19 recovery, the bloody, ichorous discharge will gradually assume a more purulent character, until finally laudable pus is formed, and the cure goes on in the usual way. White and Black Foim't.— Up to the commencement of the second stage of the disease, namely, on the second, third, fourth, or fifth day, the ejections from the stomach have been observed to be alka- line ; subsequently to which they gradu- ally give an acid reaction, and the dis- charge of a limpid, ropy, more or less transparent or opalescent, fluid, known as "white vomit, " precedes the black, and passes insensibly into it. Dr. Davy was of opinion, reasoning from analogy, that the white, or precur- sory, vomit would be found to be of a se- rous nature, and contain albumen ; but if it "remains clear on the application of heat and nitric acid," as stated by Dr. Aitken, the presence of albumen is so far negatived. As conciseness of matter must be our object in the present article, without en- tering minutely into the merits of the prolix reasoning of pathologists in favor of the bilious or of the sanguineous theory of black vomit, the following summary may be given as a fair conclusion from the facts adduced. "When hemorrhagic oozing begins to take place from the congested lining mem- brane of the stomach, the blood a6 initio intermixes with the existing and conco- mitant acescent secretions of the organ. The blood globules aggregated in masses lose their colored contents by exosmosis, while they become distended with a thin- ner fluid, and blend together with a com- mon connecting and finely granular sub- stance, composed of coagulated albumen and the liberated hasmato-globulin. Dark madder-brown flocculi thus result, float- ing in a more or less homogeneously-tinted or colorless liquid, and this is probably the simplest definition of black vomit. Free hydrochloric acid is the grand source of the acidity, tested with litmus and brown turmeric papers. Nitrate of silver throws down a white precipitate, which is redissolved by am- monia, though not by nitric acid. Liquor potassse being added to black vomit, in larger quantity than that re- quired to neutralize its acidity, the floccu- lent sediment becomes dissolved, with the disengagement of ammonia. It effervesces with alkahne carbonates, and Dr. Blair neutralized gxij with sj of carbonate of potash. At the request of Dr. La Eoche, Pro- fessor Kogers examined several specimens of black vomit, with a specific gravity ranging between 1-003 and 1-016, with the following results : — 290 YELLOW FEVER. Albumen Sulphuric acid in a state of combination Chlorine Alkaline bases Eartliy phosphates Iron Hydrochloric acid in a free state. In his communication to Dr. La Roche, he says : " These substances, although not the sole ingredients of the blood, are yet, all of them, with the exception of free hydrochloric acid, constituents of that liquid — a fact which, taken in connection with other characters, and especially the microscopic appearance of the liquids, gives strong evidence that they contain much altered blood ; indeed, the presence of several of the substances enumerated, as albumen, iron, and sulphuric acid, seems not to admit of any other explana- tion, since it could scarcely be possible that in that stage of the disease they were tlie results of any food remaining in the stomach." On submitting black vomit to micro- scopic examination all the changes above noticed with regard to the blood may be distinctly traced out, but no importance can be attached to the presence of toruliB or other humble vegetable organisms, which are by no means constant. The mention of fatty globules, epithelium (ex- cept perhaps that of the tubular glands), starch corpuscles, chicken muscle, and other matters introduced from without, only add scientific jargon to the plain facts of the case, and tend to becloud them. jMr. "WTiarton Jones states, that in the contents of the hepatic ducts of man and the sheep, extracted by means of a for- ceps and without injuring the organ, he- patic cells may be detected. This fact is a difficult problem for the microscopic anatomist to solve, but it sinks into insig- nificance when he is told that Dr. Blair has not only found the glandular cells, but what he conceived to be " the radical secreting ducts of the liver," in black vomit. The Urine. — The urinary secretion is generally diminished in quantity from the onset of the malady, and in many in- stances becomes almost or altogether sup- pressed, when the symptoms of urismic poisoning may be developed, br. Blair, who was an excellent observer, affirms that it is always acid in the first stage of the disease, and gives an alkaUne reac- tion during convalescence, or when bile is present in large quantity. Albumen makes its appearance gen- erally on the second or third day, and it may be detected in all severe cases by its appropriate tests. The color of the urine, in passing from its natural standard, changes to a bright yellow, a dirty orange, a gi-eenish brown, and olivaceous black, or to a more or less positive red, from the presence of blood.' The ordinary post-mortem appearance of the kidney, to say nothing of its minute anatomy, precludes the idea of the physi- cal detachment of its capillary vessels, or even the Malpighian tufts, and tlieir escape through the tubular system, so as to be commonly witnessed in the urine, as stated by Dr. Blair. Dr. Aitken observes that this admits of doubt, and that it is not borne out by Blair's own specimens preserved in the cabinet of microscopic l^reparations of the Army Medical School at i^etley. Tube casts, fatty cells, free fat, and blood disks, full and emptied of their contents, with such appearances as often characterize the urine in common jaundice, were the most invariable objects observed by the writer. There was per- haps a large amount of torulce and allied forms ; but, as in the case of the black vomit, notice of them is of little import- ance. Morbid Anatomy. — Mxtemal Appear- ances. — Should the individual die soon after the invasion of the complaint, the bulk of the body may be a little increased on account of a slight puffiness of the skin ; but, drained by hemorrhages and with no repair of the vital fluid, emacia- tion must happen in more protracted cases. The eye loses the suffused redness it previously exhibited, and the yellowness of the skin becomes more intense; indeed, it sometimes happens that the skin, which could scarcely be called yellow before, ac- quires that hue after death, and presents ' " On chemical analysis," writes Dr. La Roclie, "nrine taken from the "bladder after death, has been found greatly deficient of urea. In one case 200 grammes (51 drachms) of the fluid contained but one gramme and i'j°5 (about 16 grains) of urea, no uric acid, and 0'45 per cent, of albumen. In another case, 15 grammes (^ oz.) of the fluid ob- tained in the same way, gave 0-08 of urea, 2-50 of albumen, and no uric acid. In sev- eral other experiments, conducted in the same way, the results were similar. Finally, in one case the urine was examined in the flrst stage of the disease, and a short time after the death of the patient. In the first the fluid was found to contain, in 100 parts : — Water ...... Urea ....... Albumen ...... Uric acid ...... Earthy phosphates, sulphates, alka- line phosphates, and chlorates 80-00 "After death, 20 grammes gave more traces of urea, 0-50 of albumen, and no uric acid." 76-08 2-64 0-40 0-08 0-80 MOEBID ANATOMY. 291 a remarkable contrast with the rich pur- ple blotches and marblings in the more depending parts of the body. The extremities of the fingers and toes and the tips of the ears are also dai'keued with stagnant blood. The tissues in general appear to become abnormally friable, even though examined very soon after death: this is particularly the case with the muscular system, in- cluding the heart itself. The Uesh is also of a dingy color, watery, and sodden. It is, however, much paler and softer in those who have suffered much wasting. The connective tissue, moreover, is in general loose and sanguinolent — a condi- tion also observable in malarious Yellow Fever, which is admitted to be a distinct type of disease. The areolar and adipose tissues often exhibit a yellowness similar to those of the skin. Nervaus Sijstem. — The brain has been very closely examined in numerous cases, with nearly the same result, namely, that no pathological condition in the slightest degree noteworthy has been detected, even including those cases in which cere- bral symptoms, such as active delirium or profound coma, existed before death, (aillkrest.) The spinal marrow, on the contrary, usually exhibits a congested state of the vessels, more especially in the lumbar re- gion, where also the arachnoid membrane has been supposed to be in a state of in- flammation. Effasion of blood has been found in the canal, but we cannot be certain of all that has been said about the existence of actual inflammation. Tlie ganglionic system has also been examined, and with apparently still more defluite results. Thus, the semi-lunar ganglia, solar, caj- liac, hepatic, and neighboring plexuses, as well as the connecting tissue investing them, have been stated, on the authority of Dr. Cartwright and others, to be uni- formly in a condition indicative of inflam- mation. Nevertheless, excellent observers are not wanting who have never been able to discover any decidedly abnormal state of this system. Bespiratort/ Organs. — The lungs have been carefully scrutinized in epidemics occurring in difierent countries within the range of Yellow Fever, and the only important particular, not due to other complications, appeared to be small san- guinolent effusions into the connective tissue of the organs themselves, and that immediately beneath the pleurae. Circulatory System.— UsuaMj no very abnormal change is observable in the heart, if we except a dusky and flabby appearance which it often presents in common with the muscular system gen- erally. Professor Eiddell and others have laid much stress upon the pretty constant molecular degeneration occurring in the muscular fibres of the heart, with a more or less complete obliteration of their trans- verse striie ; but it is very probable that this condition, which is perhaps more usual than physicians in general imagine, would be detected in the same subjects had they died of any other malady. In the pericardium, effusions take place, with or without marks of inflammation, and the fluid may be simply serous, puru- lent or sanguineous ; and in one instance thus described by Dr. Bache, the pericar- dium contained four ounces of a very tur- bid greeuish-brown fluid, resembling black vomit. On pouring this into a bottle and allowing it to stand a short time separated into two portions: that at the bottom was of a white or pale yellow color, while the rest remained without change. An ex- amination by the microscope proved the brownish fluid to be composed of altered blood corpuscles, with less of the granular amorphous matter than is usually found in genuine black vomit. The whitish fluid was pus. The heart itself was stained of a dark color at its base, and the peri- cardium was minutely injected in points. (La Koche.) Transparent amber-looking clots have been frequently detected in the cavities of the heart, particularly on the right side. In fifty-four post-mortems made by Dr. Pennell, at Kio Janeiro, clots of the same kind were present. The endocardium commonly presents uo signs of Inflammation. The Stomach.— Aa might be expected, morbid appearances are more constant in the stomach than in any other organ, so intimately associated as it is with the most serious symptoms of the disease. The efl'usion of the coloring matter of the blood into the subserous connective tissue may give it a yellowish appearance, but, more unusually, no abnormal change pre- sents itself externally. A certain amount of the matter of black vomit is generally found in the cavity of the stomach, in some stages of conversion, from actual blood to a dark grumous fluid, like that ejected by the patient while yet alive. It would seem as though the mucous membrane of the stomach were called upon to compensate for the defective secreting and eliminating power of the kidneys ; and in those cases where little or no black vomit was found in the stomach after death, the lining membrane presented a thickened appear- ance with a muco-sanguineous coating. Sometimes the interior of the stomach presents little or no trace of congestion or inflammation where the mucous mem- brane has been cautiously washed ; while at others the little orifices of the tubular glands are seen to be filled up with a dark brown matter that may be dislodged with 292 YELLOW FEVER. the point of a needle. This appearance has been ignorantly spoken of as the open orifices of the hypothetical vessels, known to older anatomists as the "exhalents," in the act of ehmination. There appears to be no relation whatever between the amount of congestion observed in the mu- cous coat and the quantity of matter thrown olf from it into the cavity of the stomach. Thus the hemorrhagic oozing may have emptied the capillaries, in some instances, while they still remained con- gested by the "vis a tergo" filling up the loss in others. The mucous membrane often becomes mammillated, thickened, the longitudi- nal folds enlarged, and it is more easily stripped off than usual ; but veritable proofs of inflammation, though decidedly present in some cases, are far from being universal in this disease. The tints of congestion, ranging from rose red to claret purple, and dingy gray passing into shades of green and greenish yellow, impart an iridescent appearance to the mucous membrane. The Intestines present much the same external appearance as the stomach, but the glandular organs, Peyer's patches in particular, are not so uniformly in a mor- bid state as they are in other fevers. In- deed, the duodenum and upper part of jejunum are often more seriously affected than the ileum. The Liver is said to become soft and friable in those who die within forty-eight hours, and a serous discharge may take the place of natural bile. The gall-bladder is usually found empty, or with a small quantity of tarry-looking bile in its cavity. The capsule and fat surrounding the Tiidney have a yellowish appearance, but the organ itself, though prone to fatty change, even during the short period of the disease, is yet not so decidedly in- volved in it as the liver. Indeed, under ordinary circumstances, an amount of congestion in the liver, only producing the slightest biliary derangement, would be a very serious occurrence in the kid- ney; and though the latter is a much smaller organ, it would appear to occupy a longer time in passing on to a state of fatty degeneration. Little livid spots and ecchymoses are sometimes found in the infundibulum and pelvis, and pus has been found in the pelvis and ureter. Dr. Pennel notices, besides the manifest con- gestion of the kidney, that the papillfe yielded upon pressure a glutinous tena- cious exudation sufficient to interfere me- chanically with the escape of the urine. This, however, the writer is disposed to think was in great part composed of the forcibly extruded epithelial lining of the little tubes in a manner well known to microscopic anatomists. The pancreas and spleen present no con- stant pathological change worth noticing, and the same may be said of the urinary bladder, if we except the possible occur- rence of a dark grumovis fluid, closely re- sembling black vomit, recorded by one or two observers. Peognosis. — It is a difficult matter to form a reliable prognosis in almost any stage or variety of Yellow Fever, for the very cases that would strike the physician as affording most promise of speedy re- covery may prove to him, by a rapidly fatal issue, how uncertain his judgment must be. Still, there are symptoms or circumstances which experience has shown to be usually of good import, and others again which augur badly or point to an almost immediate dissolution. Favorable Signs. — If the pulse approxi- mates without reaching 110 in the febrile stage ; ■ if it preserves an even and nor- mal force and frequency when the third stage sets in ; if the urine be in good quantity and exhibits no disorganization of the kidney, under the microscope — the presence of albumen in small amount is to be regarded more as a usual than an unfavorable symptom — if epigastric ten- derness and irritability subside with the febrile state, a good hope of the case may be entertained. Unfavorable Signs. — Dr. Jackson gives the following as indicative of danger, founded upon his experience of the dis- ease, occurring on the south coast of Spain : — 1. A sudden invasion by the fever, with intense pain of the head and eyeballs, accompanied by sickness and vomiting. 2. The fever being ushered in by a fit, convulsions, or apoplectic stupor, or out- rageous delirium. 3. A torpid, heavy, or statue-like as- pect of countenance gave strong suspicion of danger. 4. A dry, rough, milk-white, or swollen and red tongue indicated danger. 6. Distress and anguish at stomach, with pain at the epigastrium, forcible eructations, or explosions of flatus from the stomach, gave impression of much danger. 6. Obscure hiccough marked danger. 7. A ghastly appearance, with a faint nauseous odor from the body, indicated extreme danger. 8. Yellowness of the skin, with turgid veins on the conjunctivse in the latter stage, "always decisive of a fatal issue." 9. Torpor of the skin — to such an ex- tent as to be insensible to the stimulation of blisters and sinapisms — is ranked among dangerous signs. ' The frequency of the pulse as a rule be- ing less in Yellow Fever than in others. THERAPEUTICS. 293 10. Extreme dampness or extreme dry- ness of the skin indicates great danger. 11. Petechise are suspicious: streaks, or patches, of livid green, or violet color, are almost certain indications of approach- ing death. 12. Vomiting of black matter, like the grounds of coffee, is reported a sign of the liighest danger ; [but] 13. Vomiting of bitter bile, whether green or yellow, even with straining and severe retching, affords a sign of compara- tive safety. 14. Black watery stools, with shreds, "are of the worst prognostics" (as quoted by Martin). To the above may be added : — 1. A very weak pulse on the invasion of the disease. 2. A pulse much exceeding 110 in the febrile stage. 3. Sudden and excessive lumbar pain, or rachialgia. 4. Countenance swollen, tense, and bloated, or on the contrary much pinched up, or terror-stricken. 5. Kery redness, with prominence of the eyes, or on the other hand a pearly whiteness of the conjunctivae. 6. Widely dilated pupils, indicative of cerebral complication. 7. Suppression of urine, or deposits in- dicating a serious condition of the kidney. Thebapetttics. — Treatment. — There can be little doubt that whatever is to be done in Yellow Fever should be done quickly, and the earUer a clear diagnosis is formed the better, if any hope may be reposed in medicine. We have it on the authority of physi- cians of experience, that the disease has been cut short by the timely administra- tion of remedies that have been tried and found wanting at a later period. Dealing with the subject in a purely philosophical light, the evidence before us is not as conclusive as it could be wished ; on this point, and "in the present state of our knowledge, we can only be guided by the common principles of medicine ; for it is plain that a specific mode of cure cannot be suggested until the nature of the spe- cific cause is known. We know also that the disease manifests itself with various degrees of intensity in different cases, and how much of any happy recovery depends upon the stamina of the system, or upon the means employed, is above all things difficult to determine— a fact which should never be forgotten by those who may be zealously inclined to advocate their own suggestions. ' ' Even a brief notice of the various modes of practice adopted by medical men from time to time, in the treatment of this disease, would occupy piore space than would be of advantage in the present article ; but we shall pass the more important remedial agents in review. The pediluvium on the first invasion of the malady is now very largely employed by American practitioners, and the indi- cation is further carried out by the use of warm drinks to excite diaphoresis and a genial warmth. Tliis may be followed by a brisk purgative, composed of calomel, gr. vi-x, jalap gr. x, and ginger gr. iij, in the bolus form, which will be found the most convenient and certain mode of ad- ministering medicines of this kind on an extended scale. [Bleeding was largely resorted to and favorably reported upon by Dr. Eush and others, a century ago.' Although this practice is by general consent now ruled out, it cannot be ignored that the relief sometimes following moderate sponta- neous hemorrhages affords a natural sug- gestion in its favor. Leeches to the epigastrium, during the first day or two of the attack, have certainly sometimes done good. — H.] A dose of calomel exceeding ten grains would appear to be rather experimental or empirical than based upon a sound physiology. No one has been able to ad- vance a therapeutical principle to warrant it, in opposition to the evil effects so often known to follow in its wake. The same also may be said of large doses of quinine, which, in Yellow Fever at least only tends to impede secretion and derange the cir- culation within the head. The employ- ment of this medicine at all is more suit- able to the convalescent than to the patient more immediately under the in- fluence of the disease. It is perhaps more useful in such febrile states as ex- hibit a periodicity in their recurrence. Should it be thought expedient to pre- scribe quinine in Yellow Fever, small doses frequently repeated are to be pre- ferred, so that any resulting prejudicial effect may be observed in good time and the medicine simply omitted without doing much mischief. As the bowels are commonly sluggish in Yellow Fever, an enema may be neces- sary after the first dose above suggested ; in which case one of turpentine, as recom- mended by Drs. Copland and Smith, will [' Mathew Carey, in his "Short Account" of the Yellow Fever of 1793 in Philadelphia, says: " The efficacy of bleeding in all cases not attended with putridity was great. The quantity of blood taken was, in many cases, astonishing. Dr. Griffits was bled seven times in five days, and ascribes his recovery principally to that operation. Dr. Mease, in five days, lost seventy-two ounces of hlood, by which he was recovered when at the low- est stage of the disorder. Many others were bled still more, and are now as well as ever they were." — H.] 294 YELLOW FEVER. prove to be the most beneficial, as it in i^eiicral brings away feculent and normal- looking stools. Turpentine, in drachm doses, by the mouth, is advocated by the same authorities, but of its use in this way the writer has had no experience. The most must be made of the time now remaining until retching and vomit- ing set in. Acetate of ammonia, nitrate of potash, nitrous ether, and the tincture of squills' and henbane, may be combined and administered in periodical doses, with lime juice for drink. In this way exces- sive febrile action will be moderated, the action of the kidney and the skin pre- served, and even if the reaction is defec- tive no further depressing influence can be exerted. Of all the symptoms of Yellow Fever the most distressing, to both patient and physician, is irritability of the stomach. It is so constantly present, and so often uncontrollable, that the knowledge of every available means of checking it is of the greatest importance. In the epidemic of Yellow Fever on board H.M.S. Icarus, in the West Indies, a few drops of chloroform prejDared the stomach for the reception and retention of food, "but the dose should be repeated a short time before food is again taken, as the effect of chloroform is transitory." Creosote and hydrocyanic acid have been used with the same intention, but the valuable suggestion of chlorodyne made by Dr. Aitken, would bid fair to supersede every other, if we may except that of lime-water, in this connection. Lime-water was used with great benefit on the Icarus, on the recommendation merely of its known therapeutic proper- ties in the practice of medicine. But it had long previously been employed by the American physicians, and with a higher object, namely, the correction of aci'dity in the stomach, due to the presence of free hydrochloric acid. Dr. Hosack used lime-water most successfully in combina- tion with milk, and with porter when the milk could not be retained. More stress ought to be laid upon the importance of this agent by English writers. A chalk mixture has also been resorted to with the same intention. Professor Froit, of Charleston, strongly advocates the chlorate of potash ; and it is richly worth extensive trial, from its known valuable properties in adynamic states generally, oxygenating the blood, and aiding in elimination by its action on the skin and kidneys. It is fair, however, to state that some cases, in whicji it was tried, were not very satisfactory. Tannic acid, besides the astringency which it exerts upon the smaller vessels, [' Many practitioners would prefer to omit tlie squills and nitrate of potassium. H.] is reputed to have the property of dimin- ishing the irritabilit}' of the stomach. Pepsine, in regulated doses, so as to as- sist an organ incapable of discharging its own functions efficiently, requires further trial. In connection with pepsine, and the internal use of ice in the intervals of its exhibition, the essence of beef should be unremittingly supplied and suited by dilution and seasoning to the nature of the case. This will be the time also for stimulants — our great object being to ob- viate the tendency to death, and to sus- tain the vital power in its struggle with the foe. Champagne, in particular, will be beneficial, when it can be obtained. The ward-room cook of H.M.S. Icarus had very nearly succumbed at this crisis, but he rallied immediately on the admin- istration of a stout glass of rum and water, and recovered steadily. The Yellow Fever poison is evidently of an intoxicating kind, and a marked difference is apparent between the mild and irritable delirium produced by it, when thrown out in contact with the brain substance and the comatose state brought about by those principles, urea in particular, that accumulate in the cir- culation in consequence of the ineffective action of the kidneys and liver. When the semi-comatose patient is aroused, he may be made to answer rationally ; but in the delirium, which is characterized by vigilance and irritability, this can scarcely be expected, and even a coherent reply may be in league, as it were, with the mental derangement. Morphia certainly has the effect of allaying this excitable state and procuring sleep. Here, again. Dr. Aitken suggests chlorodyne, as the administration of "opium in any form," on good therapeutic grounds, is objection- able. [Ice, dissolved slowly in the mouth and swallowed, is very refreshing and suitable during the febrile paroxysm. So are effervescent drinks ; probably none are better than carbonic acid water (soda water) cooled with ice. Spice poultices applied to the epigastrium may materially assist in relieving the vomiting and epi- gastric tenderness. Cold or cool sponging will be appropriate at an early stage ; even hot bathing has been found serviceable in the later prostration. — H.] Yarieties, and their Classifica- tion. —Notwithstanding all that has been ■^^'ritten on the subject of the Yellow Fever, the gist of nearly every attempted classification of its varieties amounts to little more than a grouping of them in ac- cordance with the several degrees of com- parison. Indeed, the phases presented by different epidemics, and by the individual cases in the same epidemic, with no pos- sibiHty of the interpolation of other com- plaints to be confounded with it, would VARIETIES AND THEIR CLASSIFICATION. 295 give systematists more than they could easily accomplish to define and arrange intelligibly. The types, therefore, are exceedingly variable, and little practical benefit can accrue from their nice discri- mination ; but, when they do not trans- gress broad boundary lines, they may afford a more precise knowledge of the symptoms and pathology of the disease as a whole. It is notorious that a classifica- tion, founded upon the experience of one epidemic, may be quite inapplicable to another ; consequently, whoever has to do with one, naturally makes a classifica- tion for himself. On this account, sys- tems have become so numerous, that we can only give place to a notice of one of the best of them, namely, that put for- ward by Dr. La Eoche of Philadelphia, whose masterly work on Yellow Fever, with a bibliography of sixty-one pages, has afforded the writer great assistance in the composition of this article. According to Dr. La Eoche, Yellow Fever (as a genus) is divisible into two species, viz., 1, the Inflammatory; and 2, the Congestive ; though these are often connected by cases in every conceivable degree of transition from one to the other. 1. The inflammatory species appears under three grades, viz. (a) the Intense ; (h) the Mild ; and (c) the ISphemeral. From all that has been previously said in the symptomatology, the character of these grades may be easily conceived. In the first, the fever is active and short, and death commonly happens before the ac- cession of black vomit ; in the second, the fever is more protracted, and may even exhibit partial remissions before the final stage sets in ; while the third, as its name implies, is of short duration, and easily amenable to treatment. 2. The Congestive species is marked by the passage of the disease " as it were directly from the first sign of indisposition to the last stage, without going through that of reaction. " Of this species there are four grades : viz. (a) the Aggravated ; (b) the Adynamic or Typhoid ; (c) the Walking ; and (cZ) the Apoplectic. (ft) The Aggravated grade is attended from the commencement with considerable prostration, giddiness, stupor, and loss of memory, delirium, or coma. The tongue is natural, or with white patches and red tip and edges. The countenance is livid and apathetic, and the skin yellow or bronzed. Hemorrhage occurs from one or more of the natural outlets, and the patient keeps up a low monotonous wail- ing. In some cases the pulse is nearly natural, the tongue clean, and the stomach calra ; but these are attended with exces- sive restlessless, anxiety, and distress, soon followed by black vomit and fatal collapse. (6) The Adynamic or Typhoid grade oc- curs in persons deficient in vital power, ushered in with chills, followed by burning heat, partially distributed over the body, viz., principally on the under parts of the arm and inner surface of the thighs. The pulse is small and weak. The skin as- sumes an olive hue, and is covered with potcchia3 or vibices. Hemorrhages are common from the natural outlets, or into the connective tissue beneath the skia, or amongst the muscles. (c) The Walking grade.— Here the func- tions of organic life appear to be at first alone implicated, those of animal life re- maining unaffected. The patient, though sometimes in bed, is found more fre- quently walking about his room. He only feels weak, but his eye is watery, and his countenance dull and listless ; his pulse grows fainter and fainter, until at last he is overtaken by black vomit, and death speedily ensues. ' (d) The Apoplectic grade. — The patient is more or less suddenly struck down with stupor or coma, and death, preceded by convulsions, soon follows. The pulse is rather weak, and finally becomes faltering. The skin is cold and clammy, or some- times dry and flabby. " In the mean time the patient lies as if stunned, with dilated pupils and an expression of gloom upon the countenance. From this unpromising state an effort at reaction occasionally takes place, but this scarcely ever leads to a successful result. More generally, the patient becomes perfectly comatose, the eyes assume a glassy appearance, the pulse fades away, involuntary discharges and profuse hemorrhages supervene, and death soon ensues." Some few years ago^ the writer sur- mised the possibility of the extension of the range of Yellow Fever to our own shores, all favorable conditions being ful- filled, and this has been realized in the late epidemic of Yellow Fever at Swan- sea, reported in a very able manner by Dr. Buchanan. The circumstances are briefly the following : — On the 9th September, 1865, the Beda barque, laden with copper ore, returned from Cuba to Swansea, with one case of Yellow Fever on board, three having proved fatal on the voyage home. The remaining case (James Saunders) and two convalescents were sent on shore. Soon, also, the crew had left the ship and distributed themselves over the town, and two passengers with their luggage were landed. Moreover, a good many people boarded the vessel as she entered the dock. An outbreak of Yellow Fever thus 1 Several well-marked cases of this grade occurred on board H.M.S. Icarus. 2 Healtli of the Navy for 1860. 296 EPIDEMIC CEREBRO-SPINAL MENINGITIS. originated ashore, and in a well drawn-up table of the cases Dr. Buchanan shows their invariable connection with the source of the malady, directly or indirectly, add- ing further proof of its infectious nature, should such be required. Note. — As bearing upon the question of in- fection, the following important quotation is from the remarks of Deputy Inspector-General R. D. Mason of Port Royal Hospital, recorded in the Statistical Report of the Health of the Navy for 1866 :— "During the Christmas quarter nine cases of Yellow Fever have been received into hos- pital, of which eight terminated fatally. The first case received was that of the command- ing officer of the gunboat Nettle. The Nettle had been employed between the 1st of Octo- ber and 25th of November at Morant Bay and Port Morant, spending a week alternately at each place. At Morant Bay this officer re- sided on shore, passing scarcely any time on board. The servant died of Yellow Fever at Morant Bay on the 22d of November, after about four days' illness ; and a staif assistant- surgeon, who lived in the same house and who attended him, was subsequently attacked with the same disease and died on the 10th of December. " Up to the time that the Nettle left Morant Bay no other cases were known to have oc- curred, and there had been no unusual amount of sickness, nor any cases of Yellow Fever, as far as I have been able to ascertain. "The surgeon of the Cadmus states, how- ever, that as far back as the month of July, it was reported that a merchant-ship from St. Thomas, then lying at Morant Bay, crone of the eastern ports of the island, had cases of Yellow Fever on board : cause and effect are also shown in the fact that the chaplain of the Cadmus had on several occasions visited the commander of the Nettle during his ill- ness, and that the surgeon was at his bedside about an hour before his death, and that the Cadmus, previously a healthy ship, had sub- sequently sent eleven cases of Yellow FeTer to hospital." Circumstances like these may appear very unimportant at the time of their occurrence, but it may be safely affirmed that such are always traceable in connection with the com- munication and spread of Yellow Fever. EPIDEMIC CEEEBRO-SPINAL ME:N"I]S"GITIS. By J. Nbtten Eadcliffe. Defhstttioit. — An acute, epidemic dis- ease, characterized by profound disturb- ance of the central nervous system ; indi- cated, at tlie outset, chiefly by shivering, intense headache, or vertigo, or both, and persistent vomiting ; subsequently by de- lirium, often violent, alternating with somnolence, or witli a state of apathy or stupor ; an acute painful condition with spasm — sometimes tetanoid — of certain groups of muscles, especially the posterior muscles of the neck, occasioning retraction of the head ; and an increased sensitive- ness of the surface of the body. Through- out the disease there is marked depression of the vital powers ; not unfrequently col- lapse ; and in its course an eruption of vesicles, petechia, or purpuric spots, or mottling of tlie skin, is apt to occur. If the disease tend to recovery, the symptoms gradually subside without any critical phenomena, and convalescence is pro- tracted : if to a fatal termination, death is almost invariably preceded by coma. After death, the enveloping membranes of the brain and spinal cord are found in a morbid state, of which the most notable signs are engorgement of the bloodvessels, usually excessive, and an effusion of sero- purulent matter into the meshes of the pia mater, and beneath the arachnoid. Synonyms. — (a) Technical .-—Cerebro- spinal fever' {Boyal College of Physicians); cerebro-spinal arachnitis; typhus syncopa- lis; tifo apoplettico tetanico; typhus cere- bro-spinal {Boudin); cerebral typhus; epi- ' Since the completion of this article the Royal College of Physicians, in its "Nomen- clature of Disease," has adopted the following designation and definition of this malady : " Cerebro-spinal Fever. A malignant epidemic fever, attended by painful contraction of the muscles of the neck, and retraction of the head. In certain epidemics it is frequently accompanied by a profuse purpuric eruption, and occasionally by secondary effusions into certain joints. Lesions of the brain and spinal cord and their membranes are found on dis- section." It is, however, determined to re- tain the name by which this affection was de- scribed in the first edition of this System of Medicine, and for the simple reason that such name, while sufficient for the purpose of re- cognition, conveys no opinion as to the nature of the disease. — Editoe. DESCRIPTION OF THE DISEASE. 29T demic meningitis [StiJlLV. S.); petechial fever {G. B. Wood, U. S.); fever witli ce- rebro-spinal meningitis {S. Oordon); ma- lignant purpuric fever ( Tr . Stokes)-, malig- nant purple fever ; nervo-purpuric fever (Mapotlier); malignant purpurse (ilf Sioin- ney); pestilential purpuras (UaiiAvs); febris nigra (B. D. Lyo)is). — (b) Popular: — Spot- ted fever {New England) ; cold plague , (SoMt/ier/i States, U. S.) ; Kolik, K'acken- starre, Genickkrampf {Qermany); Nacks- juka, Dragsjuka {Sweden). Desgkiption of the Disease. — I. General Symptmns ; — Epidemic cerebro- spinal meningitis is observed in three principal forms : A. — Simple, in which the symptoms indicative of disorder of the nervous centres predominate throughout the whole course of the disease ; b. — Ful- minant, in which the depressed state of the vital powers, with profound blood- change— as shown by hemorrhage of vari- ous forms into the cutis — characterizes the disease ; and c. — Purpuric, in which the cerebro-spinal symptoms, and the symptoms which mark blood-change {pete- aivE, purpurm, vihices, &c.), and flagging of the vital powers, occur together. The proportion in which the three forms of the disease are manifest varies considerably in different epidemics. In every out- break cases are observed which link, by insensible gradations, one form with an- other ; while in other, and rarer cases, the characteristic symptoms of the three forms are merged together. Continental and American writers have described an abortive form of the disease, the term l)eing given (a) to certain anomalous symptoms observed in communities among which the disease is active : and (6) to sundry symptoms characteristic of the mg,lady, but of transitory duration : such as severe cephalalgia, a sense of dragging at the back of the neck, or actual slight retraction of the head ; cardialgia, enter- algia ; — these symptoms often ending con- temporaneously with the appearance of profuse perspiration, or epistaxis. (a.) Simple Epidemic Cerebrospinal Meningitis. — In the majority of the cases , before the onset of the disease the patient suffers from more or less indisposition. There are discomfort in the head, neural- gic pains in the back, the principal groups of muscles, and the abdomen ; failure of the appetite, indifference to exertion, per- haps also slight shiverings, and a quasi- febrile state. These indications of dis- ordered innervation may persist from three to seven days, or may be manifested only during a few hours, before the con- firmed malady fully declares itself. But in numerous cases the onset of the dis- ease is sudden and characteristic. In both classes the accession of the malady IS declared by similar well-marked signs. Acute shivering is followed or accom- panied by severe, commonly intolerable, headachCj or vertigo, or both ; and after a short interval, or contemporaneously, profuse and irrepressible vomiting takes place, rarely preceded by nausea. Or vomiting may be the initiatory symptom, the shivering, headache, or vertigo fol- lowing quickly after. The intensity of the symptoms marking the onset of the disease is remarkable and characteristic. The sickness is often, and from the outset accompanied by severe abdominal pain, apparently neuralgic ; and not unfre- quently this pain precedes the disorder of the stomach, as the cephalalgia precedes mental confusion. In like manner, the shivering ushers in, or is accompanied by, an acutely painful state of the muscles, more or less general, the forerunner of spasm. Cephalalgia and delirium, abdo- minal neuralgia and vomiting, and myal- gia and spasm are the principal morbid factors of simple epidemic cerebro-spinal meningitis. They distinguish the malady, and the varying prominence with which they occur in different outbreaks gives rise to many diversities in the grouping of symptoms during the progress of the disease. The onward course of the dis- order is usually rapid. The headache con- tinues, often without a lull ; vertigo oc- curs frequently ; and after tlie lapse of a very brief period, measured usually by a few hours, the mind becomes confused, and, in some cases, a state of restlessness supervenes not unlike that observed in delirium tremens. The mental confusion assumes the form of muttering delirium, with periods of somnolence, often inter- rupted by cries provoked by the intense cephalalgia, or by the neuralgic pain else- where ; or the patient falls into a state of apathy or stupor, from which he may be partially roused, but into which he re- lapses when left undisturbed, the mind acting as in a dream ; or there is acute and violent delirium. Contemporane- ously with, or immediately prior to, the mental disturbance, the painful state of the muscles increases, certain groups being more manifestly affected than others, espe- cially the posterior muscles of the neck, the muscles of the spinal column, and those of the lower extremities. The pain, often of an acutely neuralgic character, shoots along the spine and limbs, and across the walls of the abdomen. Partly as a voluntary action, partly as a conse- quence of spasm of the painful muscles, the head is drawn backwards. The re- traction thus arising is one of the com- monest and most characteristic symptoms of the disease. As the malady advances an actual or apparent tetanoid contrac- tion of other groups of muscles may oc- cur, the trunk most frequently being curved backwards, and the legs bent upon 298 EPIDEMIC CEREBEO-SPINAL MENINGITIS. the thighs. At the same time there may be lleutiui;- spasmodic action, of s^ome of tlie muscles of the face, and occasionally of the eyeballs ; or in some cases tonic contraction of these muscles, giving rise to the so-called sardonic laugh, or to per- sistent strabismus. In many cases cuta- neous sensibility is much exaggerated, and very frequently a vesicular or roseo- lar eruption is developed, the former par- ticularly about the lips. The aspect of the patient as the disease advances is de- pendent upon the degree of pain, the state of delirium or stupor, and extent of spasm which may be present. The countenance is rigid and contracted, the expression of face betokening acute pain ; or it is domi- nated by the delirious fancies ; or reflects the mental torpidity ; or is distorted by spasm. There is frequently a slight suffu- sion of the eyes, altogether different from the dusky appearance of typhus ; and the face is commonly pale and sunken, seldom and only transitorily flushed and swollen, except when afiected more or less exten- sively by the vesicular eruption. The surface sometimes moist, sometimes dry, rarely gives to the hand a sensation of febrile heat, although the temperature of the body ranges above the normal stand- ard. The pulse from the outset is wanting in firmness, and the indications of defec- tive tone increase as the disease advances. The respiration exhibits no marked dis- turbance, excepting an increase of rapid- ity witnessed during accessions of pain and restlessness, and in the advanced stage of the malady the diminution dependent upon failing circulation and innervation. The alimentary canal, apart from the vom- iting, which usually ceases as the disease becomes fully developed, presents little indication of disturbance. The tongue is as frequently clean and moist as dry, foul and discolored ; and the bowels may be either costive or loose, the former, per- haps, more commonly than the latter. In some outbreaks, indeed, costiveness has been marked and almost general, but in others diarrhcea has been prevalent. The renal secretion is rarely much dis- turbed. As the malady proceeds, if it tends to- wards a fatal termination, the spasmodic symptoms increase, the patient becomes comatose, and death may occur either from asphyxia or exhaustion in from ten or twelve hours to seven or eight days. If the disease be prolonged beyond this pe- riod, various secondary lesions are apt to occur, especially certain inflammatory states of the eyes and the ears, the mis- chief in the former organs being shown by ulceration of the cornea, iritis, and some- times suppuration of the globe ; in the lat- ter by less obvious structural changes during life except as indicated by deafness. Or there may be paralysis affecting one- half of the body, or one side of the face, or one of the limbs, or an isolated group of muscles. Or there may be an inflamma- tory state, with sero-purulent eliiision into one or more of the large joints. Or, finally, the patient may fall into a state of marasmus and nervous exhaustion, often pirotracted and not rarely fatal. If the malady proceed to a favorable termina- tion without any of these sequences, health may be recovered in from three to four weeks. If the progress of the disorder, otherwise favorable, be interrupted by one other complication, the period of recovery is uncertain and often long postponed. (b.) Fulminant Epidemic Cerebrospinal Ileningitis. — In the fulminant form of the malady the onset is without premonition. The patient suddenly falls into a state of collapse. The surface of the body has often a cyanotic aspect, and is cold and clammy to the touch, or covered with pro- fuse perspiration, the face being not rarely shrunken and livid, and the eyes deep sunk as in the algide stage of cholera. There may be some shivering at intervals, more or less pain of the head, and occa- sional vomiting, sometimes of a grumous black or coffee-colored fluid. Drowsiness, if not present at the outset, rapidly super- venes, followed by or concurrently with delirium. Coma, rarely other thau the precursor of death, quickly succeeds. In the mean time purpuric spots show them- selves over the surface of the body gener- ally, red or purple and circumscribed in the beginning, but rapidly becoming black, and often extending their margins so as to form irregular inky blotches, or streaks, or great patches ; and not unfrequently several of the spots become gangrenous. Sometimes the purpuric spots appear con- temporaneously with the collapse at the outset of the attack. The respiration is preternaturally slow, and the pulse (if it has not been absent at the wrist from the beginning) falls with the progress of the disease. The urine is loaded with albu- men. Life may be extinguished in less than Jive hours, or it may be prolonged for two or three days. Recovery from this form of epidemic cerebro-spinal menin- gitis is not unknown, but it is an exceed- ingly rare event. (c.) Purpuric Epidemic Cerebrospinal Meningitis. — In the purpuric form of epi- demic cerebro-spinal meningitis, the symp- toms which distinguish the simple and fulminant forms of the disease occur com- bined together in various proportions, some cases approximating more or less closely to the latter, others, as is most common, to the former variety of the affection. Thus concurrently with shiver- ing, intense headache, vomiting, rachial' gia and retraction of the head, there may be depression of the vital powers approach- ing collapse, or collapse itself, with the DESCRIPTION OF THE DISEASE. 299 development of petechise or purpuras, vi- bices, ixchymoses, hemorrhage from mu- cous tracts, delirium, coma, and rapid dissolution. In by fa • the greater num- ber of cases, however, the disease follows the course of simple epidemic cerebro-spi- nal meningitis ; but within twenty-four hours, or from this period to the fourth day, or still later in the progress of the malady petechiaj or purpura are devel- oped more or less copiously, and occasion- ally hemorrhage occurs from the mucous tracts. ■ This phase of epidemic cerebro- spinal meningitis does not appear to be more fatal than the simple form of the disease. It has been observed more com- monly in the United States than on the continent of Europe, and it was the prin- cipal variety which occurred during the outbreak in Ireland in 1867. II. Special Synvptovis. — 1. The N'ervous System. — Headache is almost constant, and it is remarkable for its early and per- sistent severity. At the outset it is not localized in any particular part of the head. It may be referred to the forehead, the sides, the vertex, or the occiput ; or it may be general. Later in the disease, the occiput is, perhaps, most commonly the seat of pain. The intensity of the headache is, as a rule, peculiar. The pa- tients describe the pain as sharp, lanci- nating, stabbing, plunging, tensive, throb- bing, boring, or crushing. It is so intol- erable as to elicit groans and cries from the sufferer; often, even during delirium or stupor, the exclamations, the contrac- tion of the forehead, and the manner in which the hands are moved towards the head, show that the pain continues. In young children this state closely resembles that which is so significant of tubercular meningitis. The headache may cease when the disease has become fully devel- oped, or as is probably more common, it may persist throughout the whole course of the malady so long as consciousness remains. Occasionally, indeed, when re- covery takes place, it will continue far into the period of convalescence. Bachialgia is rarely absent. It is some- times general throughout the spinal re- gion, but more freciuently it is limited to the loins, the dorsal region, or, as is most usual, to the posterior part of the neck. Occasionally the pain radiates from the neck to the extremities and walls of the abdominal and thoracic cavities. In rare cases the pain has commenced at some point of the peripheral nervous .system, and spread thence to the back, occurring in paroxysms. This pain has the same character as the cephalalgia, and the words (intolerable, atrocious, tensive, &c. ) used to indicate the nature of the latter may be employed also to describe the for- mer. It is augmented by movements, and its chief seat is in the muscles of the spinal column. The nuchal pain and its consequences constitute one of the most characteristic signs of the disease. Frequently, at the outset of the malady, this pain is precc^ded by a dragging sensation at the back of the head. As the pain increases in intensity, the head is voluntarily thrown back to re- lieve all strain upon the exquisitely sensi- tive muscles. Or, in conjunction with the pain, spasm of the affected muscles occurs, and the head is forcibly drawn backwards. Among the popular terms of the disease, those arising from this symp- tom (Nackenstarre, Genickkrampf, Nacks- juka, &c. ) are very prominent. When the rachialgia is more diffused, and the pain extends also to the limbs, adapted or spasmodic contractions of the trunk and lower extremities are apt to occur. Ra- chialgia is not present in the fulminant and in severe cases of the purpuric forms of the affection. It is noteworthy that pressure on the spinous processes, during the most acute rachialgia, rarely causes pain. Enteralgia and other Neuralgic Pains. — Abdominal pain, neuralgic in character, and more or less closely linked to the pain in the course of the spine, is not unfre- quent, and it is often closely associated with uncontrollable vomiting. In some epidemics, as in that of 18(55 on the Lower Vistula, enteralgia was so common among children seized with cerebro-spinal menin- gitis that it gave rise to the trivial desig- nation "belly-ache," as one of the popu- lar names of the disease. Neuralgic pains in the limbs, referred to in connec- tion with rachialgia, are less common than like pains along the course of the spine and in the abdomen. Increased Sensitiveness of the Surface of the Body has been described as frequent in several outbreaks. During the late prevalence of the disease in the United States (18(51-67), cutaneous hyperresthesia is said to have been a characteristic symp- tom of the malady in its fully developed state. During the outbreak on the Lower Vistula, an increase of cutaneous sensi- tiveness was also observed very commonly, but it was not regarded by Dr. Burdon Sanderson as a characteristic symptom, but "a mere consequence or interlude of pain : " being, in fact, an excessive tender- ness experienced during intermissions, or after the cessation of pain. SjwsTO.— Sufficient care has not always been taken to discriminate between appa- rent and actual spasm in this disease. Tourdes, in 1843, showed that the retrac- tion of the head and curvature of the spine did not in all cases arise from a spasmodic contraction of the muscles, but that the position was not rarely volun- tarily or instinctively assumed by the pa- tient as most conducive to relief of the spinal pain. Dr. Burdon Sanderson con- 300 EPIDEMIC CEREBRO-SPINAL MENINGITIS. firmed this observation of Tourdes, so far as retraction of the head was concerned, in 1805. In the cases observed by him, in which the head was apparently drawn backwards, it was practicable to extend the seemingly contracted muscles, al- though the effort gave rise to exquisite pain and Instinctive resistance. There was not any tension of the muscles except such as arose from this resistance ; no tightness was felt so long as they were at rest. "It was not till the neck was com- pletely extended that the muscles became hard, and even then the hardness was not for a moment comparable to that which is felt in tetanus." The position in bed of the patients observed by Dr. Burdon Sanderson was that which would produce the greatest relaxation of painful groups [Fig. 13. Cerebro-apinal Fever (J. Lewis Smith).] of muscles. There can be no doubt, how- ever, that spasm is a frequent accompani- ment of epidemic cerebro-spinal meningi- tis. In the clonic form it is witnessed in some cases as transitory contractions of the facial muscles, cramps of the extremi- ties, the convulsive agitation and trem- bling referred to in the general description as somewhat like what is observed in delirium tremens, very rarely in local convulsions of a single limb, and still more rarely in general convulsions. Tonic spasm of the muscles of the face, jaws, (trismus), and gullet, and of the limbs and trunk, may also occur, giving rise to true opisthotonos, emprosthotonos, or general tetanic rigidity of the trunk and limbs. Paralysis is not of very common occur- rence during the progress of epidemic cerebro-spinal meningitis. Hemiplegia has been occasionally noticed, and paraly- sis more or less complete of one or both extremities, upper and lower, of the mus- cles of deglutition, of articulation, and of certain other associated groups, the latter chiefly towards the close of the malady. The general paralysis noticed by some writers was usually significant of, and in- deed a part of the phenomena of, ap- proaching dissolution. The special senses do not often manifest much change, except as a consequence of certain structural lesions. Increased, sometimes exquisite, sensitiveness of sight and hearing has occasionally been noticed, concurrently with augmented sensitive- ness to other external impressions, espe- cially towards the close of the malady, when complete consciousness returns. Amaurosis has also occurred, without ap- parent change in the ocular apparatus. It may be noted, moreover, of the eye and sight, that occasionally there are strabis- mus and double vision. The pupils may be normal in aspect and action, or they may present various changes. They may be dilated or contracted, or one dilated and the other contracted, or they may exhibit curious alternations of contraction and dilatation under the influence of the same degree of light. Both the eyes and the ears are liable to undergo certain structural lesions, consisting in well- marked inflammatory changes. These commence, in the former organs, some- times in the cornea, sometimes in the deeper tissues. Most commonly keratitis is set up, ending in opacity or ulceration ; and, in the latter case, the iris may be- come involved. Or, iritis may occur in- dependently, with efiusion of lymph or pus, and the consequences thereof (syne- chia posterior and distortion of the iris are particularly noted). Among more deeply- seated changes may be mentioned opacity of the lens or of the vitreous humor, sepa- ration of the retina from the choroid, purulent infiltration, or atrophy of the eyeball. The ear suffers, perhaps, more frequently than the eye. Deafness is probably more common than defects of vision, and it is largely dependent upon inflammatory changes set up in the organ, and particularly afl'ecting the lining mem- brane at the vestibule and semicircular canals. Occasionallj', the external meatus has been affected, and a profuse purulent discharge has flowed from it. These le- sions of the organs of sight and hearing DESCRIPTION OF THE DISEASE. 301 may occur either early or late in the course of the disease. The sense of stnell very rarely sutlers. Its loss in one nostril has been recorded in a single case, and this was, perhaps, dependent upon inflam- matory changes in the lining membrane of the nose ; as purulent discharge from the nostrils has occasionally taken place in other instances. Vertigo is sometimes observed as an in- itial symptom of the disease in conjunc- tion with the cephalalgia. Instances are recorded in which the first accession of the disease was marked by severe giddi- ness, during which the patient either staggered about Uke a drunken man, or turned round several times, and then fell. Delirium is rarely absent. It varies much in character, and may occur at any period of the seizure. It may be quiet or violent, transitory or more or less persist- ent. It sometimes, but rarely, forms one of the symptoms of invasion, when its access is sudden and its character acute. It may supervene with violence after the malady has continued from several hours to two or three days. In the acute form of delirium, the patient is very noisy, and often so violent as to require restraint. Sometimes it happens that paroxysms of furious excitement occur with intervals of placid delirium. Hence the necessity of great watchfulness in the care of these cases. Most commonly the delirium fol- lows closely upon the initiatory symptoms, and is aggravated as the disease advances. At the beginning, the confusion of thought may not be so great but that the patient can be roused so as to answer questions inteUigibly. Later, the incoherence be- comes much greater, and is usually accom- panied with considerable agitation. Much difference is observed, not only in the de- gree of impairment of the consciousness, but also in the periods of manifestation of the impairment. In some cases, the de- lirium occurs chiefly during the night ; in others, and very commonly, it alternates with periods of somnolence or of quietude. In the more persistent cases there are usually exacerbations. If the disease tend to a fatal ending, the delirium is fol- lowed by coma ; if to recovery, conscious- ness is, as a rule, gradually recovered : but, at times, a period of stupor inter- venes between the subsidence of the de- lirium and returning perception. In the slightest cases of the malady the delirium may be transient only, taking place at intervals, and chiefly during the night. In the gravest cases, when death occurs in a few hours, delirium is most commonly present. The duration of the delirium depends entirely upon the nature and duration of the case. Instances are re- corded in which furious delirium has oc- curred for three nights in succession. In other instances a delirious state has per- j sisted more or less continuously for fifteen days. Stupor and Coma. — In not a few pro- tracted cases, dehrium is followed by a prolonged state of stupor, the patient lying completely indifferent to external impressions. In six cases observed by Dr. Burdon Sanderson, in which there had been violent delirium at the outset, this state lasted from one week to five weeks, the mean duration of the several cases being nineteen days. The observer remarks, however, that as four of the cases "emerged from their stupor in a state of complete deafness, there w^as much difliculty in limiting accurately the period of unconsciousness." Sometimes the state of stupor supervenes without the intervention of violent delirium. Coma occurs in nearly all fatal cases, and is, in- deed, generally the forerunner of death. 2. The Digestive System. — The uncon- trollable vomiting, which is one of the characteristic initiatory symptoms of the disorder, is an eflfect of the cerebral mis- chief. Most frequent at the beginning of the malady, the vomiting diminishes as the disease advances, occasionally increas- ing during exacerbations. The matter evacuated, after the stomach has been emptied of food, is usually of a greenish or yellowish color and bitter taste, and is composed largely of bile ; more rarely it is viscid and white. Occasionally, in the fulminant and purpuric forms of the mal- ady, a grumous black or coffee-colored fluid is vomited. In several outbreaks, the vomiting of large quantities of Asca- rides Iwnbricoides has been specially noted. The buccal cavity and tongue do not ex- hibit any particular signs, except in those rare cases in which there is hemorrhage from the gums. As a rule, the tongue is clean and natural at the outset, and its subsequent state depends upon the degree of febrile excitement which may be set up, or upon the development of a typhous state, when it may become foul with va- rious well-known aspects, or with dry and black sordes accumulating on the teeth. From the beginning of the attack the appetite for food is destroyed, whatever the state of the buccal cavity ; and some- times there is much, at others, insatiable, thirst. The hoioels are more commonly- costive than the reverse. In some out- breaks costiveness has been of general occurrence. Diarrhosa, late in the dis- ease, is not unfrequently to be attributed to the previous administration of purga- tives, and involuntary stools are usually one of the accompaniments of complete nervous and vital prostration. 3. The Urinary System.— Inthe simple form of epidemic cerebro-spinal menin- gitis the urine does not exhibit any marked change. It may be more abun- dant, and slight deposits of hthic acid 302 EPIDKMIC CEREBRO-SPTNAL MENINGITIS. may occur. In the fulminant, and in severe cases of the purpuric forms, it com- monly (in the flrst-named form perhaps invariably) contains albumen, sometimes in large amount, and occasionally cylin- drical casts and blood-corpuscles. Reten- tion or incontinence of urine has occurred in the progress of the disease. 4. The Btspimlory System.— In all the graver cases the respiration is more or less altered. It is sighing, labored, or in- terrupted. Dr. Burden Sanderson writes of the outbreak on the Lower Vistula : "In all severe cases, whether of children or adults, the breathing was embarrassed in proportion to the general gravity of the symptoms. This embarrassment was marked by a slow labored inspiration, followed by quick respiration and a long pause,— that condition of breathing which is so frequently observed in continued fe- ver (especially in typhoid), and is often called suspirous. In all the fatal cases which came under my notice, the most prominent symptoms which preceded death were those which indicate impair- ment and perversion of the respiratory function. As the breathing became more hurried and diflicult, the general depres- sion became more intense, the pulse be- came weaker and quicker, and the tem- perature of the skin more elevated. " Dr. S. Gordon records a case, fatal in less than five hours, in which the respirations rapidly fell to nine per minute, the pulse at the time being 120. 5. The Circulatory System. — The cardi- nal point with respect to the circulation, as indicated by the radial pulse, is defect of arterial tension. This has been com- mon to all epidemics, with hardly an ex- ception; and the exceptional instances have probably been more apparent than real. The frequency of the pulse does not admit of general statement. It has a wide range. In the epidemic on the Lower Vistula, the pulse in six adult cases observed by Dr. Burdon Sanderson varied from 56 to 98, the average beats being 85. In several cases noted by the same observer, " its frequency varied con- siderably from day to day, without appa- rent relation to the condition of the pa- tient in other respects." During the Philadelphia outbreak of 1866, in 98 cases observed by Dr. W. H. H. Githens, the pulse varied from the normal beat to 150 per minute in uncomplicated cases, and reached as high as 160 in two cases in puerperal women. "It was in all very weak, with a dichrotic tendency, some- times entirely imperceptible in the radial artery, and always interrupted by slight pressure." 6. The Cutaneous System. — In respect of dryness or moisture or feeling to the touch, the skin presents no constant con- dition ; but, in numerous cases, it is the seat of various forms of eruption of re- markable interest. The extent of preva- lence or predominance of one or other of these difterent forms of eruption has varied considerably in the numerous recorded outbreaks. In the epidemics which have occurred in the United States, 2'eteehice have been so common as to have given rise to the popular name of the disease {spotted fever), and to have induced Dr. G. B. Wood, Professor of the Theory and Practice of Medicine in the University of Pennsylvania, to adopt as the technical designation of the disease the term pete- chial fever. During the recent outbreak in Ireland (1866-67), purpiura was the predominant form of eruption, and Pro- fessor Stokes proposed to designate the malady malignant purpuric fever; other observers also suggested terms founded upon this character. In the outbreak on the Lower Vistula (1865), an herpetic eruption was most common. In all the greater outbreaks, each form of eruption mentioned in the definition of the disease has been observed ; but the proportion of cases in which one or other form of erup- tion has prevailed has varied greatly in each outbreak. In some of the earUer outbreaks in the United States few cases occurred in which a petechial eruption was not noted. Of 98 cases admitted into the Philadelphia Hospital (Blockley) in 1866, 36 had petechise ; 13 mixed pete- chise and erythema ; 9 erythema and urti- caria ; 3 indistinct petechial mottling ; and 37 no eruption at all (Githens). In the outbreak on the Lower Vistula the proportion of cases exhibiting an eruption was comparatively small ; in the recent outbreak in Ireland, large. The forms of eruption observed are as follows : (a) Vesicles. A vesicular eruption {eczema, Hirsch), sometimes herpetic in character, chiefly appearing in the vicinity of the lips, but occasionally extending over the sides of the face, difltused more or less on the trunk, or showing itself in patches on the limbs. This symptom has occasion- ally taken the form of shingles. It is most commonly noticed in the simple form of the disease, but it may take place in either of the other forms, and when associated with purpura, the vesicles may be flattened and rest upon a livid base, presenting a horrible aspect. This form of eruption may appear as early as the second day. (&) Purpura. 1. Truepcf*- c/wVe. 2. Purpiuric spots, varying in size from a split pea to half-a-crown, with more or less extensive effusions of blood, or of its coloring matter, into the cutis {vibices, ecchymoses). The spots have sometimes a regular, sometimes an ir- regular, even a ragged, outline. Their size may remain fixed from the time of their first appearance, or it may increase largely or rapidly. They may be of a COMPLICATIONS — DURATION. 303 light or dark red color at tlie outset, sub- sequently becoming purple and black; or, as is most common, they may from the beginning be dark purple or black, their blackness being often fittingly likened to that of ink — the eruption re- sembling "spots" or " splashes" of that fluid. They may appear on the trunk or limbs only, or they may be scattered co- piously over the whole surface of the body, including the face. The purpuric spots are frequently hard to the touch, the margin being defined, and giving the impression to the fingers of being raised above the surface ; sometimes a vesicle forms above several of the spots, and gan- grene of the adjacent tissue takes place. Dr. S. Gordon writes of the recent epi- demic in Ireland: "Many cases are ac- companied by a distinct eruption, which comes out with great rapidity ; is found over all parts of the body, but chiefly on the lower extremities; is of a very dark color, sometimes a very deep brown, or purple, or even black. The spots are of various sizes and shapes, some small and round, others large and irregular ; some appear like large spots of very black purpura, only more mottled and more irregular in color and shape ; others are more con- fined, and raised above the level of the skin, consisting of an effusion into its sub- stance : many patients die in this stage, hut in some the disease progresses, and these spots are absorbed, leaving a yellow- ish mark under the cuticle ; or they pass into superficial gangrene, which was spreading at the time of the patient's death, or is healed with loss of substance. ' ' Purpuric spots are sometimes, although rarely, one of the earliest signs of the ful- minant and purpuric forms of the malady; or they may occur at any period during the more advanced stages. Usually they appear at some period during the first four days, chiefly perhaps during the first or second day. Sometimes, with or with- out the purpuric spots, there is a cyanosed aspect of the skin, or a peculiar livid mot- tling. During recovery the purpuric spots gradually lose their refined charac- ter and fade away, passing through the different stages of color which mark a healing bruise, (c) Boseola, erythema, &c. Bose-colored spots or patches are occa- sionally observed ; also erythema, more or less diflfiised, a rubeoloid eruption, and urticaria. 7. Temperatvre. — The temperature of the body, as marked in the axilla, is heightened in every case ; except, per- haps, those accompanied by profound col- lapse from the beginning. In many cases this heightened temperature is found con- temporaneously with the invasion of the flisease ; in other cases there is no conspi- (^uous increment until the second or third d^y. When the characteristic symptoms of the malady are developed, the tempe- rature rarely falls below 1U0° Fahr., and, as the disease advances, it ranges in adults from 100° to lUoC-, in children some- times even higher. There is no constant or conspicuous difference between the morning and the evening temperature, as in typhus and typhoid. A steady fiiU marks the decUne of the disease and the approach of recovery ; a rapid fall ushers in collapse or death. Co3[PLicATiONS.— The course of the disease is liable to be modified hj certain complications. Of these the chief are as follows : — (a) Thoracic inflammations : pleurisy, pneumonia, bronchitis, or peri- carditis. Dr. S. Gordon describes oedema of the lung and diffuse pulmonary apo- plexy, (h) Swelling or inflannnation of the parotids. (c) Inflammation of the large joints, marked by swelling and pain, and sometimes ending in sero-purulent efiusion. This complication, in its less aggravated form, has been described by some writers as rheumatic, (c?) An in- flammatory condition of the eyes and ears, as already noted, (e) Bed-sores. Large, deep, black sloughs occurred in four cases out of 161 treated in the Phila- delphia Hospital in 1866. (/) The course of the disease has also been complicated by the supervention of other maladies, namely (1) Intermittent ferer, or certain paroxysmal phenomena simulating mala- rious poisoning : a complication which has led to erroneous notions of the nature of the disease. In the outbreak on the Lower Vistula cases were observed in which regular or irregular intermissions took place that could not be assigned to a malarious origin. (2) Typhoid fever, the two diseases prevailing simultaneously in the same district. The symptoms of both diseases more or less modified, pursue their course together, and the character- istic lesions of typhoid fever as well as of epidemic cerebro-spinal meningitis are discovered after death. (3) Measles and scarlet fever. (4) Cholera (Levy). Duration. — In the outbreak on the Lower Vistula, the most acute cases ter- minated fatally in from 12 to 72 hours. Cases of less intensity, but in which the patient eventually died in a typhous state, lasted from 8 to 14 days, the characteristic symptoms of the disease persisting to the end. In the more protracted, or compli- cated cases, from 5 to 8 weeks have passed before a patient entered upon convales- cence, and death has taken place in the 6th or 7th week. Of the cases observed in the Philadelphia Hospital (1866), the duration of those which ended fatally was from 24 hours to 14 days ; of those which recovered, from 20 to .30 days, the acute symptoms rarely exceeding a fortnight. 304 EPIDEMIC CEREBRO-SPINAL MENINGITIS. In the outbreak of 1866 in Ireland Dr. S. G-ordon reported a well-marked case which ended fatally after less than five hours^ duration. A large proportion of the fatal cases in that outbreak died in from 10 to 48 hours ; in other cases the fatal ending did not occur until the close of the second and during the course of the third week of the disease. The duration of the dis- ease, as shown by death, may be clearly stated ; as marked by the beginning of convalescence, it does not admit of defi- nite description. Moreover, convales- cence is often very protracted. The course of the disease towards recovery is some- times interrupted by relapses. TERinNATiON. — The disease termi- nates, after a longer or shorter period of convalescence, in health ; or it entails during convalescence a series of physical or mental ills ; or it ends in death. The rate of riwrtality of the disease is the measure of probable recovery. It varies much in diflerent outbreaks, but is at all times formidable. Among the cases ob- served in the Philadelphia Hospital in 1866 the mortality was 33 per cent. ; in the Hardwicke Hospital, Dublin, the same year^ the mortality was 80 per cent. Dr. Stille remarks that, "while ten epidemics in various places, occurring between 1838 and 1848, presented an average mortality of 70 per cent. , a similar number occur- ring during the decade from 1855 to 1865 gives an average mortality of about 30 per cent. This remarkable fact would seem to indicate a gradual decline of power in the epidemic." The minimum rate of mortality recorded is 20 per cent. The proportion of fatal cases is greatest, and the duration of these cases least, at the commencement of an outbreak. The sequelm which interfere with the restora- tion of the patient to perfect health are : — Deafness ; impaired vision from struc- tural changes in one or both eyes ; para- lysis of one or more limbs or of certain groups of muscles ; impaired memory ; carbuncles, and boils. Dr. S. Gordon de- scribes a case in which the patient "re- covered from all the acute symptoms, but gradually passed into a state of almost organic life. He ate, drank, and slept well ; he passed solid feces and urine with- out giving any notice, yet, evidently, not unconsciously ; he was excessively ema- ciated, and there was a peculiar mouse- like smell from him ; he seemed to under- stand what was said to him, but he could not answer ; he never called for anything; his breathing was rather slow ; his pulse, 120 ; his heart acting with a peculiar strong jerking motion ; his eye was quite well, as also his knee (he had suffered from ulceration of the right cornea and immense -effusion into the right knee- jomt); he could draw his legs and arms up to him ; but he could not use his hands at all." Such was the condition of the pa- tient fifty-eight days after the invasion of the disease. Mode of Death. — Death chiefly oc- curs from (a) asphyxia, caused by damage to the respiratory nerve-centres ; { b) from asthenia ; and (c) in some of the fulminant cases probably from necrsemia, so pro- found are the changes observed in the blood. Diagnosis. — In some instances the dis- ease approximates in certain symptoms to typhus or typhoid, and it occasionally pre- vails contemporaneously with both mala- dies. But the history of the development and progress of the disease, with the ab- sence of characteristic eruption, will usually clear up any doubt. From spora- dic spinal meningitis the disease is distin- guished by its epidemicity, the almost constant concurrence of cerebral disorder, the tendency to cutaneous eruptions, the great mortality, and the rareness of pro- tracted or permanent paralysis or contrac- tion of the lower limbs. The distinction between the disease and cerebral meningi- tis is less defined as to particular symptoms, especially in children, but the mode of development of the malady will rarely leave much room for doubt during an outbreak. Tetanus (so-called idiopathic), with which it is suggested that epidemic cerebro-spinal meningitis may, under cer- tain states of spasm, be confounded, never manifests the early grave cerebral symp- toms which occur in the latter disease. The tetanoid contraction also observed in epidemic cerebro-spinal meningitis, is rarely, if ever, as in tetanus, aggravated by sudden and painful spasms. The grouping of the symptoms in the two dis- eases is, moreover, altogether different. Dr. S. Gordon points out the possibility of confounding the purpuric form of epi- demic cerebro-spinal meningitis with ma- lignant measles, which malady has often prevailed at the same time. The last- named disease may resemble the fulminant form of the first-named in several respects, particularly the rapidity of development, the dark color of the eruption, and the rapid appearance of petechiee ; also in the sudden and often extreme collapse which accompanies the invasion of the affection. But the eruption of measles rarely loses its characteristic form, and the affection of the respiratory passages is commonly present, while purpuric spots and patches are seldom observed. Dr. S. Gordon also states that he has known several cases in which the earlier symptoms of epidemic cerebro-spinal meningitis in young excita- ble females have been mistaken forhysteria. Dr. Murchison records a case which pre- sented the sj'mptoms of cerebro-spinal PROGNOSIS — MORBID ANATOMY. 305 fever, including severe headache, moaning, retraction of the head, rigidity of anus, and vomiting ; but in which, after deatli, the duration of the case having been ten days, "no appreciable lesion of the mem- branes of the brain or spinal cord could be discovered, and the cause of death was ascertained to have been uremia from contracted kidneys, and recent pericar- ditis.'" PROGisrosis. — At the best, the prognosis of the disease is very grave. The mortal- ity may be equally great in each of the three varieties, and petechiee and purpura do not, as in other acute diseases, neces- sarily indicate an aggravated degree of danger. In 50 per cent, of the cases re- corded by Dr. Githens, in one of the least fatal outbreaks known, petechias were present, and it is especially remarked that neither this nor anjr other form of erup- tion had "any reference to the progno- sis." But when hemorrhage into the cutis is extensive, either from the number or the size of the spots, and is accompa- nied by marked signs of vital prostration, it indicates an extremity of danger, al- though not a certainty of death. The disease is more fatal among infants and young children than among youths and adults in the prime of life ; but, in some outbreaks, the latter have suffered most. After thirty years of age it becomes more dangerous. Life is most endangered in the earlier days of the disease, particu- larly during the first five. But danger is present at all periods of the malady, and the convalescent is not entirely safe until health is fully restored. Of the special symptoms, whetiier of excitement or de- pression, the rules of prognosis hold good which apply to other highly fatal acute maladies. MoEBiD Anatomy.— The essential an- atomical characteristics of the disease, found after death, are hypersemia, often intense, of the pia mater of the brain and spinal cord ; with more or less copious subarachnoid and interstitial effusion into the meshes of the congested pia mater, either of serum, or of a transparent, gela- tinous material, or of purulent matter : the latter more frequently than either of the two former. The purulent effusion is of greenish or yellowish color, and is some- times flaky, it has been found in a case in which death took place in less than five hours from the invasion of the disease (S. Urdon). The extent to which these ap- pearances are observed and the amount of effusion varies greatly in different cases. ■No part of the encephalic or spinal pia ' Proceedings of the Pathological Society, Vol. xviii. VOL. I.— 20 mater and arachnoid may be free, or cer- tain portions alone may be allected ; but eftusion is limited to the sub-arachnoid space, and does not occur into the arach- noid cavity. Under the microscope, ac- cording to Dr. Burden Sanderson, the gelatinous material is " always found to consist of cell-like bodies, either adhering to each other so closely that they could not be completely separated, or imlsedded in a transparent interstitial substance ; while the sero-purulent liquid which occu- pied the spinal sub-arachnoid space, and in some cases the ventricles, exhibited corpuscles and granules floating freely. The cell-like bodies, although in general resembling pus corpuscles, did not present that uniformity of size and character which is met with in normal pus. They were usually, but not always, of regular circular contour, and varied in diameter from j^Vsth to Tj'iiirth of an inch. Occa- sionally they exhibited the appearance of an external cell-membrane, but in most instances this could not be made out even in perfectly fresh exudations — as, e. g., in those cases which were examined as early as eight hours after death. They invari- ably contained numerous granules, some of which were oleared away on the addi- tion of acetic acid. Those which re- mained were highly refractive, but did not assume any special form of arrangement. The interstitial substance was beset with granules, some of which were albuminous, others fatty. It was most abundant and distinct on "the surface of the spinal arach- noid, where it infiltrated the fine connect- ing tissue and minute bloodvessels of the pia mater." For the rest, the nervous system of the brain and spinal cord is usually gorged with blood, unless death has taken place late in the course of the disease. The vis- ceral arachnoid is frequently thickened and opaque. Dr. Klebs' has shown that often, where the eye detects opacity alone, the microscope reveals extensive cell for- mation, purulent in character. Softening of some portion of the spinal cord has sometimes been observed ; and Mr. J. Si- mon thinks that, " for practical purposes, the state of the covering membranes of the nervous centres may be regarded as a mere index of changes more or less dis- tinctive, which those centres in their own intimate composition have at_ the same time undergone ; and hence it is that the essential phenomena of the disease during life consist in disturbances, more or less grave, of the functions of these all-impor- tant organs. " Dr. Klebs describes cedema of the medullary substance and loosening ' Zur Pathologie der Epidemischen Menin- gitis. Virchow's Arcliiv. Band xxxiv. Brit- ish and Foreign Medico-Chirurgical Review, 1868. 303 EPIDEMIC CEREBRO-SPINAL MENTNGTTIS. of the nervous elements, and suggests that this may explain the extensive motor dis- turbances which have been observed in some cases, in which purulent elt'usion into the subarachnoid space has been slight. The same author has observed also purulent encephalitis. In fatal cases of the simple and pur- puric forms of epideuiic cerebro-spiual ni, iiingitis the characteristic anatouiical lesions are almost invariably found. In the fulminant form of the disease they are often absent. The cases in which there is no indication of morbid change in the nervous centres are exceedingly few. It has been suggested that in these cases death has occurred so rapidly that there was insufficient time for the formation of a structural lesion. In connection with this explanation the case recorded by Dr. S. Gordon must be borne in mind, in which purulent effusion was found, al- though the whole duration of the attack was under five hours. Practically the ap- parent absence of characteristic; anatom- ical change in the nervous centres, in cer- tain rare cases of epidemic cerebro-spinal meningitis, is a phenomenon analogous to that which sometimes occurs in rapidly fatal cases of malarious, variolous, and scarlatinous poisoning, in which the char- acteristic eruptions or lesions of the dis- eases have not been developed. No lesions manifestly peculiar to epi- demic cerebro-spinal meningitis have, as yet, been found in other organs of the body. Such lesions as occur elsewhere than in the coverings of the brain and spinal cord usually have a definite relation to the thoracic, abdominal, or genito-uri- nary complications which may have hap- pened during tlie progress of the malady. Dr. Klebs, however, describes certain changes in the intimate structure of the kidneys and liver, which he believes to be characteristic of the disease. In the fatal cases of the purpuric form of the affection recorded by Dr. S. Gordon, and other writers, an excessive fluidity of the blood was noted. History and Geographical Distri- bution. — The scientific history of epi- demic cerebro-spinal meningitis dates only from the fourth decennuim of the present century. At that period the dis- ease was, for the first time, clearly distin- guif'hed as an independent malady ; and with the light then obtained, outbreaks which had occurred earlier in the cen- tury, in various localities of both the Eastern and Western hemispheres, and had been recorded under other names, were recognized as of a similar character. It has been sought, indeed, to show that epidemic cerebro-spinal meningitis has probably existed from remote periods (Tourdes, Boudin). The probability may be admitted, for the flr^t recognition of a malady as an independent affection does not necessarily imply that the malady is new. In 1837 epidemic cerebro-spinal menin- gitis broke out in the southwest of France, and prevailed in various localities of the district intervening between Bayonne and La Rochelle, and along the whole line of the Pyrenean frontier. Dax, Bordeaux, Audi, Foix, Narbonne, and Perpignan suffered, as well as the two cities pre- viously named. The disease, according to Boudin, at the commencement and during the continuance of this outbreak, chiefly showed itself among troops in gar- rison. During 1837 and 1838 the garri- sons of Bayonne, Dax, Bordeaux, Eoche- fort, and La Rochelle suffered. From 1838 to 1841 the disease was prevalent among the garrisons of southeastern France, particularly those of the valley of the Rhone. Thus it broke out at Tou- lon, Marseilles, Aigues-Mortes, Nismes, Avignon, and Pont-Saint-Esprit. In the course of the four years 1839-40-41-42, the malady appeared in succession among the troops occupying the fortresses of Strasburg, Schelestadt, Calmar, Nancy, Metz, and Givet. From 1839 to 1842 'it prevailed among the forces at Versailles, Saint-Cloud, Rambouillet, and Chartres. Those stationed along the coast of Brit- tany, at Brest, L'Orient, Nantes, and Ancenis, suffered in 1841 ; and during 1840 and 1841 the disease manifested it- self among divers detachments of a regi- ment scattered at Laval, Le Mans, Cha- teau-Gontier, Tours, and Poitiers. It was during the outbreak — of which the most remarkable episode is thus sketched by Boudin — that a scientific knowledge of epidemic cerebro-spinal meningitis was first obtained. From 1837 to 1848 inclu- sive, forty-seven outbreaks of the malady were recorded in thirty-six of the eighty- six departments into which France was then divided. These outbreaks were dis- tributed in the departments of the Loire, Rhone, Bouches - du - Rhone, Bas-Ehin, Seine, Seine-et-Oise, Landes, Basses-Py- renees, Charente - Inferieure, Gard, Vau- cluse, Var, Moselle, and Loiret. The three first -named departments suffered most. In 1840 the disease appeared in Naples and prevailed in the Papal States. The same year it broke out among the French garrison at Douera, Algeris,, and during the next seven years it attacked numerous towns and localities of the province, affecting the civil population, ijoth European and native, as well as the military. In 1844 an outbreak of the dis- ease took place among the civil population of Gibraltar ; and in 1846 the malady showed itself slightly in Ireland among the inmates of the Rathdown, South Dub- lin, and Belfast workhouses, and several HISTORY AND GEOGRAPHICAL DISTRlliUTION. SOT cases occurred among the population of Dublin. During 1849 and 1850 the dis- ease was prevalent to some extent among the French troops in Italy, and in the last-named year several localities of France suffered from it. Epidemic cere- bro-spinal meningitis appeared in Den- mark in 1841, and prevailed in that coun- try until 1848. The disease was first no- ticed in Sweden in 1854, this country again suffering from it in 1861. In Nor- way the malady broke out in 1859, and it prevailed in that country more or less until 1867, if not to a later period. Dur- ing 1860 the disease was prevalent in Hol- land ; and the same year it was widely spread in Portugal. In 1863, 1864, and 1865 an extensive outbreak occurred in North Germany; and in 1806 the malady broke out in Dublin and elsewhere in Ire- land. Cases were recorded in St. Peters- burg during 1866 and 1807. In the United States (where the disease may be traced back to the commencement of the century), epidemic cerebro-spinal meningitis became prevalent about the same time that it exhibited great activity in Europe. From 1842 to 1850 inclusive, a series of outbreaks took place in the States of Kentucky, Tennessee, South Illi- nois, Mississippi, Arkansas, Alabama, Pennsylvania, Massachusetts, New York, and North Carolina. After this period there would appear to have been an inter- val of comparative inactivity. In 1861 the disease broke out in North and Central Missouri, and from that time to the pre- sent it has prevailed, more or less exten- sively, in almost all, if not all, the States of the Union, with the exception, perhaps, of the Pacific States. In 1862 outbreaks were recorded in Connecticut, Kentucky, Indiana, and Tennessee ; in 1863, in Rhode Island ; in 1864, in Pennsylvania, Ohio, lUinois, New York, Maryland, Massachusetts, and Vermont ; and in 1S65, in North Carolina and other Southern States. During 1867 and 1868 the disease was active in several States. It must be borne in mind that these historical notes very imperfectly represent the probable prevalence and geographical distribution of the disease. They simply inchide a brief summary of outbreaks which have come under the notice of thoughtful observers who have published their observations. The history of the malady in the British Islands is, perhaps, less liable to error from this source. The earliest recorded outbreak of the disease occurred in Ireland during the early months of 1846. It broke out to a very limited extent among the boys living in the Rathdown Union, South Dublin, and Belfast workhouses ; and two cases, both in females, one aged 17 years, the other 36 years, were admitted into the Hard- wicke Hospital, Dublin.' Prior to this outbreak, there is not any trustworthy history of the presence of epidemic cerebro- spinal meningitis in the British Islands. It is not improbable, however, that the disease existed at Blackaton, in Devon- shire, in 1807 ;!! and at Sunderland in 1830.' Dr. Benjamin W. Richardson saw, he believes, a case at Mortlake, Surrey, in 1843.* From the time of the outbreak in 1846, cases of a similar malady were occasionally observed in Dublin, until the latter half of 1850, when they became more common.^ There is no further notice of epidemic cerebro-spinal meningitis in Ireland until the year 1865, when cases began to be again observed in Dublin. I! A case of cerebro-spinal menin- gitis was observed by Dr. Samuel Wilks, in each of the three years 1856, 1858, 1859, in the metropolis.' In October 1859, a fatal case of cerebro-spinal disorder with petechial eruption, came under the notice of Dr. Henry Day, in the vicinity of Stafford. In this case, hypersemia of the meninges of the brain and spinal cord, and copious effusion of fluid at the base of the brain, were discovered after death. A similar but more rapidly fatal case was also observed by Dr. Day, in the Stafford General Infirmary in September, 1865.' The largest and most fatal outbreak ol' epidemic cerebro-spinal meningitis wliich has occurred within the limits of the United Kingdom began in Ireland in March 1866, and attained its chief develop- ment in the subsequent winter. Its effects were almost entirely limited to the sister island, and the brunt of the outbreak fell upon Dublin. Other localities affected, during the first year of prevalence, were TuUamore, Parsonstown, Mitchelstown, Thurles, Clondalkin, and the Curragh camp. Subsequently cases were recorded in the counties of Cork, Waterford, Clare, Galway, Meath, Down, &c. The cases were not very numerous in Dublin ; and in the country towns they were compara- tively few. It is noteworthy that, as in the earlier outbreaks in France, the miU- tary in Ireland, in proportion to their strength ; suffered prominently from the disease. In some of the country districts ' Dr. Robt. Mayne, Dublin Quarterly Jour- nal of Medical Science, 184«, vol. 11. p. 95. 2 Mr. Henry fxervis, Medlco-Chlrurgical Society's Transactions, vol. 11. 3 Dr. John Scott, Medical Times and Gazette, 1S65, vol. i. p. 515. * Social Science Review, May 1865, p. 398. 6 Dr. McDowell, The London Journal of Medicine, 1851, vol. iii. p. 858. 6 Dr. Kennedy, The Medical Press and Cir- cular, June 12, 1861, p. 551. 7 The Lancet, April 15, 1865, p. 389. 8 Clinical Histories and Commentaries 1866, pp. 3-7. 808 EPIDEMIC CEEEBRO-SPINAL MENINGITIS. cases were recorded among the troops alone, or among persons in immediate connection witli tliem. ' In January and February 1867, an outbreak of a disease characterized by severe rigors, tetanic convulsions, intense neuralgic pain in the head and upper part of the trunk, in- creased sensitiveness of the surface, obsti- nate vomiting, restlessness, and, in one instance at kast, by a dark purple erup- tion, but of which not a single case died, took place at Bardney, in Lincolnshire, a village about ten miles east of Lincoln, on the verge of a fen country, and having a population of 1500, the bulk of whom are engaged in agricultural pursuits.'' Two cases of epidemic cerebro-spinal meningi- tis were recorded in London in the sum- mer of 1867. One, a case of the fulminant form of the malady, in which death occurred in twenty -seven hours, took place in June f the other, a case of the purpuric form, in which death occurred in seven days, took place in June.* Since the at- tention of English practitioners has been more fully directed to epidemic cerebro- spinal meningitis by the late outbreak in Ireland, so-called sporadic instances of the disease have been noted in various parts of the kingdom, under circumstances which lead to the surmise that the malady is not so rare among the population as had previously been supposed. The peculiarity of distribution of the disease in the British Islands, its epi- demic manifestations being limited to one portion of the kingdom, and chiefly, even in recurrent outbreaks, to a small section of the population of that portion, is not an isolated phenomenon. Notwithstanding the wide geographical prevalence of the malady as shown by the foregoing details, it must not be concluded that this preva- lence represents a general diffusion of the disease among the different populations during the periods of its activity. The outbreaks of epidemic cebro-spinal men- ingitis, as a rule, are limited to small sec- tions of a population, and its distribution is by a series of isolated outbreaks, rather than by extensive spreading. This was shown remarkably, as already described, during the outbreak in France in 1837 and following years, when the ravages of the malady were principally confined to ' Dr. E. D. Mapother, and Staff-surgeon Dr. Jeffrey A. Marston, The Lancet, July 6, and July 13, 1867 ; also Transactions of the Epidemiological Society, vol. iii. p. 118, and p. 129. 1 s G. M. Lowe, M.B., The Lancet, Jiine 26, 1867, p. 790 ; Mr. Geo. Newnham WooUey, The Lancet, Aug. 3, 1867, p. 130. ' Dr. Edward Crisp, The Lancet, June 22, 1867, p. 773. < Dr. Thomas Clark, The Lancet, July 13, 1867. certain garrisons, and even to small sec- tions of a garrison, without affecting the surrounding population. A like limita- tion of the disease to certain detachments of troops was observed during the recent war in the United States ; and the re- striction of the malady to small portions of workhouse populations, as in the first outbreak in Ireland, is an analogous phe- nomenon. Perhaps the sole outbreak in which an extensive diffusion of the dis- ease among a community has occurred was that in the province of Dantzic, in 1864-65. The tendency to reproduction in a locality, as in Dublin, was particu- larly observed during the great outbreak in France from 1838 to 1848, when the disease reappeared again and again among the forces in Bayonne, Versailles, and Avignon, notwithstanding changes of gar- rison. The freedom of England and Scot- land from epidemic outbreaks of so widely spread a malady is very remarkable ; par- ticularly if the seeming occasional cases of the disease to which reference has been made are to be regarded as true examples. Etio'logt. — (a) Predisposing Causes. — Age. The personal liability to the dis- ease is not governed in any definite man- ner by age. In some epidemics children, in others young people, in others again adults of from thirty to fifty years, have suffered in greatest proportion. — Sex. Generally, and in some outbreaks very markedly, males are more liable to the disease than females. — Profession. Dur- ing the outbreaks of the disease in France from 1837 to 1849, a peculiar proclivity to the disease was observed among soldiers. But in subsequent outbreaks in France, and wide-spread outbreaks elsewhere, no special liability to the disease was mani- fested among any vocation. — Climate and Seasons. In the Eastern hemisphere our knowledge of the disease is limited to Western and Central Europe and Alge- ria, the northern boundary of the district not passing beyond lat. 61° l^T. , the south- ern not beyond lat. 35° S. — the one ex- treme closely approaching the arctic, the other the torrid zone. In the "Western hemisphere the records of the malady are confined to the populous districts of the eastern division of the United States, from lat. 30° N. to lat. 48° N. It is note- worthy that the northern and southern limits of distribution in both hemispheres but slightly overlap the isothermal fines 5'^ and 20°. Season acts as an unques- tionable and powerful predisposing cause of epidemic cerebro-spinal meningitis, which is especially a disease of the cold months. Of 216 local outbreaks in France and the United States, 166 prevailed be- tween December 1st and May 31st ; 50 in the other six months of the year. In Sweden, of 417 local outbreaks, 311 took ETIOLOGY. 809 place in the former period of tlie year, 106 in the latter (Stille). During the re- cent outbreak in Ireland, the brunt of tiie disease fell between January and July, 1867. Of 85 outbreaks in various parts of Europe and the United States, noted by Hirsch, 33 prevailed in winter, 24: in winter and spring, 11 in spring, 1 in spring and summer, 2 in summer, 1 in summer and autumn, 1 in autumn, 1 in autumn and winter, 3 in autumn, winter, and spring, and 6 prevailed tliroughout the whole year. — Locality and soil do not, so far as yet ascertained, exercise any manifest in- fluence over tlie disease. It has been observed indifferently on low grounds, on highlands, and on soils of the most vari- ous character. — Sanitary conditions. No definite relation exists between the occur- rence of the disease and the sanitary state of habitations or of individuals. It has prevailed in some epidemics alike among the affluent and the impoverished — among those who are well-fed, well-housed, and well-clothed, as among those who are ill- fed, ill-housed, and insufficiently clothed. In certain outbreaks, as in tliat on the Lower Vistula, the prosperous classes suf- fered to a much less extent from the ma- lady than the poor and miserable, who were subjected to privation and to much foulness of persons, dwellings, and atmos- phere. (b) Exciting Causes. — Fatigue has been mentioned as an exciting cause. In some of the early outbreaks of the disease among French troops, France being at war at the time, fatigue apparently exer- cised a determining influence. Again, during the recent outbreak in Ireland, the malady appeared very early among a "flying column" of troops occupied in the suppression of the Fenian disturbance, and exposed to great fatigue and in- clemency of weather. But fatigue has played little or no part in determining the disease among the civil population, espe- cially among children and the inmates of workhouses and prisons. — Cold. The marked predominance of the disease in the winter and spring months has sug- gested a causal connection with eold. Hirsch has submitted the question to a detailed examination, and with this result : that, although we cannot exclude the sus- picion that the temperature of winter and spring may have some direct eftect upon the genesis of the disease, "the modiflca- tions in the mode of Uving incidental to these seasons exert, in a far higher degree, an influence favorable to the presence of this as of many other infectious maladies. '" —Certain Insanitary States. There is not any constant or even common relationship between any insanitary state and the ap- ' Transactions of the Epidemiological So- ciety, vol. ii. p. 369. pearance of the disease. Neither foulness of house and its sun-oundings, nor of the atmosphere, whether from putrid emana- tions or from overcrowding, nor impurity of any other kind, has any determinate relation with epidemic cerebro - spinal meningitis. But Hirsch remarks' of the outbreak in the province of Dantzic in 1805, that "the disease prevailed exactly in that season of the year in which, on ac- count of inclement weather, many indi- viduals were crowded together into small and dirty rooms kept constantly closed by their occupants, and from which all venti- lation was excluded, and in which the before - mentioned unfavorable hygienic conditions (dampness, great lilth, and an atmosphere loaded with putrid emana- tions) were extremely perceptible." The causes here suggested have been held to be not altogether inoperative in other and more circumscribed outbreaks.— Conmn(- nication of the sich with the well. The great majority ot observers have come to the conclusion that the disease is incommuni- cable from the sick to the well. Among the minority who hesitate to accept this deduction without reservation are Profes- sor Hirsch, Professor Stokes, and Mr. J. Simon. The facts which suggest the pos- sibility of the active cause of the disease being portable in some way are of the fol- lowing character: — (a) A child was seized witli epidemic cerebro-spinal meningitis, and died. A second child of the same family was attacked with the malady a few days later. The day following the attack of this child, the mother, who slept in the same bed with it, sickened of the disease.'' (b) 1. On the 8th of February, 1865, a youtli, aged 20 j'ears, was attacked with the characteristic symptoms of epi- demic cerebro-spinal meningitis. He was nursed by a woman from another village. The youth died, and after his death the woman returned home. She soon sick- ened, and she died of the epidemic disease on the 26th February. d?here had been but one case previously in the village. To the interment of the woman came a family from another locality, the funeral obse- quies, as customary in the district, being performed with the coffin opened. After the return home of this family, a child, three months old, sickened immediately of meningitis and died within twenty-four hours. Then a man who had accompanied the family to the interment was attacked with the disease, and died on the 2d of March. Lastly, a girl, in the same local- ity, who had also been at the funeral, was seized, and died on the 7th March. 2. At another village, two children of one family, aged three and a half and one and a half • Ibid. vol. ii. p. 372. 2 Professor Stokes, The Medical Press and Circular, June 19, 1867, p. 581. &10 EPIDEMIC CEREBRO-SPINAL MENINGITIS. j^ears respectively, died of the epidemic, one on tlie "iTtli January, tlie other on the 7th February. The clothes of the de- ceased were taken to a neighboring vil- lage, and came into the possession of a girl aged five years. She soon siclsened of the epidemic, and died on the 14th Feb- ruary.' (c) Boudin relates instances of the appearance of the disease in garrisons, and among the civil population of towns, after the introduction of detachments of troops among whom the disease had pre- vailed or was prevailing at the time. [The occurrence of this affection in gar- risons has been too frequent to be other- wise than important. During the civil war in the United States, many cases oc- curred amongst soldiers in camp, and at their homes in Northern cities upon their return from service. Two cases at least occurred in Philadelphia, the origination of which coincided with exposure to the effluvia from filthy clothing ofreturned pri- vate soldiers. But this is, most probably, evidence of the existence of a peculiar morbid poison generated by slow organic decay ; not at all necessarily giving proof of somatic contagion. The idea of the personal communicability of cerebro-spi- nal fever has met with no support in the general experience of American practi- tioners. — li.] The foregoing facts simply suggest the possibility of the active cause of epidemic cerebro-spinal meningitis being communi- cable by the sick to the well. This possi- bility, notwithstanding tlie apparent for- midable array of facts to the contrary, is not to be lightly dealt with. The lesson taught by the difficulties and doubts which beset the discovery of the communicability of typhoid fever and cholera, will have been strangely misunderstood if it is ne- cessary to urge upon observers, the im- portance of keeping the question of the possible communicability of epidemic cere- bro-spinal meningitis constantly before the mind. In the consideration of this question, however, a caution is needed. The term "contagion" is used too indis- criminately. It has been so long employed to express the manner of transmission of disease which is witnessed in smallpox, scarlet fever, or typhus, that it is difficult to dissociate the idea of this manner from the word. It is almost impossible, in reading the opinions of those writers who have come to the conclusion that epidemic cerebro-spinal meningitis is not a "conta- gious" disease, to avoid the suspicion, from their use of the adjective, that they have looked upon the question too exclu- sively from the point of view suggested by the diseases named. It is obvious that contagiousness of a like character to that ' Hirsch, Transactions of Epidemiological Society, vol. ii. p. 373. of smallpox, scarlet fever, or typhus, is not possessed by the malady under con- sideration. The question is : Does epi- demic meningitis, like typhoid fever or cholera, possess a peculiar contagiousness of its own, a property of communicability peculiar to itself? This has yet to be solved. Another explanation of the facts which appear to indicate a possible com- municability of the disease from the sick to the well is, however, open, and is set forth in the next paragraph. Diseased grain.^Dr. B. "W. Richardson has suggested that epidemic cerebro-spi- nal meningitis may possibly arise from the consumption of diseased grain after the manner of ergotism, and perhaps acro- dynia. He thinks that the probabilities are altogether in favor of the suggestion, that " the cause in fact is a diseased grain, or fungus, contained in some kinds of flour out of which the breadstuffs are made. This fungus may not be present in large quantities, and many persons may eat of the food without getting a poisonous part; but one will get it out of a number, and this without any communication beyond the breaking of bread together : the dis- ease may occur in one member of a fam- ily, leaving the rest free, and in this irreg- ular way it may be distributed, in an epi- demic form, over a large surface of coun- try." He adds, "If my hypothesis, as regards cause, be correct, there is little danger of the disorder extending widely in this country ; for of our cereals used as food, nearly the whole of the population now select wheat, and our wheat gener- ally is selected for the market with great judgment and circumspection. Any cases, therefore, that might occur would be iso- lated, and would be easily traced out and prevented."' This suggestion opens out an altogether new field of inquiry respect- ing the origin of the disease, and it de- mands active and thoughtful considera- tion in subsequent outbreaks. Dr. H. Day, of Stafford, has endeavored, by ex- periments on the lower animals, to obtain some light on the subject. He fed three rabbits with unsound grain (wheat, oats, ergot of rye, and mouldy bread) with this result : In all the animals a spasmodic affection was produced, and in two in- flammatory changes in the right eye, pro- ceeding in one case to ulceration of the cornea, and evacuation of the contents of the globe. One of the rabbits died on the eighth day, the other two were killed on the twelfth day, and in all more or less congestion of the membranes of the spinal cord was found on dissection." The sum of our knowledge of the etiology of epidemic cerebro-spinal meningitis is I Social Science Review, May, 1865, p. 403. " Clinical Histories and Comments, pp. 18 -23. NATURE. SU this— that the clue to its explanation lias not as yet been discovered. Nature. — 1. Is the disease malarious, as sugye^ted by some writers? The out- breaks in which the disease has occurred in malarious districts, or in which the malady has shown an intermittent charac- ter, are too few in number to admit of much, if any, doubt resting upon the an- swer. There is no sufficient ground for believing that the malady is of malarious origin. The numerous examples of prev- alence of the disease in localities free from malaria set the question aside deflnitel_y. Even when intermissions or remissions have been observed in tlie progress of the malady, it must not be hastily assumed timt they are consequent upon malarious poisoning. Hirsch has shown that cer- tain cases of epidemic cerebro-spinal men- ingitis, distinguished by intermissions and remissions, which came under his own ob- servation, took place in the course of an outbreak in a district free from malaria. Further, he states that this outbreak pre- vailed at a season (winter^ and in a state of climate (intense cold) which notoriously exclude the prevalence of malarious dis- ease, even where endemic ; that the period of life (1-5 years) least liable to malarious disease furnished the largest contingent of victims, while the classes most ad- vanced in life, and who are most liable, escaped the epidemic in a remarkable degree. Finally, the infallible test of ma- larious disease, quinine, by its inutility in cases of the epidemic which assumed an intermittent or remittent character, showed the non-malarious nature of the aflection.' 2. Is epidemic cerebro-spinal meningitis a form of, or allied to, typhus f Epidemic cerebro-spinal meningitis differs from typhus in the aspect of the patient, progress of the disease, range and course of temperature, form of cerebral affection, character of eruption, sequelae, rate of mortality, anatomical lesions, and man- ner of dissemination. Differing in all essential particulars, doubt can only arise when the two diseases prevail together. Under such circumstances, cases of the fulminant and purpuric forms of the one malady may be difficult to discriminate from the graver and more rapidly fatal forms of the other. Doubt also may arise when in the course of the former disease typhous or typhoid symptoms occur. But such a doubt applies equally to the dis- crimination of the disease from measles and typhoid fever, as from typhus. 3. Is epidemic cerebro-spinal meningitis a true nr a pseudo-epidemic disease ? Is this disease a true epidemic disease in the sense of its being due to a specific febrile poison (to Transactions of the Epidemiological So- ciety, vol. ii. p. 377. which class of diseases the term epidemic is now well-nigh alone restricted) ? Or is it a pseudo-epidemic malady, as being an ex- aggerated and more prevalent form, from certain climatic or other conditions of an idiopathic intlammatory affection of the brain and spinal cord ? No aljsolute dis- tinction can be drawn between sporadic cerebro-spinal meningitis and the epi- demic malady of the same name. But there are certain broad and well-defined diflerences. The conjoined inflamma- tory affection of the covering membranes of the brain and spinal cord, which is the rule in epidemic cerebro-spinal men- ingitis, is a rare exception in sporadic inriammation of the envelopes of the cen- tral nervous centres. Again, the indica- tions of blood-change which are so com- mon in the epidemic disease have been witnessed only in exceptional cases in the sporadic disease. The question ari-es whether the exceptional cases are in- stances of idiopathic cerebro-spinal men- ingitis or of the epidemic form of the malady. This cannot be determined ar- bitraril}'. It is certain that cases of cere- bro-spinal meningitis, indistinguishable from the epidemic disease, are observed, in the intervals of prevalence of the lat- ter, even in this country (H. Day, Wilks, &c.). These cases are of much, "although as yet of indeterminate, interest, in refer- ence to the etiology of the malady. It has been suggested that the blood-change and herpetic and purpuric eruptions may be of nervous origin, and consequent upon the profound alteration in the nervous system.' It has been suggested, also, that the purpuric eruption of epidemic cere- bro-spinal meningitis may be one of seve- red signs of a general tendency to purpura in disease at the time of prevalence, and merely an incidental phenomenon of the epidemic malady. Thus in Dublin (1S66- 67), purpura has been observed in rheu- matic fever, and there was an outbreak of purpura among swine,'' contemporane- ously with the epidemic. The first sug- gestion touches a very curious question, which as yet does not admit of solution. But it is worthy of remark that the form of eruption which of all others is peculiar to epidemic cerebro-spinal meningitis is the herpietic — a form which, in some of its manifestations at least, as in herpes labi- alis, and in shingles, has singular neurotic relations. Mr. Jonathan Hutchinson has propounded the riddle, Is herpes zoster an exanthem or neurosis?' This is certain, that it is a symptom which has some defi- nite connection with lesions of nerve ' Dr. Banks, The Medical Press and Circu- lar, .June 19, 1867, p. 580. 2 Dr. Mapother, The Lancet, July 13, 1867, p. 39. ' London Hosp. Reps., vol. iii. p. 70. 312 EPIDEMIC CEREBRO-SPINAL MENIXGITIS. trunks, if not of nerve centres.' The facts upon which the second suggestion is based are of interest, but they form too narrow a basis for conclusions. 4. Is epidc'inic cerebrospinal meniwjitis a disease, sui ge- neris ? Tlie association of symi^toms shows that it is an independent malady ; the aptitude to blood-changes in the course of the disease, judged by analogy with like changes which occur in acute specific dis- eases, suggests the inference that it also is dependent upon a specific poison, from whatever source derived. This is the con- clusion which appears to have the highest degree of probability in the present state of our knowledge. An intercurrent question arises here — • Is the fulminant form of epidemic cerebro- spinal meningitis really a variety of the disease, or a different malady altogether ? Dr. E. D. Lyons maintains that during the prevalence of the epidemic in Dublin in 1800, two independent diseases existed. The one, characterized by collapse, pro- fuse purpuric eruption, great rapidity of course, excessive fatality, and absence of anatomical lesion in the nervous centres after death, he designates /c6r?s«i(yra,' the other was the disease commonly known as cerebro-spinal meningitis. But it is to be remarked that the two varieties of disease have never been observed except in the same epidemic ; that they pass by insensi- ble grades the one into the other ; that the > Dr. H. Day (Lancet, vol. i. 1867, p. 731) expresses the opinion that an eruption would probably be more commonly found in cases of sporadic cerebro-spinal meningitis if it were more carefully looked for; and he remarks that the petechial spots which he has ob- served in cases coming under his own notice, sometimes do not appear until after death. My own observations coincide with those of Dr. Day. In connection with this subject it is well to bear in mind Trousseau's so-called cerebral or meningeal macula (Lectures on Clin- ical Medicine, Bazire's Trans., vol. i. p. 459), a phenomenon of wider occurrence in diseases of the central nervous system than even the distinguished professor suspected. I may add, that a short time ago I was present at the examination of the body of a patient who had died from a s.vphilitic disease of the right hemisphere of the brain. I was particularly struck with a peculiarity in the after-death lividity which seemed to me not uninstruc- tive with regard to the purpuric forms of cerebro-spinal fever. Life had been extinct eighteen hours. The greater part of the de- pending portions of the body was ecchymotic ; but, in addition, many livid, circular spots, of about the size of a split pea, a few of larger size, were scattered over the upper aspect (dorsal) of the feet, and of the legs beneath the knees ; also, over the upper aspect (dor- sal) of the hands, and of the arms beneath the elbow. These spots, had they been ob- served in a case of cerebro-spinal meningitis, would have been designated "purpuric." most highly developed symptoms of the so-called febris nigra sometimes occur to- gether with the most marked symptoms of cerebro-spinal meningitis ; and that it is more consistent with experience to con- sider the two series of symptoms as indi- cations of one and the same malady, rather than two maladies going forward at the same time in the same patient. A second intercurrent question is, whether the pur- puric form of the disease be of scorbutic origin ? The question amounts to little more than a suggestion. There are no facts which suiiport an aflflrmative an- swer ; for, apart from other well-known signs, purpuric spots are not indications of a scorbutic taint. Treatment. — Prophylactic. — Igno- rance of the true etiology of the disease limits our preventive efforts to general sanitary measures, applicable to all epi- demic diseases, for the purification of houses and localities. Mr. J. Simon, re- cording the conditions under which the disease has prevailed, writes: "I am strongly of opinion that the best sanitary precaution which in the present state of knowledge can be taken against the dis- ease, must consist in care for the ventila- tion of dwellings." He adds, however, "that in some cases, according to local reports, the distribution of an epidemic has very decidedly not been governed by conditions of overcrowding and ill-ventila- tion." Dr. B. W. Richardson's sugges- tion as to the cause of the disease should lead to the careful microscopic examina- tion of all breadstuffs and farinaceous preparations in use among famihes and communities where the disease breaks out, and the disuse of such as maybe of doubtful character. Curative. — The treatment of epidemic cerebro-spinal meningitis is as unsatisfac- tory as that of cholera. The evidence of the course of the disease having been ben- eficially affected in any outbreak by the administration of medicine is very doubt- ful. The too common rapid progress of the malady to death, as in cholera, and the nature of the lesions determining death, necessarily set at naught efforts to check it ; medicine not being guilty either of inaptitude or inactivity. The control of this disease, as of cholera or trichiniasis, is a question of preventive rather than curative treatment, and must depend upon the discovery and limitation of its cause. In the earlier outbreaks, epidemic cerebro-spinal meningitis was treated, as an acute inflammatory affection, by bleed- ing and purgatives, with the general re- sult that the fatality of the malady was probably almost invariably augmented. During the outbreak of 1866 in Philadel- phia, it was found that. In the more sthenic cases, cupping the nape of tlie TREATMENT. 313 neck was " of essential service in mitigat- ing, and generally, indeed, in wliolly re- moving the neuralgic pains which form so prominent and so severe a symptom in many cases of the disease" (Stille). When the state of the patient forbade the ab- straction of blood, dry cupping used in the ■same locality afforded signal relief, and rendered the effects of vesication more prompt and complete. This was the ex- perience in one of the least fatal outbreaks recorded. The experience of the majority of epidemics has been against any blood- letting, local or general. The deduction to be derived as to depletion from the gen- eral state of the circulation, entirely coin- cides with the results of practice. For, as a rule, the pulse from the very outset contraindicates the withdrawal of blood ; and, if in any case it should seem from the general symptoms that depletion might exercise some control over the central mischief, a thoughtful regard should be given to the future. The application of oM to the head and spine, either by means of ice or a freezing mixture, in Esmarch's india-rubber bags, is not open to the same objection as blood-letting, and has furnished by far the most satisfactory results of all direct treatment of the acute cerebro-spinal symptoms In its use care should be taken not to prolong the appli- cation so as to depress, or increase the depression already existing of, the whole system. When the acute nervous symp- toms are accompanied by marked prostra- tion, it is advisable during the application of the ice to swathe the limbs in hot flan- nels, to pack the legs and thighs with hot- water bottles, or bags filled with hot sand or salt, and to cover the abdomen with thick layers of flannel or cotton-wool. From the very outset of the disease, care should be taken to economize the tempe- rature of the body, and anticipate its fall ; and in cases characterized by collapse, or much vital depression, the application of external heat in the manner just suggested is a cardinal point of treatment. Of med- icaments directly addressed to the nervous symptoms, opium is the most valuable. It is especially indicated when there is much restlessness, acute delirium, sleep- lessness, hypersesthesia, or painful spasm. Morphia is the best form of administra- tion, and subcutaneous injection perhaps the best mode. The drug should be given in decided and frequently-repeated doses, and carefully watched. Stille says of its 'use during the late outbreak in Philadel- phia : " We were in the habit of giving one grain of opium every hour, in very severe, and every two hours in moderately severe cases, and in no instance was pro- duced either narcotism or even an ap- proach to that condition. Under the influence of the medicine the pain and spasm subsided, the skin grew warmer, and the pulse fuller, and the entire condi- tion of the patient more hopeful. It seemed probable, however, tliat the full benefit of the opium treatment could be received by those only who were subjected to it in the early stages of the attack. Direct experience is here in perfect accord with the expectation which a knowledge of the pathological processes involved in the disease would naturally suggest." A Committee of the American Medical Association has reported favorably of the sulphate of quinia in large doses, given at the very beginning of the disease. In some instances the drug seemed to abort the attack. The committee speaks also of favorable results reported from the combined use of enjot and ddoride of iron. [Dr. Joseph Klapp, of Philadelphia, as- serts the recovery of a number of cases, some of them of a very threatening cha- racter, under the early and free use of tincture of chloride of iron ; 20 to 25 drops every two or three hours. — H.] Some American physicians have given ergot in combination with belladonna and belladonna in combination with quinine, but with equivocal benefit. Mercurials have been freely used, particularly in the form of calomel, but their effect has been most questionable, except as purgatives. Their indiscriminate use is to be utterly condemned, and their use at all to be dis- countenanced. A host of other medica- ments have been made use of, of which it is requisite to note only iodide of potuasiam, bromide of pjotassium, and arsenite of pot- ash. The circumstances under which the two former drugs have been used, and are most likely to prove beneficial, will sug- gest themselves to the practitioner. It does not appear that any decided good has arisen from their administration. In pro- tracted cases of convalescence the arsenite of potash may prove a valuable remedy. Of the general treatment of the patient the hot bath (1020-106°) is, when prac- ticable, the most important feature. The Committee of the American Medical As- sociation recommend, when the surface is cold, friction with hot, coarse towels, or even with warm oil of turpentine, after the bath. The regimen should be gene- rous and nutritious from the beginning of the disease. In the acute stages soup of some kind or other, or milk, is needed ; and as soon as appetite returns, solici viands of any diges-tible character must be given. In the graver cases, when there is much restlessness and spasm or stupor, and food cannot be given by the mouth from the patient's refusal or in- ability to swallow, an attempt should be made to administer it by the rectum : when there is much thirst, the patient's fierce desire for drinks may be freely in- dulged. The state of the pulse is the principal guide to the use of stimidants. 314 THE PLAGUE. Their administration as a special remedy independently of the indications which generally govern their use has not been followed by good results ; but they are called for when the condition of the pulse and the aspect of the patient show mani- fest flagging of vital power. The sequelce of the disease must be traced oc. ordinary principles. Too frequently the state of the pa.tient as to delirium, spasm, and irritability of the stomach limits the use of medicine to subcutaneous injections, prevents the pro- per administration of food, and restricts even the application of external mea- sures. To this unhappy combination of unfortunate and uncontrollable conditions the inefficiency of treatment may partly be attributed. Bibliography. — In addition to the references in the text may be noted : The Eighth Keport of the Medical Officer of the Privy Council, containing Mr. J. Simon's Memorandum on the Disease, and Dr. J. Burdon Sanderson's Report on the Epidemics prevailing about the Lower Vistula in the beginning of 1805. — Dis- cussion in the Medical Society of the Col- lege of Physicians of Ireland ; The Medi- cal Press find Circular for May 'iHth, June 5th, 1-Jth, and 19th, 18(.)7.— Transactions of the American iledical Association, vol. xiii, 18U6, coutainiug a Report of a Com- mittee on the Disease. — Dr. "W. H. H. , Githen's Notes of 98 cases ; The Ameri- can Journal of the Medical Sciences, July, 18(J7. — Dr. S. Gordon ; Dublin Quarterly Journal of Medical Science, May, 1867. — Dr. C. Murchison ; The Lancet, 1865, vol. i. p. 41. — Prof. A. Hirsch, Handbuch der historisch-geographischen Pathologic, 1866, vol. i. p. 163 : Die Meningitis Cere- bro-spinalis Epidemica vom historisch- geographischen und pathologisch-thera- peutischen Standpunkte, 1866. — Dr. Stille, Epidemic Meningitis or Cerebro-spinal Meningitis, 8vo., 1867, Philadelphia. This work contains a very copious bibliogra- phy, particularly valuable for its refer- ences to American monographs. — G. Tourdes, Histoire de I'Epidfemie de Men- ingite Cerebro-Spinale observee a Stras- bourg en 1840 et 1841. Paris, 1842.— J. Ch. M. Boudin, Traite de Geographie et Statistique Medicales et des Maladies de Endemiques, vol. ii. p. 564 ; Paris, 1857. — Dr. Sandford B. Hunt, on Cerebro-spinal Meningitis (Contributions relating to the Causation and Prevention of Diseases, and to Camp Diseases. Edited by Austin Fhnt, M.D., for the United States Sani- tary Commission. Ch. xi.). — Dr. Ed. W. Collins, Report upon Epidemic Cerebro- spinal Fever (Dublin Quarterly Journal of Medical Science, August, 1868). — Con- sult Hirsch 's monograph and great work, to which reference has been made already. THE PLAGUE. By Gavin Milroy, M.D. Defixition.— The Plastue may be briefly defined to be a fever, usually of an adynamic type, accompanied with bubos, carbuncles, and petechise. Synonyms.— Tliis is the Xotfuij of Hip- pocrates and Galen ; the Pestilentia of Celsus and other Roman writers ; the Pes- tis ; Typhus pestilentialis ; Typhus gra- vissimus ; Typhus bubonicus, &c., of many nosologists. It is the Pebris Adeno-ner- vosa of Pinel, and the Peste Orientale, Typhus d'Orient, of other French au- thors ; the Black Death, Levant Plague, Pestilential Fever, of English writers. Dr. Copland terms it the Septic or Gland- ular Pestilence. Symptoms.— The bubos may be in the groms, axillffi, or the neck ; occasionally, but very rarely, the popliteal glands have been affected. The carbuncles are gen- erally on the upper or lower extremities — most frequently on the legs, but some- times on the chest, back, or cheek. Their number may be from one or two to a dozen or more, and they vary much in size and in the tendency to become gan- grenous. The petechise and vibices may be scattered over every part of the body. The pyrexial symptoms of the Plague dif- fer in no respect from those in other forms of pernicious or malignant fever. There are the usual prodromal phenom- ena of lassitude, rigors, nausea, headache, and vertigo ; oppression about the prse- cordia, anxiety and restlessness, with a heavy stupid expression of countenance, and a muddy or suffused state of the eyes. Then follow heat of the skin and great DIAGNOSIS. 315 thirst, frequent vomiting, a coated tongue and fetid breatli, a rapid, weak, or irregular pulse, prostration with, perhaps, tendency to syncope, in some cases high excitement and delirium, and in other cases heavi- ness and stupor. The bowels are more frequently relaxed than constipated, and the stools are generally dark and very offensive. The matters vomited are sometimes nearly black ; and the urine, which is often very scanty, and in bad cases almost suppressed, is occasionally sanguinolent. Hemorrhage from the mouth, stomach, and bowels, or from the respiratory passages, is not an unfrequent accompaniment. In some cases the in- tellect remains unclouded to the last, while in others the patient dies convulsed or comatose. To describe at length the different va- rieties of the Plague, which have been enumerated by authors, would be very unprofitable, and only serve to obscure a subject which has often been made unne- cessarily intricate by extreme verbiage in the attempt at over-subtle distinctions. The fever may vary from a simple syno- chus, or even an urgent synocha with violent delirium, &c., to typhus of a pu- trid type, with rapid sinking and speedy death. The three forms or varieties of some recent writers appear to be merely three degrees of malignancy, according to the intensity or virulence of the febrific poison, the constitution and condition of the patient, the sanitary state of the lo- cality attacked, and the general sickliness of the season. In an epidemic outbreak the fever is usually much more malignant and deadly at first than at a later period of the invasion, its intractability and fa- tality very sensibly abating after a period. Sydenham tells us that, "in the infancy of the Plague (in 1665), scarce a day passed but some of those who were at- tacked died suddenly in the streets, with- out having had any previous sickness ; the purple spots, which denoted imme- diate death, coming out all over the body; whereas after it had continued for some time, it destroyed none unless a fever and other symptoms had preceded. ' ' It seems not improbable that panic has often had a good deal to do with the very rapidly- fatal cases to which the name of ' Pests foudroyante' has been given by French writers. Clot-Bey, in his account of the Plague in Egypt, says that the worst cases usually proved fatal on the second or third day, the cases next in point of severity on the fifth or sixth day, and that in the milder cases death clid not generally occur till the second or third week after the first setting in of the symp- toms.' ' De la Peste observ^e en Egvpte. Paris, 1840. During an epidemic, many pci-sons have often been aftected with glandular pains and swellings, and occasionally also with carbuncles, but with so little febrile disturbance that they have been able to follow their occupations, and have speed- ily got quite well under very simple treat- ment. Such cases have often been the occasion of no little controversy as to whether the persons should be considered as infected with the Plague, and there- fore liable to an enforced segregation un- der the old system of quarantine police. In connection with this point, it may be noticed that in Egypt and some other countries, where the Plague used to be a frequent visitant, glandular swellings and carbuncular disease are extremely com- mon affections in most seasons. Diagnosis. — If the presence of bubos, carbuncles, and petechia were an invaria- ble and necessary feature of the Plague, and of no other febrile disease, there would, of course, be no greater difficulty in discriminating it than there is in dis- criminating smallpox or measles from other pyrexite. But such is far from be- ing the case. Fevers have repeatedly been alleged in certain countries, and at certain epochs, to be cases of the Plague, although they were at the time unattended with these external phenomena ; and, on the other hand, fevers accompanied with these symptoms, occurring in other coun- tries and at other epochs, have as fre- quently not been designated or considered cases of the true pest. Diemerbroeck, who saw much of the Plague in Holland, during the early part of the seventeenth century, distinctly states that there is no one characteristic or pathognomonic symp- tom of the Plague ; and the remark of Heberden, that, "on first breaking out, the disease has never been known to be the Plague," strictly accords with the observation of all the most experienced writers of the present century, as well as of former times. It is well known that in Constantinople, or in Cairo, no physi- cian ever ventured to say what was the true nature of a prevailing fever, however fatal it might be, or would give it the name of the Plague, until a case occurred in which a distinct Ijubo or carbuncle was seen. This hesitation was mainly due to the universal unwillingness to admit the presence of a disease, the bare mention of whose name carried with it such dire con- sequences to the freedom of personal and commercial intercourse ; and the result was, that the pestilence had generally existed among a community for a consid- erable time before any prophylactic or precautionary measures were adopted. That glandular swellings, and occasion- ally also carbuncles, may be present in other forms of pernicious fever, malarial 316 THE PLAGUE. or not, besides the Plague, has been fre- quently noticed by writers of difl'erent countries. For example, the endemic fevers of the Danubian Principahties, which were so terribly destructive to the Russian armies in the campaign against the Turks in 1828-29, as on all former occasions, and which were called some- times putrid typhus, and at other times pernicious intermittent, are described as being often accompanied with bubos, car- buncles, and purple blotches on the skin. Their greatest malignancy was in the months" of August and September. In the earlier part of the year dysentery, with ordinary intermittents and remit- tents, were very common and fatal ; the latter insensibly lapsed into the pestoid fever. The worst cases were evidently undistinguishable from the Plague ; but the authorities studiously avoided all mention of the word, from dread of the panic among the troops that would have inevitably ensued. In the fever known as the "Pali Plague" in India, to which reference will be subsequently made, the symptoms were often closely akin to, if not identical with, the pestilence of the Levant, &c. ; and the same has been the case in some other pernicious fevers, both in India and in other tropical countries. In the en- demic tjqihoid fevers of Syria petechife and enlargement of the parotid glands have been noticed as being frequently present, so that it has been difficult at times to distinguish them from the true pestilence ; ami it is well known that glandular swellings, and even carbuncles, not unfrequently occur in the typhus of our own country. Some striking instances are on record of a fever directly produced by the inhalation of putrescent animal effluvia, exhibiting all the characteristic phenomena of the Plague. In the Medi- co-Chirurgical Review for January, 1825, is related a case of this sort, which oc- curred to four sailors at Whampoa, who had gone on shore to bury the body of a comrade, who had died of dysentery. On digging the grave, they accitlently opened a coffin which contained a putrid corpse. Two of the men were immediately struck down with the horrible stench, and soon afterwards were attacked with fever, ac- companied with petechise over the breast and arms ; in one of the patients a bubo formed in the right groin and axilla. Both men died— one on the fourth, the other on the fifth day. On dissection, most of the inguinal and axillary glands were found enlarged and hardened ; sev- eral of them, when cut into, contained matter. Another man of the party did not sicken with fever until the eighth day after exposure ; but for two or three days previously one of the inguinal glands had been swollen and painful. The symptoms were serious for a few days, but eventually the patient recovered. The fourth man was but sUghtly indisposed. To make use of so uncertain and varia- ble an attribute as the contagiousness, or the degree of contagiousness, of an exist- ing fever, as a diagnostic mark of the Plague — as some nosologists and other medical writers have done— is obviously illogical, and must inevitably serve to mislead. In the case of the malignant Danubian fevers, several of the Russian medical officers denied their pestilential character, on the sole ground that no dis- tinct proofs of '■'■ ccmtagion par uttouche- menV^ had been observed ; while they ad- mitted that all the symptomatic charac- ters of the true Plague were present. Many similar instances might be cited where this fallacious test has been trusted to. Indeed, most of the absurd errors in the history of the disease during the pre- sent and last centuiy may be traced to this very source. Morbid Anatomy. — The necroscopic appearances observed by Bulard,' Clot- Bey, and other French and Italian physi- cians in Egj'pt, were in most respects the same as have been noticed in the bodies of patients who have died from malignant congestive fevers, continued or remittent, in other countries, tropical and temperate. The viscera and their investing mem- branes, whether of the head, chest, or abdomen, exhibited marks of great ve- nous injection, and there was usually more or less serous effusion into the cere- bral ventricles, and the cavities of the pleura and peritoneum. All the paren- chymatous viscera were loaded with fluid dark blood, and were generally much more lax and softened in texture than in health ; the spleen in an especial degree. On the peritoneal covering of these organs, and also of the stomach and intestines, patches of ecchymosis and petechial spots were frequently met with. The mucous surface of the gastro-intestinal canal fre- quently exhibited the same appearance ; and the stomach often contained a quan- tity of dirty viscid fluid, like a mixture of bile and semi-putrid blood. Some writers have asserted that the mesenteric glands, and indeed the whole lymphatic glandular system, internal as well as external, are always more or less diseased, swollen, dis- colored, and often softened, or otherwise altered in structure. Bulard has found the entire chain of glands from the groin to the solar plexus enormously developed, forming a compact mass, to which the veins, arteries, and nerves closely adhered, and imbedded in blood etfused into the ' De la Peste orientale d'apr^s les Matfiriaux recneillfe h Alexandrie, k Smyrne, &c., pen- dant les Annies 1833 i 1838. Paris, 1839. NATURAL HISTORY, CAUSATION, PROPHYLAXIS, ETC. 317 surrounding cellular texture. Similar appearances have been observed along the course of the auxiliary "lands, when they were chiefly affected. Clot-Bey remarks, that the bubos in the Plaoue are always formed by swollen lymphatic glands ; tli'^se in the neck and about the angles of the jaws being independent of the salivary glands, which usually remain uuaflected. Even in cases which had proved fatal be- fore the outward appearance of any bubos, some of the lymphatic glands were, he states, almost always found on dissection to be aifected ; the morbid change vary- ing according to the stage of the disease, from simple enlargement and increased hardness to dark-colored softening and putrescent degeneration. The blood, whether drawn during life or observed only after death, has very gene- rally been found to be darker and more fluid than in health, and only imperfectly coagulating ; the clot being loose and pliable, and never exhibiting a true fibrin- ous or bulfy coat, while the serum is often excessive in quantity, and occasionally more or less deeply' sanguinolent. After resting for some time, oilj^ globules have been sometimes noticed on the surface, and the whole mass has been observed to pass rapidly into putrefaction. Curative Treatment. — There is lit- tle on this head in medical writings at all satisfactory or encouraging in respect of the recovery of the sick, but much that is admonitory as to the baneful effects of an over-active and meddlesome medication, and of neglecting the prime essential in the treattnent of all fevers, viz., the inha- lation of a pure atmosphere, of equable temperature, at all times, both Bight and day. Without this indispensable condi- tion, other remedies will be of compara- tively little avail.' The perusal of the recorded histories of cases of Plague, as observed at Malta in 1813, and in Egypt in 183.5, leaves the impression on the mind that the patients would have fared better had they been treated with light nourish- ' Nowhere have the effects of orowdhig the sick, and the neglect of hygienic measures in fever, been so dreadful as in the pest hos- pitals 01 lazarettos, even within the last thirty years. Dr. Bulard said of the hospital at Smyrna, " II n'est que le vestibule du s^pulcre :" and it was doubly, literally true, for the cemetery was within the walls of the establishment. In the British colony of Malta matters were no better in 1813 ; few of the patients sent to the lazaret left it alive. Of twenty-eight inmates seen by Sir B. Faulk- ner on one occasion, and some of whom then seemed to have not been seriously ill, all perished within forty-eight hours ; the only attendants were convicts 1 See his Treatise on the Plague, from facts colleuted during the author's residence in Malta. Loudon, 1820. ing food and cordials frequently adminis- tered, together with simple saline or acid medicines, and without active purgation, blood-letting, and such energetic mea- sures. The treatment which is most suit- able for ordinary typhus is doubtless that which is applicable to the Plague. In anticipating or in estimating results, it is always most needful to have regard to the period of an epidemic, when the remedies have been employed ; otherwise, the most misleading mistakes may be fallen into respecting the value of remedies or modes of treatment. I cannot better close these few remarks on this head than by quoting the words of a recent experienced writer,' in regard of the treatment of other bad forms of fever, viz., the pernicious remit- tent and yellow fevers of tropical climates. "In considering this subject, it should ever be kept in mind that not only in dif- ferent situations and countries, but also in different years, these diseases, what- ever the form of fever, may vary more or less, and if not in type and character, at least in intensity and complications ; so that the remedial means which may have been found useful in one epidemic may fail in another, each, it may be, having a constitution of its own. We are told by Sydenham how difficult he found it, on the breaking out of an epidemic, to deter- mine on the best mode of practice to be pursued, and how he came to a decision only after imjenti aiVilhila ccmtela, inlestique animi nervis — an example, this, well de- serving to be followed. ' ' Natural History, Causation-, Pro- phylaxis, &c. — Prior to the end of the seventeenth century, the Plague seems to have been as truly endemic — with oc- casional outbursts of epidemic violence — in most of the countries of Europe, in- cluding our own, as it was in the Levant and in Egypt from remote times, and con- tinued to be during the first forty years of the nineteenth century. In London, for example, during the first seventy years of the century, not a year passed without some deaths from the Plague being regis- tered ; and epidemics occurred in 1603, 1625, 1630, and 1665. The last, known as the Great Plague, was followed by a marked decline in the prevalence of the fever ; the number of deaths from it be- came fewer and fewer, and after 1679 none have been recorded in the bills of mortality of the metropolis. Whether it continued to linger in other parts of Eng- land after this date, I am unable to say; for it is to be remembered that the disease had not been limited to London, but was widely spread over difterent parts of the kingdom, just as typhus is at the present ' On Diseases of the Army, by Dr. J. Davy, F.R.S. 1863. 318 THE PLAGUE. day. In Holland, too, the decline and disappearance of the pestilence seem to have taken place about the same time as in England, or somewhat later. During the eighteenth century, although there was a marked diminution in the persistency of the disease in a sporadic form, and in the frequency of occasional wide-spread outbursts throughout Europe generally, many severe and very fatal epi- demics occurred in different countries, as in Poland, including Danlzic, and other ports in the Baltic, in 1710; in Provence and other parts of Southern France, and especially Marseilles, in 1720-21 ; at Eochefort in 1741 ; at Messina and other towns in Sicily in 1743 ; in several dis- tricts of Portugal in 1757 ; in Wallachia, Podolio, &c., in 1770; and at Moscow in 1771. In the present century the chief seats of the pestilence have been in Egypt, Syria, Asia Minor, and the coast of Barbary. Eor details on this point I would refer to a " Sketch of the Geography, &c., of the Plague," in the Brit, and Eor. Med.- Chirurg. Eev. for April, 1864. The most recent recognized appearance of the pestilence occurred in the neighbor- hood of Benghazi, between Alexandria and Tripoli, on the African coast, in 1858. It has been described by Dr. Bartoletti, who was sent by the Turkish Government to investigate its history, in a memoir ad- dressed to the Imperial Society of Medi- cine of Constantinople, in August of that year, and of which an abstract is given in the Quarantine Parliamentary papers af- terwards referred to. A brief notice of the "Pali Plague" of India may be here introduced. This pestoid fever was first recognized in Cutch, in the summer of 1815, after a season of great scarcity and distress. Erom that year to 1820 it prevailed in different places in Guzarat, spreading to Scinrle in a !N". W. direction, and also to- wards Ahmedabad and other places in the British possessions eastward. The fever was remittent in character, with a great tendency to become continued, of a very adynamic type, and extremely fatal. In most cases there were glandular swell- ings in the groins, axilte, and neck. Car- buncles or petechise are not mentioned as being present. There was often dyspncea with cough and bloody expectoration. Vomiting, of at first bilious matter, and subseciuently of a dark coffee-colored fluid, was likewise a not unfrequent symptom. In some cases the urine was sanguiuolent, and blood oozed from the gums. After the beginning of 18-21, there was no recur- rence of the fever known until 1836, when it was observed in the town of Pali (lat. 26° N. and long. 74° E.I, then the prin- cipal depot of tratfic between the coast and the IST. W. Provinces of India. It spread to numerous plices in Marwar in that year, and in 1837 on ro the middle of 1838. In 1849 there was a similar fever in Gurwah and Kuraaon, on the southern slopes of the Himalayas, and in 1853 in Kohilcund. As to tb i. na ture and affini- ties of the fever. Dr. Morehead, in his valuable Clinical Researches on Disease in India, remarks: — "The description of jail or hospital fever by Pringle, in his work on the Diseases of the Army, has con- siderable resemblance to that of the fever at Pali. . . . The causes were supposed to be crowding, filth, and effluvia from decomposing animal and vegetable mat- ters." — Second Edition, p. 158. In every country where the Plague (and pestoid fevers in general) has prevailed, certain local conditions have been found to favor its dcveloimient and spread. "The principal of these are, residence upon marshy alluvial soils along the Mediter- ranean, or near certain rivers, as the Nile, Euphrates, and Danube ; the dwell- ings of the people being low, crowded, and badly ventilated ; a warm, moist atmo- sphere ; the action of putrescent animal and vegetable matters ; insufficient and unwholesome food ; and physical and moral wretchedness."' An elevated site, even in the immediate neighborhood of an infected city, has often remained quite exempt, although intercommunication was not interrupted — e. g., the citadel of Cairo, and the village of Alem-Daghe, near to Constantinople. The higher parts of Valetta suffered very httle in the Malta epidemic of 1813; the ratio of the attacked became greater and greater in descending from the higher to the lower levels of the city, towards the foul shores of the har- bor ; and so much less frequently were the occupants of the upper and more airy stories of the lofty houses attacked than those of the basement floors, that it was a common remark. Dr. Hennen (in his Medical Topography of the Mediterra- nean) says, that "the Plague was a dis- ease which seldom went up stairs." It has been very generally in the crowded and filthy parts of a town that the earliest cases of an epidemic have occurred, and the chief sufferers have been invariably the poor and neglected. The state of most Turkish or Egyptian towns in the present age represents very nearly what London and many other European cities were in the seventeenth century. Outbreaks of the Plague, as of typhus, have often followed in the wake of famines and other desolating calamities. This was strikingly the case with the visitation at Benghazi. For two or three years pre- viously there had been an unusual drought, ' Rapport Si TAcad^mie Royale de M^decine, sur la Peste ct lea Quarantaines, fait, au iiom d'uue Commission, par Dr. Prus. Paris, 1846. KATURAL HISTOKY, CAUSATION, PROPHYLAXIS, ETC. 319 and the cattle had perished in great num- bers from ail epidemic disease. In 1857 the destitution of the Bedouin tribes be- came extreme, and it was tlien that tlie pestilence commenced. "Why it was the Plague rather than typhus, I know not," says Dr. Bartoletti ; " but the fact was so ; and I may add that the great epidemic of Plague at Erzeroum, in 1841, was also preceded by a terrible famine. One of the essential conditions for the production of typhus was wanting, viz. the agglomeration of human beings in a con tilled space." Epidemic Plague has generally been preceded by a sickly season, — the sickli- ness consisting in the great prevalence and severity of the ordinary endemic fevers, of tluxes and other forms of bowel complaints, and not unfrequeutly also of catarrh. Sydenham's account of the epi- demic constitution, previous to the great Plague of London, may be taken as typical of what usually occurred in respect of tlie disease during the sixteenth and seven- teenth centuries in this and in other coun- tries of Europe. In the Spring of 1665 catarrhs and pulmonic disorders were very prevalent and fatal. About the same time a bad form of fever, attended with vomiting, diarrhoea, &c., began to be very coninmn, and this was increased in severity as the season advanced. Towards Midsummer, cases of this fever (which Sydenham calls " pestilential") were ac- companied with bubos and carbuncles on the surface ; then only was it recognized and designated as the Plague. The pes- tilence went on increasing in deadliness until the third week in September, when nearly 8000 died in the course of the week, although two-thirds of the inhabit- ants had by this time fled from the city. It had then reached its acme, and forth- with began to abate. It very nearly ceased on the approach of cold weather ; a few sporadic cases only occurred during the winter and following spring. The same form of fever, however, as had pre- ceded the first recognized cases of the Plague, was again observed throughout 1666 ; but it was not so general as in the previous year. Sydenham expressly says that it was of the same species as the Plague, only not so violent — revera enim cum ipsissima Peste specie convenit, nee ab ea nisi ob gradum remissiorem discrind- natur. Morton, a contemporary of Sydenham, has remarked of the Plague, as he saw it in London, that "it often appeared under the form of a continued or remittent fever; but this changed into the other, and vice versd ; and that each in its turn became epidemic, the one yielding to the other." A similar remark has been made by many other writers in former, as well as in more recent, times. The epidemics In Egypt in 1835 and 1841 were ushered in by the unusual prevalence of the ordi- nary endemic fevers, in some places of a continued, and in other places of a periodic, type. The influence of season on the preva- lence of epidemic Plague will be seen from the following facts. In England the pestilence was most severe in the epi- demic years 1603, 1025, 1030, and 1005, from about the middle of July to the first or second week in October. The Plague at Marseilles raged most fatally in the autumn months ; and the same was the case at Moscow in the epidemic of 1771, when upwards of 1200 deaths took place for several days out of a population of 150,000. In Constantinople it has gene- rally reached its acme in September ; in Smyrna about a month sooner ; and the same may be said of Tunis, Algiers, and other places on the North African coast, where it has usually manifested itself in spring, and committed its greatest ravages in July and August. Malta suffered most in July. In Syria the summer months have ordinarily been tlic most fatal. In Egypt most epidemics have commenced toward the end of the j'ear, and gradually advanced, reaching their acme in March or April, when the southerly winds are most prevalent. The disease generally ceased in the second or third week of June. At Cairo it never continued, it has been said, beyond St. John's Day, 24th June. It thus seems that in Egypt the chief prevalence has generally been a good deal earlier than in other countries. Volney remarked on this subject: — ■" The winter stops the Plague at Constantino- ple, because the cold is great ; and the summer lights it up, because the heat is then humid : while in Egypt the winter favors it, because the climate is then warm and moist ; and the summer stops it, be- cause it is hot and dry. The heat is only injurious when associated "with hu- midity." That the peculiar meteorology of the climate of Lower Egypt may have something to do with the point in question seems very probable. Mention is often made, in the history of Plague epidemics, of the weather having been before, and during, their prevalence remarkably oppressive and distempered. This was notably the case, according to Maitland in his History of London, in the Great Plague, when, for months, scarcely a breath of air was to be felt, and the little that there was came from the south ; it was generally hot and stagnant, and mildews were abundant. A like state of atmosphere has often been noticed in other countries. Dr. Brayer specially alludes to the circumstance in his account of the Plague in Constantinople. Dr. Hennen, in his narrative of the visitation at Malta, relates the fact, as indicative 320 THE PLAGUE. of a distempered atmosphere, that, during the prevalence of tlie fever, " every whit- low festered, and every scratch became an u'j,ly sore ; a tiglit shoe was sufficient to produce a Uvid boil. The military hospi- tals were crowded with such cases." The mode in which the pestilence has been wont to manifest itself in a place, and to spread among a community, may be gathered from what has been said above respecting tlie usual antecedent state of the pubUc health, and the physi- cal conditions, &c. of the localities chietiy attacked. It has been often alleged that outbreaks of the Plague have been known to occur among a population previously quite healthy, immediately or very soon after the arrival or introduction 06 extra of a person or object already affected with the disease, or believed to be impregnated with its infective poison ; and that from the first case or cases, as from a focus or centre, the subsequent extension could be distinctly traced. But whenever there has been an opportunity of ascertaining the real and complete history of the facts, the course of events has been found to be much less simple and consecutive. Un- fortunately, most of the past history of Plague epidemics rests on mere rumor, or on most imperfect information. It has only been within the last thirty years that thoroughly trustworthy records on the subject have been published. The admira- ble Report of the French Academ}' has shown that the pestilence has generally appeared in single cases or small groups of cases, at or about the same time, in dif- ferent spots or localities of a town, or per- haps in different districts of a region, often considerably distant from each other, and without any traceable direct communica- tion between the persons attacked. Some- times several towns have become the seats of the fever nearly simultaneously, the intermediate villages remaining exempt, while at other times it has advanced in a more regularly progressive manner, invad- ing a number of places "deproc/ie en pro- cJic,''^ and in succession, over an extensive tract of country. That the Plague may be diffused by transmission from the sick to the healthy near to them — in other words, by personal contagion — cannot be reasonably doubted ; and it is equally cer- tain that both its development and spread have often occurred independently of such agency. Extravagant opinions on this subject were in vogue amongst most phy- sicians until of recent years, when the ac- curate observation of facts and a rigorous examination of previously recorded testi- mony sufficed to show that the influence of contagion in the dissemination of the Plague is very much the same as in the dissemination of the bad forms of typhus, and that the laws which regulate its ac- tivity" and power in the one disease are equally true in respect of the other. The limits of the present paper preclude any discussion of the various important ques- tions of State Medicine connected with this subject, and which relate to the pub- lic measures to be adopted for the preven- tion or arrest of the Plague, and for the protection of countries from its introduc- tion by shipping and other channels of intercourse. To such measures the term of Quarantine has been usually applied. For full information on the subject I would refer to the Report of the French Academy,' and to the elaborate documen- tary evidence, and report thereon, pre- pared by a committee of the National Association for the Promotion of Social Science, and printed, by order of the House of Commons, in May and August, 1860, and August, 1861. [Early in 1879, alarm was produced in Europe by an outbreak of Plague in As- trakhan, which proved very destructive in some villages, and threatened to extend into different parts of Russia. There is evidence that its existence in the same and neighboring regions really dated back as far as May, ISTS.'' Even in 1877, it appears from Russian official in- formation, that Plague had been widely scattered in Russia ; especially near the river Volga. At the beginning of the year 1879, its devastations became known, as they occurred in Vetlianka and a num- ber of other fishing villages, extending on both sides of the Volga for a hundred miles. In a few places, the mortality was as great as 95 per cent, of those attacked. These villages are described as being in an extreme state of filth. Nothing but fire could disinfect such localities. By order of the Imperial government, a num- ber of villages were destroyed ; their in- habitants being elsewhere cared for at the public expense. The immediate danger of the spread of the disease appeared then to be averted. From reports and papers by Dr. G. Milroy, J. Netten Radcliffe, and others, it appears that this outbreak in Astrakhan was onlj' one of several occurring in differ- ent places, especially in Mesopotamia and Persia, since 1873. In 1875 it was fatal to about 4000 people ; and a yet larger num- ber perished from it in 1876 ; although it ceased in the hottest weather of that year, Bagdad lost about 1700 lives by it in 1877. At Resht, in the province of Ghitan, near the Caspian Sea, it destroyed about 4000 lives. ' A summary of this Report, with Introduc- tory Observations, Extracts from Parliament- ary Correspondence, and Notes, was publislied by the writer of this article in 1846. [2 The Plague as it Concerns England; From Official and other Sources. London, Hardwicke & Bogue, 1879.] ERYSIPELAS: NATURAL HISTORY. 321 It does not seem irrelevant to the prac- tical purposes of this work, to cite here the conclusions of two emhieut medical and sanitary officers, in regard to the pre- vention of danger from Plague, as well as from other diseases kindred to it. Dr. E. C. Seaton,' in a memorandum " On the Systematic Action in Use in England to Prevent the Importation of Infectious Diseases," uses the following language : " Of systematic action adopted in Eng- land for the prevention of the importation of infectious diseases, the system of quar- antine (in the commonly received sense of that term) forms an extremely small part, if, indeed, it may not be said to be abandoned; an altogether different sys- tem, called the system of medical inspec- tion, having for some time past been em- ployed." Dr. Seaton quotes, in the same memo- randum, with approval, this expression of his predecessor, Mr. Simon : "A quarantine which is ineftective is a mere irrational derangement of com- merce ; and a quarantine of the kind which insures success is more easily im- agined than reaUzed. Only in proportion as a connnunity lives apart from the great highways and emporia of commerce, or is ready and able to treat its commerce as a subordinate political interest, only in such proportion can quarantine be made eft'ec- tual for protecting it. In proportion as these circumstances are reversed, it be- comes impossible to reduce to practice the paper plausibilities of quarantine. The conditions whicli have to lie fulfilled are conditions of national seclusion." Accepting these views as correct, it needs only to be added, that ' ' what is true of typhus," in regard to prevention by meas- ures of local sanitation, "ought to be true of Plague." In any but tropical or sub- tropical countries, it must be much easier to exclude Plague^ than typhus. There is abundant reason to conclude that the non-appearance of Plague in England since the visitation of 1605 has been due, not in any sense to measures of quaran- tine, but altogether to improvements in local and general sanitation. — li.] ERYSIPELAS. By J. Russell Reynolds, M.D., F.R.S. DEFnsnTiOK. — An acute specific dis- ease characterized by fever of a low type and a peculiar inflammation of the skin. This inflammation exhibits a marked ten- dency to spread over the surface, to induce serous infiltration and suppuration of the areolar tissue in its neighborhood, to affect the lymphatic vessels and lymphatic glands, and to cause serous exudation be- tween the cutis and the cuticle. Stkontms. — Scientific N'nmes. — Ipuw'rt- fJjif (Greek) ; Febris erysipelatosa (Syden- ham) ; F. erysipelacea (Hoffinann) ; Kosa (Senaert) ; die erysipelatose Dermatitis (Grerman) ; Erysipele (France) ; Eisipola (ItaUan). Popular JVame^.— Ignis sacer (Latin) ; die Rose, der Eothlauf (German) ; the Rose (Scotland) ; Saint Anthony's fire (England). ^ . Natural History.— Causes. — Local irritations of the skin, such as the appli- [' Seventh Annual Report of the Local Gov- ernment Board ; Supplement : Report of the Medical Officer for 1877.] VOL. I.— 21 cation of blistering fluids, or of boiling water, produce dermatitis, but they do not, of necessity, cause Erysipelas. The inflammation they produce may be very severe, and may resemble that disease ; but the differences between such common inflammation and the special malady we are now describing are greater in number and more important in kind than are their points of resemblance. There is, then, some " cause" of Erysipelas over and above that, whatever it may be, which produces simple inflammation of the skin. There are some facts which go far to show that this cause, or that some one or more of a number of concurrent causes, may exist in the "individual;" for it is well known that some persons are liable to suffer from repeated attacks of Erysipelas, and these either with or without the slightest provocation ; whereas others may be blistered, burned, cut, torn, or otherwise injured, without exhibiting any indication of the existence of such ten- dency. On the other hand, it is equally clear that Erysipelas sometimes has an "epidemic" character; and it is still more common to find it haunting certain 322 ERYSIPELAS. localities, and thus exhibiting the features that we term " endemic ;" so that in tliese cases its most eifective cause would seem to be outside the individual, viz., in some external circumstances. If we admit, as indeed we must do, the special liability of some individuals or families to the occur- rence of this disease, then the conditions underlying such Uability must be regarded as "predisposing causes" of Erysipelas, and we must seek still further for the so- called "exciting causes" of the affection ; and these may commonly, but not invari- ably, be found in accidental or other in- juries to the skin, such as exposure to cold or heat, to moisture, or physical abrasion. If we accept, on the other hand, the pres- ence of a distinct morbific agent — either epidemic or endemic — as the efficient cause of Erysipelas, then the constitu- tional state of the sufferer sinks into com- parative unimportance, although we may still retain some belief in its action as a predisponent. The truth as to causation lies, most probably, not between these two ideas, but in their combination ; and such con- clusion is by no means at variance with the belief that sometimes the one and sometimes the other factor is the more influential. It may be that either one may sometimes be so potent as, per se, to produce the disease ; but it is more proba- ble that, in all cases, there is some consti- tutional predisposition, and also some agent operating from witliout. Among constitutional predisponents the most important is that of which we know nothing more than the fact of its exist- ence, viz., an individual or family pro- clivity to the disease. The next in value is age. Erysipelas is common in newly- born infants, but rarely occurs between the first year of life and the twentieth ; after this period it is frequent, as an acute affection, till the fortieth year ; whereas in more advanced age it is seldom seen except as a chronic, or subacute, and less important malady. It has been stated that women are much more liable than men, and especially so during menstrua- tion, and at the climacteric period ; but such statement is not supported by relia- ble facts, although a woman, subject to Erysipelas, may exhibit the disease with especial frequency during the catamenial flow. Little that is of any value can be said of "temperament" as a predisponent; but it appears probable that the "gouty diathesis" increases the frequency of its occurrence. In addition to the " exciting" causes already mentioned — viz., all undue im- pressions upon the skin — we must enume- rate errors in diet, and especially the taking of certain things, such as shell-fish, or improperly smoked, dried, salted, or otherwise " half-preserved" meats. But by far the most important cause, acting from witliout, is the "poison," wliatever may be its nature, which exists in one case and can be communicated to another, either by inoculation, simple contact, transmission through the air, or by fo- mites. It is not intended in this work to deal with Erysipelas as it is commonly seen in tlie surgical wards of hospitals, but with that form of it which, arising often with- out any distinctly defined external cause, and certainly in the absence of any proved contagion, has a history differing widely from that of the disease as it is seen to follow surgical operations, under circum- stances of apparently endemic aggrava- tion. It is not asserted that the disease is essentially different in the two classes of cases ; but it is held that their clinical history is so different that it is desirable to treat them separately, and to confine the description given in this "System of Medicine" to the latter, which usually falls under the care of the physician. Symptoms. — These are both general and local : on the one hand there is fever, on the other definite structural change in the skin, mucous membrane, and, it may be, in the subcutaneous and submucous tissues. AVhen fever precedes the ap- pearance of redness on the skin, the dis- ease resembles one of the exanthemata : when local inflammation exists before marked pj-rexial change, the case, in its general career, is more like that of pneu- monia, pleuritis, or inflammation of any other organ. The former course is the more common of the two. The commencemeid of Erysipelas is usu- ally marked by uneasiness of not very definite character •, rigors, sliglit shiver- ing, or only a feeling of chilliness may mark the onset of the malady ; but more commonly rigors do not exist at the be- ginning, 'they occur after several hours of discomfort, and either immediately before or simultaneously with the appearance of local inflammation. Usually, then, prior to the occurrence of rigors, there is ma- laise, aching of the limbs, loss of appe- tite, thirst, nausea, or vomiting, diarrhcea, soreness of the throat, increased heat of skin, and frequency of pulse, headache, giddiness, confusion of thought, feeling of depression in spirits, epistaxis — as an oc- casional event — and, in fact, all the signs of pyrexial disturbance, without any such special predominance of any one of them as should enable the physician to forecast the nature of tlie impending evil. It is not possible to affix a definite dura- tion to these symptoms : sometimes they commence after, sometimes simultane- ously with, the local changes ; but more commonly they precede the latter by a few hours, i. e., from eight to ten, or by SYMPTOMS. 323 ♦■WO or even three days. It often happens that a man feels well in the morning and at mid-day, but towards evening is un- easy ; passes a restless night, growing worse from hour to hour ; and on the morning of the next day observes some redness of his nose or ear. Or feeling better, but not well, on the second morn- ing, he goes through a day of increasing discomfort, which becomes very consider- able towards evening ; passes a second night worse than the first, sometimes ac- companied by delirium ; and the special phenomena of Erysipelas appear on the third day. But their appearance may be delayed until the fourth or even fifth day from the onset of symptoms. On the appearance of the cutaneous in- flammation there is no remission of the pyrexial symptoms ; on the contrary, they are sometimes aggravated in intensity. The usual site for their development is some part of the head ; but they may ap- pear in any other portion of the body. Local disease or injury of the skin, or even of the subcutaneous tissues, may de- termine the place of commencement. Abrasions, scratches, or wounds, wher- ever they are situated, may be the start- ing places of specific inflammation of the skin ; whether this be of the kind we call Erysipelas, measles, or scarlet fever. But this determining power is not limited to such injuries or affections as "break the skin;" for the locality of appearance, and even recurrence, of Erj'sipelas may be de- termined by the presence of gout in a par- ticular joint of either the upper or lower extremit}', and also by the irritation of diseased teeth in either the upper or lower jaw. Usually, however, the nose or the ear is the point at which the inflammation may first be seen. The change is, so far as my own observations extend, com- monly seen to commence in close prox- imity to one of ihe passages through the skin, i. e., where the skin undergoes that transition which consists in its becoming what we term mucous membrane. Thus, not only at the nose and at the ear does Erysipelas begin, but it commences just where the skin of the nose turns upwards into the nostril, or just at the point where the skin of the ear loses the dryness and other characteristics of ordinary skin. Again, Erysipelas often is noticed first at the angles of the mouth, or at the edges of the eyelids ; it is met with at the anus, about the genital organs, and in the neigh- borhood of the recently-divided umbilical cord. To the patient the part affected feels tot and irritable ; and, upon touching it, sore, stinging, and smarting. It is of red color and shining aspect ; it is warmer and harder than the surrounding tissues, swollen, and, as the disease advances, very tender to the touch. The inflamma- tion extends from the spot first ailccted, sometimes in all directions, but more com- monly in one much more rapidly and more widely than in another. For in- stance. Erysipelas starting from the ear will sometimes extend downwards and not upwards, backwards and not for- wards, and so on ; whereas in other but, I believe, rarer cases, the progression ap- pears to radiate about equally in all direc- tions. At the advancing edge of Ery- sipelas the elevation of skin (swelling) may often be not only felt but seen, and that most distinctly ; whereas at the re- ceding margin there is so gradual a de- cline of swelling that it would be diflBcult to say with certainty that it existed. Where the inflammation is advancing the line is marked not only by elevation of the surface, but by sharply-defined differ- ence of color ; the white or pale healthy skin is invaded by a distinct line of red, with an occasional streak, branched or not, in advance of the general boundary. Where the skin-affection is receding there is no such abrupt transition, but the heightened tint of the most active inflam- mation is gradually shaded down through medium and mixed tints until, without any clear line of demarcation, the skin is found in its ordinary healthy state. Sometimes the amount of swelling is not considerable ; at other times it is enor- mous ; and the disfigurement is such that none Avould recognize the features of the sufferer, nor for a moment think that they were features at all, or even parts of any human being. The amount of swelling is greatest where the skin is the most loosely attached to the subjacent structures, and where there is much areolar tissue which can be distended with fluid. Thus we find the eyelids and the neighborhood of the mouth the most disfigured in appear- ance, and all trace of the former may be completely obliterated by the efl:usion. The swelling, when confined to the skin, is moderate in amount, uniform in ele- vation, hard to the touch, pitting only sUghtly on pressure, and shading off on the side of recession, but terminating more or less abruptly on that of advance. When the areolar tissue is much mfil- trated, the swelling is carried to a higher degree, its surface is irregular in elevation and consistence, and there is often deep pitting upon pressure. Under the latter circumstances there is generally suppura- tion, probably determined by the slough- ing of small or larger portions of the sub- cutaneous areolar tissue. The surface of the inflamed skin re- mains, in mild cases, intact throughout, exhibiting, besides redness, only slight increase of desquamation as the malady dies away. In more severe and more common cases there is some vesication oi 324 ERYSIPELAS. the surface ; little bladders are seen like those produced by a blistering fluid, or a scald. Whereas, in very severe cases, large bullce, of irregular shape, make their appearance ; they soon burst, and leave dry and thick crusts, which render still more hideous the face that they have covered. It often happens that the in- flammation is extending in one direction and receding in another, so that Erysipe- las in all its stages may be witnessed at the same time in the same individual ; but the maximum of redness and of swell- ing is usually reached on the second or third day. In almost all cases there is distinct in- flammation of the neighboring lymphatic vessels, with pain, swelling, and tender- ness of the lymphatic glands : but sup- puration of the latter is not met with in ordinary cases, although severe. Inflam- mation of the lymphatics is most com- monly observed when Erj^sipelas has been set up by a poisoned wound. ' The pulse is generally full and with a frequencj' varying from 100 to 120 in the minute ; the heat of skin is well marked, perhaps over the inflamed surface undvily marked in comparison with the elevation of the temperature generally. This may be owing to the local arrest or diminution of transudation and evaporation. In a severe case, recently under my care, the temperature in the" morning of the eighth day of illness, but fifth day of eruption, was 104° Fahr. ; on the next day 102f o ; on the following lO.S^o ; then came twenty -four hours in which it ranged between 99|0 and 1001° ; to be followed by another rise, — coincident with some extension of the inflammation, — to 102f°; after which it became normal. The even- ing temperature in this case was daily lower, and sometimes considerably lower (2° to 4° and even 6°) than that of the morning. A similar relation between the morning and evening temperature was observed in another almost equally severe case occurring at the same time. The prevailing relation between morning and evening temperatures is, however, similar to that observed in other acute specific diseases, viz., an excess of elevation in the evening ; but the variation from this general type is, I believe, more common than is supposed not only in Erysipelas but in other allied maladies. It is quite clear that relapses are attended by re- newed rise of the thermometer ; and such relapses may occur in the morning as well as in the evening, and so pervert the characteristic febrile course. Such re- lapses may possibly be overlooked, as in some cases the symptoms are almost im- perceptible to the patient, and may occur in some locality which is not necessarily ' Niemeyer, Lehrbnch der speciellen Pa- thologie und Therapie. Bd. ii. p. 396. exposed to the e3-e of the physician ; and yet, aUhougli so slight as not to attract attention in auy other way, they may do so by their ettect on the thermometer. Lately, for example, in a patient appa- rently convalescent, — feeling tolerably well, and taking food with relish, the temperature having been normal for two days, — I have seen a sudden rise in the thermometer, unattended by any return of pain or malaise, but, upon examination, shown to be coincident with renewal of the inflammation below the shoulder blades; it having commenced at the ears, extended to the back of the neck, and for some days stopped at the level of the scapular spines. The fever, as measured by the ther- mometer, is very variable In duration; and the temperature, after having re- turned to the normal amount, may ex- hibit several re-elevations coincident with extensions of the inflammation. Usually the maximum is reached on the third day of eruption, and the decline commences on the fifth or sixth. The pulse, — usually exhibiting an in- creased frequency bearing direct relation to the abnormal elevation of temperature, — may revert to the habitual standard at the end of the third or fourth day, and not again rise far above this, although one or more relapses may occur, each of which is marked by a rise in the thermometer. Albumen appears in the urine in many cases. It may make its appearance from the fourth to the eighth day, or even later, in relapse. Unless there be pre- existent disease of the kidneys, it is small in amount and of short duration ; it has been noticed to be absent on the fifth day, present on tlie sixth, and again absent on the seventh. The quantity of urea is in- creased, while that of the chlorides is di- minished. The course of symptoms varies widely. In one class of cases there is a speedy diminution of their severity both locally and generally; whereas in others the re- verse is observed. Sundry local changes, proportionate to the amount of swelling, may occur, and become excessively an- noying. Such, for example, are blind- ness, deafness, and impossibility of breath- ing through the nose. But, beyond these and the relapses which have been already mentioned, there are others depending upon the sloughing and suppuration of areolar tissue. When such changes take place, the symptoms become much more distinctly adynamic; and in bad cases the tongue is brown, the lips and gums are covered with sordes, the pulse rises in frequency and loses in force so that it is often quite uncountable ; there is low muttering delirium, with jerking contrac- tions of the limbs, and, indeed, aU the other signs of impending dissolution. DIAGNOSIS — MOKBID ANATOMY. 325 Diagnosis. — It is not very easy to con- found Erysipelas witli any other malady when once its ordinary symptoms are de- veloped; but it may sometimes be inferred to be present before the skin has shown signs of inflammation. Where there is marked pyrexia, with vomiting at its commencement, without notable pain in the back, or obvious change in the mu- cous membrane of the throat or nose, but with enlargement, pain, and tenderness of the lymphatic glands in the neck. Ery- sipelas may be, and ought to be, suspect- ed. Attention to the description of symptoms already given will be sufficient to prevent any errors of diagnosis. The spreading character of the inflammation, as this is seen in the skin and also in the subcutaneous cellular tissue, distinguishes Erysipelas from true phlegmon, where lymph speedily circumscribes the swell- ing. Although the sjauptoms of Erysipe- las occasionally exhibit intermissions, and by no means rarely some remissions, it would be difficult now for the mistake between it and intermittent fever to recur. Prom what has been termed ' ' difliuse cellular inflammation," Erysipelas may be distinguished by a constant presence of inflammation of the skin, which latter bears a direct ratio to the affection of the areolar tissue, and precedes it, as a rule, in regard to time. Erythema differs from Erysipelas in the comparative mildness of its general symp- toms, in the absence of swelling of the skin, and in the tendency which it exhibits to form patches, of various sizes and shapes, which show no marked tendency to spread. Pathology. — There can be no doubt that some cases of Erysipelas resemble those of simple erythema, or simple in- flammatory redness of the skin, such as may be produced by a mustard poultice. Nor can there be any doubt that, on the other hand, there are cases of Erysipelas which resemble more closely diff'use cellu- litis and pyaemia. Between these ex- tremes there are patients whose symptoms are those of phlebitis or of inflamed ab- sorbents ; and others whose cases can hardly be distinguished from genuine phlegmon. In all these we may have no doubt of the existence of Erysipelas ; but the idea we entertain of the " pathology" of this disease will be determined by the fre- quency with which we find it assuming this or that typical form, the amount of import- ance we attach to these several associated conditions, and the clearness of our knowl- edge about them. Thus, Erysipelas may be regarded as a disease having its first local manifestation in the absorbent sys- tem, or it may be held to be essentially a Wood disease, always called into play by some external injury, however slight that injury may be ; it may be thought to be so distinctly hseniic, that it should find its place among the symptoms of pyaimia ; while, on the other hand, the view may be entertained that a true inflammation of the cutis is its one essential condition — that Erysipelas is a morbus yer se, having powers of easy association with each of those maladies alluded to, but being, at the same time, essentially distinct from all of them. Those who entertain the last opinion, again differ among themselves, some regarding the inflammation as iden- tical in its essence with that which might be produced by an irritant ; others, as being of special type, the result of one specific poison, the presence of which in the system is the sine quQ, non of the exist- ence of that form of inflammation which we term Erysipelas. And here, in this last resort, diversity of opinion may still be found ; for some hold that the poison is developed from within, that it arises from "crudities," from "digestive derange- ments," and the like ; while others believe that it is always imported into the body from without ; and it would seem that yet a third view might be taken, viz., that it is by the conjunction of these two elements that the disease is established ; that is to say, neither internal conditions (predispo- nents), existing alone, nor external poi- sons (septics, or endemic influences), act- ing by themselves, can produce Erysipelas; but that the outside poison, however ac- tive, or however greedily swallowed by the organism it may be, is inoperative unless it finds in that organism the proper, i. e., "special," nidus, conditions, or material for its development. It would be possible so to select and ar- range the facts about Erysipelas as to make them support any one of these theo- ries or pathological positions ; but, taking them without selection, and only arrang- ing them so far as to render the teaching inteUigible, the conclusion most consist- ent with them appears to me to be that which is expressed the last in the forego- ing paragraphs, and in the deflnition of the disease : viz., that Erysipelas is an inflammation of the skin, that it may in- volve the absorbent or the venous sys- tems, that it may change the character of the blood ; but that it may act independ- ently of any such complication ; further, that it is an inflammation of "special" character; and, lastly, that it depends upon the action of a particular poison upon a peculiarly predisposed constitu- tion. Morbid Anatomy.— The slighter cases of this disease rarely furnish opportuni- ties for the study of their anatomical con- ditions, but analogous states of the skin and neighboring tissues may be observed in the outskirts of the severest inflamma- 826 ERYSIPELAS. tion in cases of fatal Erysipelas. In them, after death, as well as during life, the dis- ease may sometimes, but of course at dif- ferent points, be observed in all its stages, and in all its degrees of intensity. The skin is thickened by increase of vascularity and of serous infiltration, while there is a marked absence of lymph so thrown out as to circumscribe the swell- ing. In mild cases, no suppuration is ob- served, but, in the less mild, there are de- tached patches of suppuration, sometimes affecting the cutis only, but more com- monly extending into the areolar tissue ; whereas, in severer cases the skin may be completely separated from the subjacent tissues, and this for a very considerable extent, by large quantities of pus, in which shreds of sloughing or dead areolar tissue may be found, semi-detached or floating. The disease, although com- monly limited to the skin and its imme- diately connected tissues, sometimes ex- tends to the deeper and more important structures, and then muscles and liga- ments and bones become involved in the general mischief Mr. C. de Morgan' states that a very im- portant fact had been " mentioned" to him by Busk, viz., "that in all the fatal cases which he examined, the lungs were highly congested, and that, on close inspection, the smaller pulmonary vessels were always found to contain pus ; that, in fact, a minor degree of pyaemia was always pre- sent. He (Mr. Busk) has observed the same thing in the small vessels of the head, when that part has been the seat of Erysipelas." Dr. Bastian has found minute embolic masses in the small arte- ries and capillaries of the gray matter of the cerebral convolutions. Some of these masses, which are small, appear to be made up of white blood-corpuscles ; but the larger, irregular, and rounded bodies are, in "Dr. Bastian's opinion, amorphous masses of albuminoid material, separated from the blood-plasma.^ Dr. Copland' says, "The veins proceeding from the part chiefly affected are often inflamed, or contain pus, as first observed by M. Ribes . and confirmed by ^Messrs. Dance, Arnott, and l>y my own observations. " It is well known that in many cases of fatal Erysipe- las evidences of disease may be found in the spleen, liver, kidneys, lungs, bronchi, larynx, trachea, and fauces ; I3ut there is nothing specific in the character of the changes discovered in these organs — no- thing, that is, which is peculiar to the dis- ease called Erysipelas — nothing, indeed, which depends upon the Erysipelas per se; but all that may be found is only the sign ' Holmes's Surgery, vol. i. p. 237. " British Medical Journal, January 23, 18r;9. s Dictionary, art. "Erysipelas." of such general blood-change as may be associated not only with the disease now under consideration, but also with that large group of maladies which stand in close relation with pyfemia. (Seep. 330.) Occasionally, gangrene is found in some portions of the inflamed skin or cellular tissues ; and this particular termination of Erysipelas has appeared to me the most common in those cases which are asso- ciated with dropsical effusions. Some- times the Erysipelas has appeared around natural or artificial openings made for the escape of serum, and then either portions of the integuments of the lower extremi- ties, or, more commonly, of the genital organs, become greatly inflamed and gan- grenous. The association of gangrene with dropsy may be due, in some measure, to the altered blood-condition — which almost always exists in extensive ana- sarca, whatever may be the seat of that mechanical obstruction to which it is re- ferred, and which determines the locality of its appearance, — an altered blood-state, moreover, which in some dropsies appears to constitute the whole of the essential condition for their development. But, in addition to the blood-change, there is, in the fact of the existence of dropsical effu- sion in the cellular tissue, a change in the nutrition of the vessels, and an altered relation of the fluids and solids of the parts involved: and there is, further, a simple mechanical interference with the circula- tion in the skin, exerted by the pressure of the effused fluid not only on the capilla- ries, but on the vessels which lead to and from them. Thus, dropsical limbs are, unless reddened by Erysipelas or other conditions not essential to the dropsy, ill- nourished, pale, and cold ; and a slight addition of difficulty to the already em- barrassed circulation of the part, often ends in gangrene. Prognosis. — A case of Erysipelas is bad in proportion to the predominance of the symptoms of blood-poisoning over those of simple inflammation. It is bad just in the degree to which it resembles typhoid fever or pyajmia, rather than sim- ple dermatitis. Mere extent of inflamma- tion is not of itself of evil augmy ; a high degree of inflammation is of no greater value; but a very rapid and weak pulse, with a dry brown tongue, and low mut- tering delirium, with marked prostration of the strength, is of almost fatal omen, although the local changes may be closely limited in both distribution and severity. Cases which arise from the introduction of poisonous matter are worse than those in which the malady appears sponta- neously ; and this, whether the poison has been introduced by a wound made with an infected implement, such as a dissec- tion wound, the prick by a bone from dis- TREATMENT. 827 eased meat, &c. ; or whether it has been conveyed through the air, or by other means, to a wounded surface, placed where Erysipelas is endemic. The extremes of a^e, the presence of disease in either the kidneys or the liver, the dropsical constitution, a state of chronic alcoholism, or of any morbid blood-condition, are prognostic of an un- favorable termination. The extension of Erysipelas to the throat may introduce a source of danger altogether different from that which be- longs to the disease itself. Life may be threatened and indeed terminated, and that too very suddenly, by apnoea. The inflammation of the fauces may bring about serous or other infiltration of the neighboring submucous tissues, and the opening into the windpipe may be closed. In Erysipelas of the head or neck it will always, therefore be necessary to examine the throat most carefully, and to observe the manner and number of respirations, as well as the tint of the skin, in order to guard the prognosis against a false security. It is the more necessary to do this, because in some cases the patient — owing probably to the dulled state of his sensations and perceptions, brought about by the poisoned condition of his blood — may make no complaint of dyspnosa, or of discomfort in the throat ; whereas an altered tone of voice or cough, an occa- sionally hurried respiration, a slight lividity of the lips or finger nails, an undue movement of the alse nasi, or any other signs of impaired respiration, may lead to the discovery of danger the most grave and imminent. Again, the appearance of symptoms of disturbance in the nervous centres, over and above, or out of all proportion to that which might be accounted for by the gene- ral febrile condition, is of very serious omen. The occurrence of delirium, and especially of nocturnal delirium, is of com- paratively little importance; but a marked drowsiness — sometimes alternating with delirium, sometimes persisting and in- creasing in intensity — is a very serious symptom, forecasting that mode of termi- nation which is by no means rare in Ery- sipelas, viz., " coma" from either effusion within the cranium or impairment of the brain-nutrition by embolism of the small vessels. It is, however, by no means probable that in all cases terminating thus, there is or has been an extension or metastasis of inflammation to the mem- branes of the brain. In some instances there are symptoms of "meningitis" ob- served during life, and evidences of its presence and its results may be discovered after death ; but in others the cerebral symptoms are those of oppression rather than excitement, and the pnst-mortem ap- pearances are those of effusion only, or of that embolic occlusion of vessels de- scribed by Dr. Bastian. In the latter class of cases the symptoms are probably due partly to the direct effect of altered blood upon the nervous centres, and also to the indirect effects of that alteration in leading to passive efliiision, or unobstructed circulation. The relation between dropsy and Erysipelas has already elicited re- mark. Erysipelas is a much more serious dis- ease when epidemic or endemic than when it occurs sporadically ; and the " type" of the epidemic— as observed in other in- stances which have been watched to their termination— will be the basis for an opinion as to the probable issue of a par- ticular case. It is said that the wandering or "er- ratic" form of the disease is attended with considerable danger, but in my own experience cases have exhibited this cha- racter to a high degree and yet have not only terminated happily, but have never exhibited the slightest disposition to do otherwise. The cases of Erysipelas which are the most dangerous are those which, com- monly occurring after wounds of consid- erable extent — either accidentally or scien- tifically produced — are attended with much diffuse cellular inflammation ; and which, finding their way, if not from their commencement, at least very early in their history, into the hands of the sur- geon, will not be described in this place. Treatment. — As I believe that the class of cases which have been described in such manner as to justify the use of antiphlogistic treatment, do not exist ex- cept in the histories of the past and the imaginations of the present, it appears to me unnecessary to say how much blood should be taken from the arm of a man, provided that he is found in a condition that we may never meet with. The general medical treatment of Ery- sipelas resembles rather that of the ady- namic fevers than of inflammations, even supposing that the latter should present occasionally what is called a "sthenic" form. Almost all the cases — so far as ray own experience reaches, all — that come under the care of the physician from the first, not only bear well, but are positively benefited by, supporting and tonic treat- ment. The kind and degree of such treatment must be determined by, and proportionate to, the severity of the symp- toms which have been already described. In some cases, stimulants are required from the first, the conditions which neces- sitate the employment being identical with those which are common to that large group of diseases in which Erysipe- las finds its place. When stimulants are not required at the onset, httle or nothing 328 ERYSIPELAS. is gained by such use of salines, or any other general treatment, as shall do more than maintain a normal amount of the secretions. Thus, in very mild cases, in persons of average health, one or two doses of the simplest saline aperient may be all that is requisite. When the dis- ease is more severe, and exhibits a ten- dency to spread after the balance of secretion has been restored, the patient at the same time becoming restless and exhausted, the most efficacious general treatment consists in the administration of bark with ammonia, during the day, and an efficient but not heroic opiate at night. Should the adynamic symptoms increase, large quantities of alcoholic stimulant are required at short intervals ; and the amount that may be taken with advantage is as large as that which has been found useful in any of the specific fevers. [In the period preceding the recent prevalence of alcoholic stimulation in practice, ample opportunity occurred for the observation of cases of hospital Ery- sipelas, in the treatment of which the use of alcohol was the exception rather than the rule ; and which often did very well ■without any stimulation at all.' The same experience has been prolonged much later with cases occurring in private med- ical practice. The conviction has hence resulted, that neither alcohol nor the tincture of iron is a necessit}' in all cases of Erysipelas. Like other inflammatory affections (see the last sentence under Pathology, supra), it may occur with either a sthenic or an aathenic type. — H.] The tincture of the sesquichloride of iron of the London Pharmacoposia is by far the most useful medicine that I know of in the treatment of these cases. So marked is its action that it has been thought by some to exert a "specific" influence in Erysipelas ; but without as- serting that it po.-sesses such power in the strict sense of the word " specific," it may be well to mention that its utility appears equally great in diphtheria, and perhaps still greater in cases of diphtheroid sore throat. The essential condition of its success is its administration in large and quickly repeated doses ; it has often hap- pened that disappointment has arisen in the use of this tincture of iron, but in most of these instances the -tincture has been given in doses of ten or fifteen min- ims three times daily, and such doses are certainly useless. But when the tincture is given in doses of fortj- minims, or even more, every four hours, the results have usually been most favorable. The most convenient form for its administration is a mixture containing in each dose forty [' E. g., in tlie Pennsylvania Hospital, 1845-50, etseq.—R.} minims of the tincture with an equal quantity of spirit of chloroform and gly- cerine, with an ounce and a half of water. The effects of this medicine may be seen sometimes after the first, often after the second, dose : the local inflammation ceases to extend ; the inflamed part be- comes paler, less tender, less swollen ; the feeling of exhaustion is diminished, and v^ith it such symptoms of exhaustion as exaggerated frequency of pulse, and dry brown tongue ; the temperature falls ; and sleep frequently ensues. As soon as such changes take place the quantity of the tincture may be reduced. It is not, how- ever, safe to trust to this medicine alone ; alcoholic stimulant is often required at the same time, but the action of the former has been too obvious in numerous cases for it to be confounded with that of the latter, or to be mistaken for those cura- tive processes which occur in the natural history of the disease. In the local treatment of Erysipelas two things are to be strenuously avoided ; the one anj'thing v\rhich shall expose the skin to variations of temperature, and the other anything which shall interrupt its natural function. Among the former are included exposure to draughts, and to the chilling effect of wet applications ; among the latter the covering of the skin with any oily matters, ointments, &c. It has occurred to me frequently to see Erysipe- las spreading rapidly under the use of "cooling lotions," and to see it arrested by their discontinuance, and the applica- tion of simple dry flour, violet powder, or oxide of zinc — the inflamed part being sometimes covered lightly with dry cotton wool ; the latter, however, being really necessary only when wishing to protect the patient from such draughts of air as are almost unavoidable in any large rooms, and which are sometimes quite unavoida- ble, and absolutely pernicious to certain classes of cases which find their way into the very well-ventilated wards of hospitals. The application of collodion has ap- peared to me of use only when the Ery- sipelas has been closely limited in extent. Its application over a large surface has not only failed to do good, but, in conse- quence of its cracking and leaving rough edges, has done positive harm. [Not only by this application, but by nitrate of silver, acetate of lead, ice water, &c., the direct suppression of the cuta- neous affection over an extended surface appears to be unsafe ; being sometimes followed (as in the analogous instances of scarlet fever, measles, &c.), by cerebral or pulmonary congestion.- — H.] Various attempts have been made to arrest the spread of the inflammation, by some applications to the sound skin in the direction of, but beyond, its extending margin. The most approved of these lias VARIETIES. 329 been, and is, the application of nitrate of silver, and there are facts to warrant this approval. It is desirable, however, not to attach too much importance to this measure. When nitrate of silver is ap- plied in such manner as to aft'ect the in- tegrity of the true skin, I have seen Ery- sipelas start from the line of its application as from a new focus ; and when, on the other hand, this evil has been carefully avoided, I have seen the Erysipelas ex- tend through the line upon which it had been used. [At the very beginning of an attack of Erysipelas, a facility of arrest by the mildest emollient applications, especially fresh lard or cold cream (unguentum aqua3 rosse), reminds one of the prevention of a conflagration by the extinction of a fire at its commencement. Probably no local application will do more good at any stage, than such unguents, unless when the subcutaneous areolar tissue, lymphatic vessels or veins are so deeply involved as to make appropriate the use of poultices of bread, slippery-elm bark, or flaxseed meal.' — H. ] As already stated, the tendency to death from Erysipelas exists in three principal directions. To that by asthenia I have aheady referred ; the other two which are most important, are either by implication of the brain, or by obstruction to the res- piration. In the former the symptoms may be due to the blood-poisoning, or to extension of the inflammation to the me- ninges. When the cerelwal symptoms are referable to the condition of the blood, no change in the treatment is required ; but when to meningitis or meningeal conges- tion — supposing that this diagnosis can be accurately made — the application of ice to the head, and warmth to the extremi- ties, together with free purgation, will be found useful. It is certain that such mea- sures will relieve and lead to the cure of many cases of a most unpromising ap- pearance. When the danger to life depends upon interference with the respiration, either the fauces or the glottis is the most usual seat of mischief. It is then necessary to relieve, if possible, the swollen mucous membrane, and so allow of the passage of air through the larynx ; but when this cannot be accomplished, the surgeon should be ready to perform laryngotomy or tracheotomy. When pus is known or is supposed to exist, even in small quantity, in the neigh- borhood of important organs, such as the eye or the glottis, it is necessary that in- cisions should be made for its evacuation. When it exists in larger quantity under the skin of limbs, in the neighborhood of joints, or glands, the same plan should be adopted ; and afoHiori, when large tracts of cellular tissue are so affected, and the case resembles that of " difluse cellular in- flammation," free incisions are necessary. Eor all the details of the treatment of Erysipelas, when thus requiring surgical interference, the reader is referred to sys- tematic and other treatises on surgery. In conclusion, it need only be stated that all those hygienic measures, such as good feeding, fresh air, and quiet, which are essential in the treatment of all acute specific diseases, are required and under similar direction in the treatment of Ery- sipelas. Vakieties. — The following terms have found their way into ancient and modern books, and have been used to denote the several so-called varieties of Erysipelas: — E. neonatorum. E. complicatum, et simplex. E. idiopathicum, et symptomaticum. E. verum, et spurium. E. phlegmonosum, vesiculare, buUosum, &c. E. acutum. E. erraticum. E. nervosum, cedematodes, &c. The above list shows that the principles of nomenclature have varied widely ; names having been constructed on the fact of their representing such conditions as — the age of the individual attacked ; the presence or absence of complications ; the supposed mode of origin ; the fact of the disease being Erysipelas or something else ; the degree of development of one or more anatomical elements of the disease ; the time of its duration ; the mode of its distribution; and the nature of its com- plications. It does not appear to me to be neces- sary to explain these words ; their enu- meration is sufficient to show their unsci- entific character and practical inutility, and to lead towards the hope that they may not be perpetuated. 330 PYEMIA. PYEMIA. By John Syer Bkistowe, M.D. The present article will be limited to tlie consideratiou of tliat morbid state of the system to which the term "Pyiciiiia" has of late years been generally applied. This morbid state is closely related to phlebitis ; with which disease it was until recently confounded, and on which it un- doubtedly often supervenes. It is related to those diseased processes which Virchow has named "thrombosis" and " embolia;" for the secondary deposits which charac- terize Pyaemia immediately depend, in great measure if not solely, on the obstruc- tion by solid material of the vessels lead- ing to the spots in which these deposits occur. It is related to erysipelas, and such like "unhealthy" inflammations; for not only does it occur as a sequela of these aflections, but their neighborhood serves often to induce Pysemia in patients who but for this neighborhood would have escaped. Again, it is related to puerperal fever ; or, to speak more precisely, the loosely applied term "puerperal fever" includes, with many other diseases, a large number of cases of puerperal Pj'se- mia. And lastly it is related to several more or less well-defined morbid condi- tions of the system (septicaemia) brought on by the entrance into the blood, through the veins or lymphatics, of various non- specific animal poisons. These related affections will all be fully discussed in their proper places ; and will be noticed here so far only as the due elucidation of the subject before us renders necessary. I. Etymology. The word " Pytemia, " derived from the two Greek words niov and alfia, signifies literally pus in the blood. Its English synonyms are "purulent absorption" and ' ' purulent infection. ' ' Every one of these terms implies a theory, viz. — that an essential feature in the disease to which it relates is the presence in the circulating fluids of the elements of pus. In this respect they are all objectionable ; for while some authors accept this theory of the disease, others (whose opinions are equally well entitled to respect) reject it, and to them the name is necessarily the embodiment of error. The term "Pyse- mia" is nevertheless a convenient one ; it has come to signify to the practising medi- cal man, quite apart from all theoretical considerations, a form of disease attended with certain definite symptoms and cer- tain definite anatomical lesions ; and even if some equally euphonious but less objec- tionable term were now to be proposed, it is more than doubtful whether the incon- venience of its substitution would be at- tended with any adequate compensatory advantage. In this qualified sense the term "Pysemia" will be used in the fol- lowing pages. n. Definition of Fymmia. Pysemia is a disease originating often in contagion, and attacking for the most part those who are suffering from the results of serious injuries attended with wounds, or who have undergone grave surgical opera- tions, or who are laboring under acute suppurative inflammation involving bones, or in whom parturition has recently oc- curred. Its onset is usually sudden, and marked by the occurrence of a severe rigor followed by profuse perspiration. Rigors succeeded by perspirations for the most part recur ; the pulse becontes feeble, rapid, variable, often intermittent, the respirations shallow and frequent, and cough (attended or not with expectora- tion) commonly shows itself; the tongue generally becomes dry and furred ; the appetite fails ; and nausea, vomiting, and diarrhoea not unfrequently supervene; the surface generally soon gets sallow or even distinctly jaundiced ; the patient acquires very much the aspect of a person suffering from enteric fever — delirium at night often comes on ; but he remains for the most part conscious, at least when roused ; and soon becomes excessively feeble and pros- trate. It happens often that, in the pro- gress of the maladyr, inflammation, or even suppuration, occurs in some accessi- ble part or parts, especially in or about the joints and in the muscular and cellular tissues. The duration of Pysemia is gene- rally from about four to ten days; but it now and then becomes chronic, and may then last for several weeks or even longer. Its result is almost invariably fatal. The chief lesions discoverable after death are patches of hemorrhage, or of inflammatory consolidation, or abscesses, scattered in various proportions among the different PATHOLOGY OP PYiBMIA. 831 organs and tissues of the body, but occur- ring tar more often and far more numer- ously in the lungs than elsewhere. The part antecedently aflected is generally found in a state of suppuration, and un- healthily inflamed or sloughy. The most characteristic features of Py- emia seem to be :— first, its supervention on certain special conditions of the system; second, the occurrence of rigors with per- spirations; third, the presence of jaundice; fourth, the formation of external abscesses; fifth, the great prostration and early death; and sixth, the occurrence of certain charac- teristic lesions, easily to be recognized after death. III. Pathology of Pyemia. 1. Morbid Anatomy. Discarding, in our detailed account of the morbid anatomy of Pysemia, those ab- normal conditions of organs and tissues which may be now aud then discovered after death from this disease, but have only a fortuitous connection with it, we •will limit ourselves to the consideration of those morbid changes only which form, so to speak, an integral part of Pyfemia. (a) Morbid Anatomy considered gene- rally. — The lesions which characterize Pysemia consist in local congestions, ex- travasations of blood, inflammatory de- posits, abscesses, and necroses. Simple congestion is a phenomenon which is apt to disappear after death, or to be modified and masked by mere post-mortem changes ; it is frequently observed during life to ac- company superficial pysemic inflamma- tions, it is frequently recognized after death in the vicinity of so-called " secon- dary deposits," and doubtless as a rule it precedes all the more important changes which attend this disease. Congestion is therefore a real and important link in the chain of pysemic events, but its pre- sence or absence post mortem cannot in all cases be taken as trustworthy evidence of its presence or absence during life. Ex- travasations of blood are of almost con- stant occurrence ; sometimes they appear as petechial spots or vibices ; sometimes as clots infiltrating the tissues of organs — abruptly marginated and resembling patches of pulmonary apoplexy ; some- times they form decolorized fibrinous tnasses, much like the fibrinous " blocks" observed under other conditions in the spleen, in the liver, and in the kidney. Inflammatory deposits are rarely if ever absent ; and may be associated or mixed up with other morbid conditions, such as extravasations of blood, or may occur in- dependently of them. In the former case they often surround the extravasations, and in connection with serous surfaces form distinct false membranes. In the latter case they constitute, in the lung, patches of lobular hepatization ; and pro- duce in other organs nearly equally well- marked changes. The term " secondary abscess" has been largely employed to designate the localized morbid processes taking place in the course of Pyasmia. And in most cases of Pyaemia abscesses doubtless exist. Sometimes, especially in joints and certain other places, suppura- tion takes place so instantaneously that the formation of pus would almost seem to be the first evidence in them of a de- parture from the condition of health. But more commonly the formation of an ab- scess is distinctly a later process, super- vening on the extravasation of blood or on the effusion of lymph, and commencing either at the margins of the diseased patch, or at some central point in it, or involv- ing the patch simultaneously in its whole extent. In some cases the cavities which pass for abscesses would seem rather to be the results of circumscribed gangrene than of true suppuration ; for they yield a gangrenous odor, and contain a soft shreddy material, more or less adherent to the parietes, and infiltrated with a dirty-looking fetid puriform fluid. A few words will comprise all that need be here said generally in regard to the microscopic appearances observed in the several mor- bid conditions above described. The elements of blood, more or less modified, may of course be discovered in abundance in the hemorrhagic patches ; flbrillated lymph, of the usual character, may be recognized in the inflammatorj'- deposits, especially in those occurring on serous surfaces ; and in those deposits occupying the parenchyma of organs granular mat- ter, exudation corpuscles, and compound granule -cells are generally abundant ; true pus cells are by no means infrequent in pyasmic abscesses, but the puriform fluid is sometimes found to consist of the debris of tissue, oily particles, and disintegrating cell-forms only. Although the description which has just been given is generally applicable to pyaamic lesions, in whatever part of the body they may occur ; there are yet so many diflerences between different organs in regard to the relative frequency ivith which they become involved, in regard to the relative frequency with which the various forms of lesions above enumerated aflfect them, so many minor differences dependent probably on structural and other peculiarities in the organs them- selves, that a special description of these lesions, as they occur in the more impor- tant organs at least, can scarcely be avoided. [h) Morbid Anatomy of Lnngs.— In the lungs the diseased patches are scattered irregularly, but are generally most abun- 332 PYEMIA. dant in the lower part. Their numbers vary considerably ; sometimes they are exceedingly numerous, while one lung is aftected, the other lung is quite healthy. Most of them abut more or less exten- sively on the surface of the lung. The individual patches range generally in size between that of a filbert and that of a pea. Sometimes they are smaller, and not infrequently larger ; but in the latter case the increase of size is generally pro- duced by the coalescence of contiguous patches. The characters of these patches vary very considerably. Sometimes they are distinctly apoplectic ; that is to say, they are reddish-black, void of air, firm, abruptly niarginated, yield blood-stained serum on pressure, and differ in no respect, but that of size, ftom the pulmonary ex- travasations due to mitral-valve disease. More frequently, although still distinctly apoplectic, they have undergone changes; they have become more or less decolor- ized, the margin has assumed a pale buff color, and the more central portions a rusty or brownish hue ; at the same time some degree of softening has generally taken place. This softening often begins in, and may be limited to, the outer buff- colored layer, which then forms an inter- rupted puriform interval between the bulk of the diseased patch and the surrounding healthy tissues ; at other times this pro- cess commences internally, probably in connection with the bronchial passages leading into the affected portion of lung ; at yet other times a more general soften- ing takes place, and the whole patch comes to form an abscess-like cavity. Some- times, though much more rarely, the patches of lung disease are rather pneu- monic than apoplectic, and then strictly resemble the patches of lobular pneumonia which supervene on larj'ngitis, diphtheria, and other diseases obstructing the larger air-passages. Under these circumstances the patches vary considerably in color, according to the relative degrees in which congestion and inflammatory deposits may be present in them, but are granular and have the ordinary aspect of inflamed lung tissue. Pneumonia of this kind, however, is more often combined with other pyeemic changes in the lung, than it is an uncomplicated phenomenon; some- times surrounding apoplectic and other patches, and it may be combining several of these into a common mass of consolida- tion ; sometimes forming independent patches scattered indiscriminately among them. Abscesses or collections of puri- form matter are common, but very far from universal ; often they are formed, as has been described, by the breaking down of clots, still more often they result from the purulent infiltration of pneumonic patches, and in both such cases are found in combination with patches of hemor- rhage, or of inflammation, or of both. But there are some cases of Pyaemia where abscesses alone, sometimes surrounded by solid infiltrated parietes, sometimes by breaking-down tissue, are discovered. In these cases it would almost seem that the process is diflerent from the beginning ; that in some of them the formation of pus takes place coincidently with, if not prior to, whatever other inflammatory changes may be found associated with it ; that in others the diseased and puriform patches are the simple result of necrosial disinte- gration or sloughing. The lung tissue in which the diseased patches are imbedded may be, and often is, healthy ; but very frequently more or less of it is congested or oedematous or even carnified. The bronchial tubes mostly present an excess of secretion, and those which are directly connected with the diseased tracts often contain pus, and sometimes the rusty tenacious fluid which characterizes pneumonia. The subpleural tissue, especially that investing the lung, is generally the seat of extravasations of blood ; and appears therefore studded more or less thickly and more or less irregularly with petechial spots and vibices. The surface of the pleura may be smooth and healthy-look- ing ; or it may be invested in its whole extent by a layer of recently effused lymph ; and the cavity may be occupied in a greater or less degree by transparent, opaline, or even distinctly purulent fluid. But, perhaps more commonly, the lung is only partially covered with lymph — each lump of pulmonary disease, which abuts on the surface, forming a centre of in- flammation and of a disk of inflammatory exudation which is thickest at the centre and becomes thinner and thinner as it re- cedes from that point, until at length it ceases. This lymph presents a reticu- lated surface, and differs in no degree, microscopically or otherwise, from that of ordinary pleuritis. (c) Morbid Anatomy of Heart. — The sur- face of the heart, like that of the lung, is often studded with extravasations oi blood ; and these are generally most abun- dant about its basal portion. Similar extravasations may also be seen in the substance of the muscular parietes, and beneath the endocardium. In the walls of the heart, too, may not infrequently be discovered (generally in the midst of ex- tra vasated blood, or at all events within a zone of congestion) yellowish spots, from the size perhaps of a horse-bean down- wards, which consist either of muscular tissue infiltrated with some inflammatory exudation or of a cavity full of pus or puriform fluid, or of broken-down and disintegrated tissue. The muscular fibres in and around these spots will be found under the microscope to be more or less PATHOLOGY OF PYEMIA. 333 broken into fragments, devoid of trans- verse markings, and studded thickly with minute oily molecules. Tlie diseased patches in the lieart vary much in num- ber ; sometimes not more than one is present, sometimes they are almost innu- merable. They vary too as regards their position ; perhaps tliey are most common about the base of tlie ventricles, but no part is free from liability to them, and they are sometimes found in the musculi papillares. As in the case of tlie lungs, so here, the patches of disease act as cen- tres of inflammation. AVhen they reach the pericardial surface, they induce in- flammation in that membrane, with exu- dation of lympli ; and when they reach the endocardial surface, they may lead to important changes in the endocardium it- self. In the former case the exudation is of the same nature as tliat which occurs in connection with the pleura ; in tlie lat- ter case the endocardium itself is apt to become thick and granular, from intersti- tial intlaminatory deposit, and its free sur- face to be studded with so-called "vegeta- tions." Occasionally vegetations become deposited upon the valves. Excepting the various morbid conditions just de- scribed, the heart is generally found quite healthy. {d) Mwbid Anatomy of Liver. — Jaun- dice is a marked, though not an invari- able symptom of Pyremia ; yet notliing has been detected post mortem, in the con- dition of the liver to ex^jlain its occur- rence. Frerichs asserts' that "the bile duets are open, and usually pour out a lit- tle thin secretion," and that "the organ itself is in most cases anremic and dry." The Hver in these cases has, in fact, a healthy appearance, except in so far as it happens to be the seat of special pyaemic changes. These changes consist in con- gestions, inflammatory exudations, and localized disintegrations or suppurations. They have no special seat. The earliest condition of disease, and one that is often alone seen, is the presence of congested patches of a port-wine hue. These vary in size and shape, have often a superficial area of two or three square inches, dip to a greater or less extent into the substance of the organ, and for the most part in- clude irregular patches of unnatural pal- lor. Such patches often differ, so far as can be ascertained, in color only from the surrounding healthy tissues. Sometimes studding these patches, sometimes occur- ring independently of them, spots may be seeu of an opaque buff color, in which the liver tissue is evidently infiltrated and softened, and it may be broken down into a puriform pulp. These spots have usu- ally around them a halo of congestion, ' Klinikder Leber-Krankheiten : Sydenham Soc. TransL, vol. i. p. 162. and their contents consist sometimes chiefly of pus-corpuscles, sometimes of disintegrated liver substance only. But besides these, larger abscesses are not in- frequently met with— abscesses the size of a filbert, a chestnut, a hen's egg, or of still larger dimensions. These generally contain a greenish-colored purulent fluid ; and are sometimes, judging both from their odor and from" their appearance, distinctly gangrenous. (e) Morbid Anatomy of jSjjIeen.— When the spleen is secondarily affected in Pyce- mia, the morbid appearances which it pre- sents are very much Uke those observed in cases of heart disease. They consist generally either of circumscribed extrava- sations of blood, or of fibrinous "blocks," which are both often of considerable size. The "apoplectic" clots tend to become decolorized at the surface and to break down variously into a puriform pulp ; the fibrinous blocks are usually softer and more juicy than those of heart disease, and tend, like the clots, to hquefy. Dis- tinct al)?cesses, too, of various sizes are often scattered throughout the organ. (/) Morbid Anatomy of Kidneys. — The liidncys are frequently involved ; and the morbid changes which occur in them are observed both more frequently and to a greater extent in the cortex than in the medulla. The medulla, however, by no means escapes. Sometimes these changes are limited to a single spot in one kidney, sometimes they affect both organs almost universal]}'. But more commonly they are present in both and in some interme- diate degree of severity. Occasionally no abscesses have formed, but almost the whole tissue of the organ is mapped out by tracts and bands of deep congestion, wdiich alternate with and surround patches, of which the color is unnaturally pale. More frequently distinct abscesses are present ; these are generally small and tend to become clustered ; and both the individual abscesses and the groups of ab- scesses assume a linear arrangement, per- pendicular to the surface of the kidney. The abscesses contain a distinctly puru- lent fluid, have invariably a margin of in- tense congestion, and vary generally in size from that of a pea or horse-bean to an extreme degree of minuteness. Some- times, however, they are so large as to contain an ounce or two of pus. They can almost always be seen on removing the capsule of the organ, and very often the removal of the capsule allows the con- tents of the more superfi(.'ial ones to es- cape. The formation of pus in these ab- scesses seems to take place, originally at least, in the intertubular tissue ; and very often in the early stages the Malpighian bodies and tubules in the affected spot are quite healthv. (g) Morbid Anatovvj of other Abdominal 334 PYEMIA. Ch-gans and of Peritnneinn. — Congestions and petechial extravasations are apt to occur, both in the gastro-intestinal mu- cous membrane, and in that of tlie genito- urinary apparatus. As regards tlie tirst- named mucous tract, it is an interesting fact that tliere are occasionally observed upon it, and more especially on that part of it which belongs to the csecum and co- loUj patches of granular exudation. Oc- casionally, too, the intestinal submucous tissue becomes the seat of well-marked pytemic deposits, which may lead to the destruction of the mucous surface over them, and the production of a sloughy ulcer, not unlike the ulcer of enteric fever or that which follows the opening of a boil. As regards other organs connected with the abdomen little need be said. They are rarely affected secondarily, and even when they are thus affected they present few points of importance or interest either to the pathologist or practitioner. Of them all, the prostate and the testicle probably most often undergo suppura- tion. The pyajmic affections of the perito- neum resemble those of the pleura and pericardium. Sub-serous extravasations of blood are common ; and inflammatory changes occurring within viscera (especi- ally the liver and the spleen) lead to in- flammation in the serous surface external to them, which may remain limited in extent, or become general peritonitis. Yery often an abscess forms between the surface of the diseased lump and what- ever organ or part is in contact with it — • the abscess being limited laterally by ad- hesions, which correspond accurately to the margin of the lump. The same thing, though on a much more minute scale, is of general occurrence in the case of the lungs and pleura. (h) Morbid Anatomy of Brain. — The brain does not appear to be a very fre- quent seat of pyo3mic changes. When present, however, they consist of conges- tions with extravasations of circumscribed softenings, and of abscesses. The ex- travasations affect chiefly the surface of the organ, and though perhaps generally petechial, sometimes become sufficiently abundant to occupy an extensive tract of the subarachnoid tissue. The circum- scribed softenings and abscesses occupy indifferently any part of the brain— the gray matter, the white matter, the cere- brum, the cerebellum, the corpus striata, the optic thalami, the pons Varolii — no part necessarily escapes. The former are yellowish, more or less congested, more or less softened, patches, such as are met with in cases of so-called "embolism" of the brain, but of smaller size, varying mostly from that of a horse-bean down- wards ; the latter are distinct abscesses containing glairy greenish-yellow pus, and sometimes attain considerable dimensions. The number of foci of disease present at one time varies very considerably ; some- times not more than one or two are dis- covered, sometimes they are so numerous that scarcely any part of the brain, so large even as a chestnut, is found free from them. The softened patches con- tain, in addition to disintegrated nervous tissue, vast numbers of compound granule cells. (i) Morbid Anatomy of Organs of Sense. — Of the organs of sense the eye only calls for special remark. This organ occasion- ally becomes the seat of suppurative in- flammation, especially in cases of puer- peral Pj'semia. In these cases the affection of the eye is characterized' " by redness of the conjunctiva, intolerance of light, and contracted pupil ; rapidly followed by opacity of the cornea, and excessive che- mosis. " The eye ultimately sloughs, and its contents escape. Ue) Mm-bid Anatomy of Bones and Joints. — Suppuration sometimes takes place in connection with bones. The afi'ected bone or portion of bone then becomes rapidly denuded of periosteum ; fetid pus accu- mulates upon its surface, while at the same time probably pus infiltrates its can- cellous texture, and rapid necrosis ensues. The joints are much more frequently affected than the bones. The synovial fringes become intensely congested, and the synovia increased in quantity or re- placed by pus or puriform fluid. The capsule of the affected joint becomes dis- tended, and the parts external to it be- come more or less inflamed. When the fluid within the joint assumes a purulent character, which is by no means always the case, it often happens that the parts of the lining membrane which had been congested become pale, that destruction of cartilage takes place, that the joint, in fact, becomes disorganized. All joints, small as well as large, are liable to be affected. (I) Morbid Anatomy of Celhdar Tissue and Muscles. — Again, the secondary effects of Pysemia show themselves constantly among the muscles and in the cellular tissue of the body generally. Extravasa- tions of blood here are exceedingly com- mon, inflammatory congestions and exu- dations frequently occur, and abscesses (often of large size) form rapidly, and almost without warning. These morbid changes are often observed in the walls of the chest and belly, and in the neighbor- hood especially of joints, for inflammation of which latter parts they are then very liable to be mistaken. Pyasmic abscesses have been met with in the tongue. ' Arnott, Medioo-Chlrurgioal Transactions, vol. XV. PATHOLOGY OF PYEMIA. (m) Morbid Anatmny of Skin. — The skin necessarily partakes sooner or later in any morbid process which is going on imme- diately below it ; and hence discoloration of skin is frequently observed over super- ficial pysemic intiltrations and abscesses. When jaundice is present, the skin neces- sarily partakes in the general icteroid tinge. Apart from the alsove, the morbid conditions of the skin in pysemia are not very important. Petechias are not very common ; sudamma are frequently present ; and occasionally vesicular and pustular eruptions have been observed. (n) Relative Frequency ivitli which Orgems are affected. — There is considerable differ- ence in the relative frequency with which the various organs and tissues of the body become secondarily affected in Py- emia. The lungs rarely escape, and not infrequently are the only parts in which morbid changes are observed. The vis- cera affected next in frequency to the lungs would seem to be the kidneys. After these the liver, spleen, and heart. Then perhaps the brain. Among organs less often affected may be enumerated the intestinal canal, the testis, the prostate, and the eye. The joints and the general cellular tissue of the body become of course very frequently the seat of secondary affec- tions. And indeed, from the great extent of the one and the great number of the other, disease in these parts is without doubt constantly overlooked. The serous membranes, at least one or two of them, are rarely found uninflamed : this condi- tion may occasionally depend on morbid processes originating in themselves, but in the great majority of cases, as has been already explained, is due to the extension of inflammation from some subjacent organ. (o) Morbid Coiulition of Blood. — The chemistry of the blood in Pyteniia has not, so far as we know, been investigated. We must content ourselves therefore with the discussion of its physical properties. With certain important exceptions, which will be presently fully considered, the blood in Pyemia presents no important differences fi-om the blood of health ; it retains its natural color, the blood disks and the white corpuscles preserve their due numerical relation to each other and to the mass of the blood, and so far as can be recognized their normal characters, oometimes the blood appears to be unu- sually fluid, to present in the cavities of the heart and in the larger vessels only traces of coagulum. More commonly it coagulates in the usual way ; and we find distinct clots in one or more or all of the cavities of the heart. Sometimes these ^re ordinary-colored post-mortem clots, sometimes they consist wholly or almost wholly of pure flbrine ; and in either case they may be prolonged in a cylindrical form into the large vessels. There is no special tendency for the right side of the heart to be occupied, far less to be occu- pied exclusively, by these clots. They may be found there, it is true, and found there while the left cavities are contracted and empty. But in many cases, while the right side is empty, the left is dis- tended with them. In fact there is noth- ing in the situation or character of these clots to distinguish them from those which are found in many other forms of disease. The adherent rounded clots, which soften in their interior into a puriform pulp, have sometimes been supposed to charac- terize PT^femia. But this is clearly a mis- take.' Such clots are far more commonly observed in other cases ; indeed are alto- gether exceptional in Pysemia ; and when present are evidently accidental and pro- bably trivial complications. The most important and characteristic clianges of the blood in pysemic cases are manifested more particularly in the veins of the part at which infection is supposed to have occurred, and in the small arterial twigs leading to the spots in which secon- dary lesions have become developed. The veins leading from the seat of supposed infection have been examined over and over again with extreme care ; and the general results of these examinations may be shortly summarized. In some cases the veins, though traced into suppurating and even sloughing regions, are found, both as regards their walls and their con- tents, apparently entirely healthy ; in other and more numerous cases they are seen to be in various ways and degrees diseased. Their parietes are thickened and indurated ; they may be seen to com- municate by orifices, resulting from ulcer- ation or some other cause, with the mor- bific elements in which they are lying imbedded ; and their interior is occupied by coagula. These coagula are mostly adherent, and more or less decolorized ; they may be solid throughout, but more commonly are reduced in their interior into a reddish or yellowish puriform pulp or fluid. This fluid appears generally to consist merely of disintegrated fibrine, but in some cases is undoubtedly true pus. ^ It is mostly, but not always, sepa- ' See Papers on Softening Clots in the Heart, in the Transactions of the Pathological Society of London. Vol. ii. p. 134, and vol. xiv. p. 71. 2 The following case bears out the state- ment in the text. A man died of erysipelas of the face and Pysemia. ' ' The brawny tissue of the face was infiltrated with pus, and pus oozed from numerous divided vessels. The facial vein of the right side was thickened and surrounded by indurated adherent tissue, and its canal was dilated. The first inch of its course was occupied by thick purulent fluid ; to this succeeded a cylindrical a^lberent 336 PYEMIA. rated from the venous walls by a layer of hitill consistent tibrine ; and is generally shut out from the proximal portion of the venous channel in which it lies by a con- tinuation of this layer of fibrine, which forms a kind of septum or diaphragm be- tween them. Generally the rounded ex- tremity of the hollow fibrinous cylinder thus formed has adherent to it and pro- longed from it a process of ordinary colored clot. Sometimes one, sometimes several veins are found thus aftected, and sometimes a considerable length of one is converted into an elongated abscess. The ultimate arterial twigs, distributed in the lungs to the masses of diseased lung structure, seem to be invariably oc- cupied, indeed distended, by a soft pulpy yellowish material, or by something more nearly approaching to ordinary coagidum, This material is found to consist mostly of mere disintegrated fibrine presenting the debris only of cells. But sometimes it contains distinct pus' — that is to say cells resembling in all their visible charac- ters pus-corpuscles or the white corpus- cles of the blood, but so abundant and so closely aggregated as wholly to negative the notion of their being normal blood- elements. Similar coagula have been de- tected in the small vessels leading to the diseased patches occurring in other organs besides the lungs — in the vessels for ex- ample of the heart, the spleen, and the kidneys. (p) Connection between hlocTced-up Con- dition of Vessels and Secondary Deposits. — So constantly are these coagula found in the small arteries, if looked for carefully, that the conclusion is forced upon patholo- gists that there is between them and the patches of diseased tissue a relationship of cause and effect. It might be surmised that the coagula in the bloodvessels are secondary to the local pyeemic formations with which they are connected, due to fibrinous coagnlum, tbe distal extremity of whieh formed a hollow cone. The lower or proximal extremity gradually dwindled away, and was succeeded by purulent fluid : this latter continued throughout the rest of the facial vein as far as its junction with the jugular. No coagulnmor adhesion separated this fluid from the general circulation. The purulent fluid found in the veins presented under the microscope large numbers of cor- puscles, but they were mostly smaller and more irregular in shape and size than normal pus corpuscles ; and few, if any, presented division of their contents under the influence of acetic acid. There were numerous secon- dary abscesses in the lungs." — Manuscript Notes of Post-mortem Examinations, St. Thomas's Hospital. Nov. 2, 1857. ' See Transactions of Path. Soc. cf London, vol. xiii. pp. 203, 204. See also Dr. Wilks's Report on Pyemia, in the Guy's H»spital Re- ports, vol. vii. 1861. obstruction in the capillaries of the af- fected part and consequent stagnation of blood in the vessels leading to them. The characters of the coagula show, however, that this cannot be the true explanation of their mode of formation. They are not mere coagulated blood, nor even mere coagulated fibrine ; but, if fibrine at all, are fibrine which has undergone changes, requiring time for their production, and often in point of time clearly in advance of the changes which have taken place in the patches of diseased tissue. There can be no doubt indeed that the sequence of events occurs in the reverse order; that the small afterent vessels become blocked up, and that on this blocking up super- vene those changes which, according to circumstances, end in extravasation of blood, inflammation, purulent infiltration, or gangrene. This view is partly based on direct observation in Pysemia itself, partly on corroborative evidence derived from other sources. Thus, it has been clearly established by experiments that if a small artery leading to any spot be obstructed, that spot be- comes the seat of congestion and inflam- mation. The careful experiments of Mr. Wharton Jones' show that if in the frog's foot such an artery be divided, and the capillary area to which it leads be thus cut off from all direct supply of blood, these capillaries nevertheless become filled with blood by regurgitation from neigh- boring anastomosing vessels; and further, that since by the same operation they have been cut off" from the direct influence of the heart's systole, the blood which is poured into them becomes stagnant there, and intense congestion results. Again, the experiments of Cruveilhier, Sedillot,* Henry Lee,' and others show that, if mer- cury, oil, pus, fibrine, be injected into the veins, they become impacted in the small arteries connected with the network of capillaries next beyond the seat of opera- tion, occlude them, and induce conges- tion, if not hemorrhage, and inflammation in the respective areas to which they lead. Each of these experiments has no doubt some point of special interest, but all con- cur in establishing one common fact of fundamental importance, viz., that the sudden stoppage of the direct supply of blood to a limited area tends to the pro- duction in that area of congestion and in- flammation — of the very processes in fact which mark the secondary effects of Py- semia. The analogies afforded by other forms ' Astley Cooper Prize Essay, "On the State of the Blood and Bloodvessels in Inflamma- tion." Guy's Hospital Reports, Second Se- ries, vol. vii. p. 23 et seq. * Sedillot, De 1' Infection purulente. ' Lee on Phlebitis. PATHOLOGY OF PYEMIA. 337 of disease are still more lo the point. Wheu arteries become obstructed either from morbid changes in their walls, or from plugs in their interior, the parts which they supply fall into an unhealthy condition. It is needless to dwell upon the changes which take place in the lower extremities, when in old age the arteries become closed by accumulated atheroma- tous and earthy deposits, or even upon the circumscribed softenings in the sub- stance of the heart (leading to rupture), which attend similar changes in branches of the coronary artery. The effects, how- ever, of thrombi and emboli must be con- sidered a little more in detail. It has been clearly ascertained by the researches of Virchow, Kirkes, and succeeding ob- servers, that, in cases of heart disease with vegetations on the valves, these vegetations are apt to be detached, car- ried with the onward current of the blood, and impacted in the first artery they reach which is too small to permit of their transit. It has been clearly ascertained that such detached fragments, or " embo- li" as they are termed, become fixed in the arteries of the brain (more especially in the middle cerebral artery), and lead, in the brain structure beyond, to circum- scribed congestion, inflammatory soften- ing, and disintegration of tissue ; that they become fixed in the small arteries of the spleen, and lead to extravasations of blood and so-called "fibrinous blocks;" that they become fixed in the renal ar- teries, and lead at one time to exudation of blood and lymph, at another time to minute abscesses; that they become fixed in the arteries of the retina, and lead to similar results there ; that in fact they may occlude any artery of any organ, and thus lead to specific changes in the bit of tissue which that artery supplies. It has been clearly ascertained also that clots or ''thrombi" formed in the interior of veins break down and crumble ; and that their fragments, swept away by the stream of the blood, pass onwards with it from the smaller to the larger veins, through the cardiac cavities and orifices, and thence still onwards along the arteries, until, like the broken off cardiac vegetations, they become impacted, and by their im- paction produce identical results. Fur- ther, it has been ascertained that clots form spontaneously, so to speak, not in the veins alone, but in the heart's cavi- ties, and in the arterial system ; and that the clots thus formed in the latter situa- tion occlude the arteries in which they arise, and lead in the parts beyond to the same changes as have been described in connection with emboli. Here again, throughout the whole series of allied but not identical processes, we find that ob- struction of the supplying artery causes ii the part supplied precisely those lesions TOL. I.— 22 which occur as the specific local manifes- tations of Pyremia. It has been already stated that the secondarjr eflfects of thrombosis and em- bolia are identical with those of Pyaemia ; and essentially no doubt they are so. Yet there are between them certain minor dif- ferences — diflerences chiefly of degree — which it may be desirable to consider. This will be most conveniently done by taking three or four important organs and comparing the eflects of these diseases up- on them. In the brain the influence of embolia or thrombosis is almost invaria- bly limited to a single spot ; Pyoemia pro- duces many spots of disease. The region affected in embolia is generally larger, at least in the beginning, than the individual regions affected in Pytemia. Moreover, in the former case breaking down of tissue is far less rapid than in the latter case, and actual suppuration rarely if ever oc- curs. The pulmonary apoplexy attendant on heart disease is we believe generally, if not alwa3'S, due immediately to throm- bosis of branches of the pulmonary artery belonging to the apoplectic region, fol- lowed by congestion and rupture of the capillary network of the part. Now the clots of ordinary pulmonary apoplexy are almost identical with the pulmonary clots of certain cases of Pyaemia. Like them they become decolorized upon the surface, like them they may become more or less perfectly suiTOunded by a rim of softening or suppuration, or may present similar changes in their interior, and like them, when they abut on the surface of the lung, they lead to the deposition of a layer of fibrine on the overlying pleural lamina. But as a rule they are less numerous, and individually much larger, than pytemic clots ; and their tendency to soften, to suppurate, to slough, is far less. In the spleen, the wedges or blocks of effused blood, or fibrinous exudation, which so commonly result from cardiac emboli, are in their general aspect almost exactly like those connected with Pyaemia ; but here again the tendency to rapid suppuration or decomposition distinguishes for the most part the one form of deposit from the other. In the case of the kidneys the dif- ferences are less pronounced : in both af- fections minute abscesses are of common and early occurrence ; in both, hemor- rhages and exudations of fibrine alone are occasionally met with. It would seem then that the chief distinction between pyfemic deposits and those resulting from simple embolia resides in the fact of the greater tendency of the former to undergo changes of degeneration and destruction. But this after all is chiefly a difference of degree ; and the difference in this respect between them is no greater than the differ- ence which may often be observed between actual cases of 'Pyemia. Thus in one case 338 PYjEMIA. of P}-8smia hemorrhagic effusions only will be discovered in the internal organs, in another case patches of inflammation only, in a third abscesses, in a fourth gangren- ous excavations ; though more commonly doubtless these various conditions are to a greater or less extent commingled. 2. General Pathology of Pymnia. (o) Conditions of System essential for the Development of Pycemia. — Exclusive of a few cases in which, from want of a trust- worthy history or from some other cause, it has been impossible to determine what has been the original seat of disease ; and of a few other cases which may be found recorded, wherein after very minute and careful investigation nothing that could be regarded as a starting-point for Pyjemia has been discovered, and which may pos- sibly, therefore, have been idiopathic— exclusive of these, all cases of Pytemia ap- pear to take their origin in some one or more well-marked local conditions of dis- ease ; some coming naturally under the care of the physician, others under the care of the accoucheur, others under the care of the surgeon. "We will enumerate them with- out particular reference to the department of practice to which they respectively be- long. First. — Pyasmia frequently follows on accidental injuries, such as extensive burns or scalds, bruising and lacerating of tissues, and compound fractures, especially on fractures of the long bones, and of the bones of the head and pelvis. Such acci- dents often, of course, become repaired witliout any untoward complication; often they are followed by serious results, and even death, quite independently of any- thing approaching to Pyaemia ; but often, and even at a time when they appear to be progressing favorably, the symptoms of Pyfcmia come on and the patient dies rapidly of this disease. The occurrence of Pyemia in these cases is generally dis- tinctly preceded by sloughing, unhealthy suppuration, by erysipelatous inflamma- tion, or some allied process. Second. — Pyaemia is the bane of certain operations. No operation possibly can be regarded as absolutely free from liability to the super- vention of Pyaemia ; but large operations, operations that is to say which leave ex- tensive raw surfaces, especially therefore amputations of the larger limbs, opera- tions too in which bones are involved, and operations in which certain parts (the bladder, prostate, and urethra, to wit) are implicated, are especially liable to the supervention of Pyasmia. But here again the pyaemic symptoms are mostly preceded by the occurrence of unhealthy processes at the seat of operation. Third. — Pyte- mia is peculiarly apt to follow on acute suppuration taking place in connection with bones. Sometimes from an accident (unattended by breach of surface), some- times, so far as can be made out, sponta- neously, acute inflammation is suddenly lit up in connection with one of the bones ^probably one of the long bones— suppu- ration rapidly takes place on the surface of the bone, between it and the periosteum, and in its interior ; the bone dies ; and in the course of these processes the symp- toms of Pyasmia suddenly declare them- selves. Fourth. — Phlebitis, as the disease is called, whether it be idiopathic or whether it be induced by injury or by operation,' is a pregnant cause of Pytemia. This complication has been especially ob- served in connection with the operation of phlebotomy, in operations on varicose veins and hemorrhoids, and in connection with the wounding or tying of large veins in the course of certain other operations. Fifth.- — Pycemia is by no means an un- common sequela of suppuration involving certain of the organs of sense, such as the eye and the internal ear. Sixth.— Ho- called ' ' low inflammations ' ' attended with suppuration — in the male in connection with the bladder, prostate, and urethra, and in the female in connection with the ovaries and other genito-urinary organs — are not infrequently succeeded by Pysemia. Seventh. — The period immediately after parturition is peculiarly obnoxious to the occurrence of Pyaemia. " Puerperal fever" is the generic term which is used for a variety of diseases occurring shortly after child-birth. What these diseases are it is not our province now to discuss ; but cer- tainly one form of so-called "puerperal fever" and one which causes no incon- siderable proportion of the deaths ascribed to puerperal fever, is Pyaemia. Eighth.— Certain forms of so-called "unhealthy'' inflammation are not infrequently followed by Pyaemia. Such are phlegmonous ery- sipelas, diffuse cellular inflammation, car- buncle, dissecting wounds, malignant pus- tule. Ninth. — Pyaemia is described as taking place occasionally in the course of certain febrile affections, such as typhus, enteric fever, and variola. Now, in reviewing the above series of cases in which specially Pyaemia is apt to occur, several facts come into prominent relief. It would seem in the first place that, in such cases, Pyaemia is almost in- variably, if not always, preceded by some local suppuration, and that this suppura- tion is erysipelatous, gangrenous, or other- wise unhealthy. Such is the case after in- juries, after operations, after affections of the bones, of the organs of sense, of the genito-urinary organs, of the veins ; sucli too is certainly often the case in puerperal ' Py!emia is described as following on the operation of tying the funis in the new-born child. PATHOLOGY OF PYiEMIA. 339 ■women. It would seem in the second place that Pysemia is pecuharly apt to supervene in cases in which bones are in- volved in tliese morbid processes. It would seem further that in the great ma- jority of cases, if not in all, there is reason to believe that veins are in some way or other specially implicated. Thus it has been conclusively determined that wounds and injuries of veins, and suppu- ration taking place in connection with them, not infrequently lead to Pysemia ; it has been pointed out that the veins in the interior of bones are peculiarly thin- walled, and at the same time from their connections prevented from readily con- tracting, and that when inflammatory processes are going on in the interior of bones these vessels are necessarily pecu- harly implicated ; as regards the skull, again, it is clear that the bones which form it, besides having in their interior the veins of the diploe, are related by their inner surface to the venous sinuses — channels which if not thin-walled like the veins of bones, are like them permanently patent; the eye and the ear stand in much the same position as the skull itself, they are bounded in fact by osseous tissue which almost necessarily becomes in- volved when serious inflammation occurs in the adjacent structures, and they com- municate almost directly by special veins with the sinuses, the peculiarities of which have been pointed out; again the prostate and neighboring parts are supplied with an almost superabundant net-work of veins ; and lastly in parturient women the uterine portion of the placenta is pro- vided with huge thin-walled venous si- nuses which receive blood from the curl- ing arteries and pour it into large uterine veins : at tha time of parturition these are necessarily ruptured, and although by contraction of the uterus their orifices be- come in great measure closed, it is obvious that they are so circumstanced as to be peculiarly exposed to the influence of poi- sonous and other injurious processes going on in the interior of the uterus, or in con- nection with its lining membrane. (6) Essential Causelyf Pycemia. — We are now in a position to consider what is the essential cause of Pysemia. The sudden onset of the disease, the markedly febrile and characteristic symptoms which it ex- hibits, the limited term of its duration, and its terrible mortality, together with the occurrence of specific lesions, all sug- gest a close analogy on the one hand be- tween it and certain contagious fevers — typhus fever, enteric fever, smallpox, diphtheria, and the like ; on the other band, between it and certain diseases, such as glanders and hydrophobia, arising from the inoculation of animal poisons. In each of these analogous cases the dis- ease is due to the entrance into the system of some morbid poison, to the circulation of this poison through the vessels with the blood, the chemical changes thereby in- duced in the blood, and through the agency of the blood in the system generally. In Pysemia, too, it is manifest that the symp- toms are due to the entrance into the blood of some mMeries morhi, and to changes thereby induced in that fluid and in the tissues through whicli it circulates. There are, however, marked points of dif- ference as regards the mode in which the several classes of poisons above referred to enter the system. In contagious fevers it is mostly by the breath that the conta- gium takes eftect ; in glanders and in hydrophobia it is by inoculation; but Pyffimia, thovigh in a certain sense con- tagious, is never imparted through the instrumentality of gaseous exhalations alone, and never even by inoculation, ex- cept the appropriate condition be present of a raw, suppurating, or sloughing sur- face. Further, though it may be imparted by some contagious influence, it may, equally originate de novo, but never prob- ably becomes developed even in the latter case except in connection with some area of suppuration, and through the direct agency of that area. The poison which produces Pysemia is evidently something more gross, something less subtle, than the poisons of those diseases with which we have compared it, and is capable only of acting on parts especially prepared as it were to receive and to develop it. It is important to determine what this poison is, and how it gains an entrance into the system. It was at one time be- lieved that pus, as such, is absorbed by the veins from the region of primary sup- puration, and carried bodily to the various localities in which secondary accumula- tions of pus are discovered — that a true process of metastasis takes place. Again, it was imagined that this disease is simply phlebitis, in which the inflammation of the veins has extended to the vena cava and the heart. Arnott' maintained that the cause of what is now termed "Pyse- mia" is "inflammation of the veins, the consequent production of pus in their cavi- ties, and the entrance of this into the cir- culation. " And since the period at which Mr. Arnott wrote, his views, with various more or less important modifications, have generally found acceptance. Thus, some have believed with Mr. Arnott that pus finds its way into the blood in conse- quence of the secretion of pus by the inner surface of some vein or veins inflamed by the extension of inflammation from sur- rounding parts ; others have considered that pus is absorbed from some suppurat- ing region by the open orifices of veins —orifices existing naturally (as in the ' Med. Chir. Trans, vol. xv. 340 PYEMIA. uterus), or made by operation or disease; others again, have supposed that the pus- corpuscles carried witli the blood become arrested in the capillary vessels of the lung, and there produce the characteristic lesions of Pysemia, either by multiplying by means of cell-growth and thus forming an abscess, or by acting as foreign bodies and thus inducing congestion and inflam- mation in the surrounding parts. In sup- port of some at least of these views, it has been pointed out that the veins connected with the seat of primary disease are often thickened, and occupied by adherent coagula containing within them a puri- form fluid ; it has been maintained that pus-corpuscles may be recognized in the circulating fluid; and it has been found experimentally that the introduction of pus into the veins leads to changes in re- mote organs like those of Pysemia. But Virchow' (whose researches in connection with Pyaemia are most important) main- tains that the puriform fluid in the affected veins is not pus, but simply disintegrated clot, that the clot is formed in the veins wholly independent of phlebitis, and that the diseased condition of the venous walls is not the cause, but (if related to it at all) the consequence of the clot within it. Again, though Sedillot^ has taken pains to show that pus-corpuscles circulate in the blood in cases of Pysemia, and may by their microscopic characters be recognized there, it is now generally allowed that pus-corpuscles do not mingle with the blood in the manner supposed, and that even if they did it would be impossible to distinguish them from the white corpus- cles of the blood itself. And lastly, although it has been shown that pus in- troduced artificially into the systemic veins may produce lobular inflammation of the lungs, it has been shown that the pus acts in such cases as an embolus, and much in the same way as other sub- stances which lead to mechanical obstruc- tion of the small pulmonary vessels. The theory which at present finds perhaps most general acceptance is that of which Vir- chow' is the chief exponent. He denies that in Pya;mia pus (meaning, by pus, pus- corpuscles) enters the blood ; he denies that pus is ever found either in the thrombi occupying the veins of the region primarily diseased, or in the small vessels leading to the patches of secondary disease ; he asserts that what had been regarded as pus is merely disintegrated fibrine, and that the material choking up the small afferent vessels of a secondarily-diseased tract is simply an embolus resulting from the crumbling away of the fibrinous mate- ' Virchow's Cellular Pathology, translated by Dr. Chance. ^ De 1' Infection Purulente. * Cellular Pathology, Lectures IX. and X. rial occupying the veins at the seat of primary disease ; he maintains that all secondary pysemic formations and changes are thus the result of embolia, but that the differences which these formations exhibit in different cases are due to the difference of process which has led to the disintegration of the original thrombus. So much with regard to his explanatioa of the mode of production of secondary pysemic lesions : to explain, however, the general symptoms of Pyaemia, to explain certain diffused inflammatory processes (as inflammation of joints and of serous surfaces), which do not seem to be easily explicable on the embolic theory, he assumes that in many cases of Pysemia, at least, certain ichorous juices are also absorbed into and act upon the system. Thus, according to Virchow, it would appear that Pyaemia is a complex condi- tion ; that from the veins at the seat of a primary disease solid matters and poison- ous fluids are circulated throughout the system; that the solid matters lead to the more material secondary lesions, the fluid matters to the more subtle changes, which combine to constitute the disease under consideration. These views are intelligible, and give a plausible explanation of most of the phe- nomena of Pyaemia ; but they do not, we conceive, explain all the phenomena of the disease, neither, as it seems to us, are they based on an impartial appreciation of all the facts. We admit that in the majority of cases the puriform fluid in clots is simply disintegrated clot, but we maintain that the true pus is occasionally met with in venous clots and in the clots of arteries, and that pus is occasionally discovered in transitu in the blood— not, we allow, in the form of scattered pus- cells, but in that of soft pellets.' We see ' The following case of malignant and ra- pidly fatal scarlet fever may be quoted in confirmation of this statement: — " There were no pysemic deposits ; but the following was the condition of the blood in the heart's cavi- ties : The left ventricle was empty, but all the other cavities were filled with largish fibrinous coagula. The greater part of the clot in the right ventricle consisted of per- fectly decolorized, recently deposited fibrine, straw-colored, elastic, and semi-transparent. Embedded in its substance were a few small opaque whitish masses, which looked like clots of older formation entangled in the sub- stance of the more recent one. These in- creased in number towards the pulmonic valves, and were very numerous in the cylin- der of clot occupying the trunk of the pulmo- nary artery and its left branch, rendering it in fact somewhat nodulated. All these masses had an opaque, bufif-colored, creamy aspect, were irregular in shape, and appeared in the majority of Instances to consist of convoluted, folded, wrinkled, or twisted fragments as PATHOLOGY OF PYEMIA. 341 no sufficient reason to believe that veins do not share iu the morbid changes which are going on around tliem, or that phle- bitis may not exist at a time when no ap- preciable thickening of their walls has taken place ;" indeed, we have reason to believe that pus may be formed not only on the lining surface of these tubes, but even in the interior of clots adherent to them, by the communication to them of those tendencies to cell-production which are a part of the inflammatory process. We believe that in the above views undue importance has been attached to the em- bolic theory, too little to the independent formation of thrombi within the arterial system. We do not see how the embolic theory explains satisfactorily those cases of Pysemia, starting from some portion of the systemic venous system, in which the lungs escape in great measure, or en- tirely, while secondary deposits are found, it may be, abundantly in other organs. Lastly, it seems to us as erroneous to re- gard the corpuscular element of pus only as pus, as it would be to attach that name to the liquor purls exclusively. Pus con- sists of both a solid and a fluid portion. On the whole, we are disposed to believe though they had been formed and moulded in other parts, and had become entangled and compressed by the surrounding clot. The masses were somewhat soft, and could be separated readily from the fibrine investing them; and when separated some of tliem could be unfolded, but at the same time gave no clear indication as to what their original shape had been ; some looked as though they might be collapsed bags, others were possibly cylindrical ; none contained fluid. The same appearances were found iu the right auricle. The left auricle contained, besides an ordi- nary clot, a single soft mass of the same kind as those that were found on the right side. Under the microscope the ordinary fibrinous ' coagula presented the usual characters of such formations ; but the soft masses consisted entirely of corpuscles, which had the size and general characters of pus, and of which (under the action of acetic acid) the nuclei were divided into two or three spherules." — Manu- script Notes of Post-Mortem Examinations, St. Thomas's Hospital, September 15, 1858. The soft opaque masses above described were very likely emboli carried from the seat of suppuration in the tonsil ; but they were also, so at least It seems to the author, un- doubtedly pus. See also Transactions of the Path. See. of London, vol. ix. p. 279. ' If the presence of phlebitis is to be de- nied in all cases where there is an absence of thickening and congestion of the venous walls, it may with equal justice be denied that bronchitis has been present when the bronchial mucous membrane is found after death neither congested nor thickened. But in many cases of fatal bronchitis the mucous membrane itself looks quite or nearly healthy. that, owing to some form of unhealthy process supervening in the region of pri- mary disease, unhealthy pus or the ele- ment of unhealthy pus (call it ichor if you will) finds its way into the circulating fluid, and poisons it ; that this poisoning partly shows itself in producing in the blood a tendency to coagulate in the smaller vessels, partly shows itself by in- ducing more subtle but even more serious effects upon the system at large. We are not disposed to deny that some of the local effects may really be due to embolism, some even to the impaction of coagulated masses of pus-cells ; but we believe that thrombosis alone is the more general ex- planation of that obstruction of the minute vessels which leads to the secondary de- posits. (c) Cause of relative Frequency ofPycemic Deposits in different Organs. — On either view of the question, it is easy to under- stand why the lungs should be, as they generally are, first and most seriously affected. For since the majority of cases of Pyseraia originate in connection with the systemic venous system, the poisonous matters which induce the disease must reach first the pulmonary capillaries; and in connection with these, which act as a kind of filter and purifier, their effects are naturally earliest manifested. Further, since, as regards the circulation, the lungs may be regarded as the equivalent of the whole of the body besides, it is obvious that even if all the morbid effects of Pyse- mia throughout the system were produced simultaneously, the lungs would be still (if the morbid processes in them held any relation to the amount of blood passing through them) the equivalent in quantity of pysemic disease of all the rest of the body, and would therefore far surpass in their liability to secondary deposits any other one viscus. It is not so easy to understand the differences presented by other organs as regards their relative lia- bility to disease ; "why, for example, the brain should so often escape, why the spleen, the liver, and the kidneys should so often suffer : all are equally exposed to the effect of emboli originating in the lung ; all are equally liable, it might be supposed, to the formation of thrombi in their smaller vessels. To explain these differences there must, we imagine, be something in the character of the circula- tion, something in the formation of the various organs, which modify both the tendencies to morbid changes in the blood circulating in them, and the mode in which these morbid changes affect their i"! SSll PS {d) Cause of different Cliaracter of Pym- mic Deposits in different Cases. — What, we may now ask, is the explanation of those differences as regards the character of the local deposits (described on a former page) 3-12 PYEMIA. which distinguish one case of Pyaemia from another, and cases of Pyemia from cases of ordinary embolia and thrombosis? Something is doubtless due to the different dates at which patients die. In those persons who succumb early, local pro- cesses of disease have had but little oppor- tunity to develop themselves ; in those who die late the later stages of suppura- tion and sloughing have had ample time to become estabUshed. But this explana- tion does not apply to all cases ; neither does it apply to the differences observed between cases of embolia and cases of Pysemia. Here, as elsewhere, those sub- tle chemical changes (termed vital) so deeply interesting, so little understood, come into play. Why is it that when a cancerous growth has appeared in one part of the body, the whole system speed- ily becomes influenced, and diseased pro- cesses occurring elsewhere assume also the cancerous character ? Why is it that when tubercular disease has manifested itself in one organ, the same form of dis- ease ere long becomes developed in other organs ? Why is it, again, that amongst all the varieties — shades — of cancer and of tubercle, that one variety which has first shown itself in any case is the pattern upon which the subsequent deposits of the same disease are formed ? It would seem that morbid processes, limited in the be- ginning to one spot, influence the che- mistry of the blood, and that of the system generally, and thus produce in the tissues a tendency to repeat, under the influence of exciting causes, those very morbid pro- cesses out of which the tendency arose. Again, certain conditions of unhealthi- ness, dependent on a variety of causes, give a type to the morbid changes acci- dentally occurring in different parts of the body. Thus, according to the former rule, the occurrence of gangrene at one part tends to the production of gangrene in other parts ; the existence of suppura- tion in one corner of the system tends to render inflammation suppurative else- where : thus, according to the latter rule, a certain condition of system (as that ac- companying typhus) is apt to favor the occurrence of gangrene, another condition of the system (as that accompanying con- valescence from various febrile affections) to favor the formation of local collections of pus ; and thus on one or other or both of these principles it doubtless depends that Pyaemia, which is mostly sequential on some localized mortification or suppu- ration of tissue, presents in the character of its secondary processes not only those differences which distinguish it from em- bolia and thrombosis, but those differences (not due to relative duration of disease) which distinguish cases of Pyaemia from each other. (e) Certain Varieties of Pycemia Consid- ered. — We may here add a few words in regard to certain, real, or supposed varie- ties of Pyaemia. Pyaemia is generally an acute and quickly fatal disease : and when this is its character, pyaemic deposits may almost invariably be found. The deposits however are not generally related numeri- cally or otherwise to the severity of the case ; and cases are sometimes observed which, judging from the symptoms during life and from other evidences, are truly cases of Pyaemia, yet in which no pyaemic deposits are discovered. It would seem that Pyaemia resembles the exanthema- tons fevers in this respect, viz., that the blood-poison occasionally produces death ere local lesions have had time to mani- fest themselves. Sometimes cases of Pyae- mia become chronic ; the evidence that such cases are pyaemic being furnished chiefly by the occurrence of successive suppurations, in joints,' in the cellular tissue, in the eye (it may be), and in other parts. Cases of this kind are sometimes observed after parturition, and such are some of the cases following on enteric and other fevers. The frequent occurrence of pyaemic deposits in the lungs only has suggested the possibility of a local Pye- mia — a Pyaemia in which the poisoned condition of the blood is confined within certain limits, and effects its secondary changes within those limits only. By such a local condition of Pyaemia, con- fined within the ramifications of the por- tal system. Dr. George Budd^ has endea- vored to explain the occurrence of hepatic abscesses in cases of dysentery. This ex- planation of the frequent occurrence of dysentery and abscess of the liver is prob- ably erroneous f and, indeed, our know- ledge of the progress of true Pyajmia does not justify us in admitting that the poison of Pyaemia can be hmited in the manner suggested. (/) Origin of Pycemia in Contagion. — Pyaemia, which probably only occurs in the classes of cases which have been enu- merated — cases presenting the common features of some unhealthy suppurating surface — may arise in them either spon- taneously or as the result of some con- ' Dr. Wilks, in tlie Guy's Hospital Reports, remarks that there is a special tendency in Pysemia to produce inflammation of the jpints ; that in cases rapidly fatal this tendency has scarcely time to manifest itself ; hiit that in chronic cases (cases, that is to say, in which the blood-poisoning has not been excessive and in which visceral inflammations have been but little pronounced) this special fea- ture of Pysemia has full time for its develop- ment. 2 Budd, On Diseases of the Liver. ' See Frerichs, Clinical Treatise on Dis- eases of the Liver ; Syd. Soc. Translation, vol. ii. p. 113 et seq. : also Trans, of Path. Soc. of London, vol. ix. p. 241. PATHOLOGY OF PYEMIA. 313 tagious influence. Cases of spontaneous origin are not infrequent. Many of the cases in which (whether as the result of injury or not) acute suppuration rapidly involves some large portion of bone are cases in which there has been no previous ill-health, no exposure to niorbic influ- ences. Many of the cases occurring after compound fractures or after operations arise under personal and surrounding con- ditions of good health. Other cases are induced by modes of dressing wounds which prevent union by first intention, and promote suppuration and unhealthy discharges. Many of the deaths ascribed to puerperal fever, and occurring sporad- ically, arise under similar conditions, and, so far as we can see, wholly independently of contagion. There are many cases however, and these are in all respects the most important, where the occurrence of Pyaemia is distinctly due to the agency of some contagium. These cases are par- ticularly met with in surgical practice and in obstetrical practice. As regards surgical practice, it is well known that Pyaemia may be often absent from a hos- pital ward in which cases of serious acci- dent and cases of operation are in course of treatment, and may continue absent for a considerable period ; that after a while a case of Pyaemia, or a case of ery- sipelas, may be introduced into the ward or may originate within it, and that from that time operation case after operation case, accident case after accident case, may be attacked with pytemic symptoms. There can be no doubt here that the spread of the disease is due to the pres- ence in the ward of some contagious in- fluence — not of a pytemic contagium, for the disease cannot be excited in any pa- tient who is not suffering from a wound, nor in any wound probably unless it have become first unhealthy ; but of a conta- gium which excites first unhealthy pro- cesses in the wound, and, by means of these unhealthy processes, Pyaemia. This contagium originates not only in cases of Pysemia, but also in cases of erysipelas, diffuse cellular inflanunation, phagedasnic processes, and the like, and in cadaveric poisons. There is no doubt that the ac- cumulation of many wounds in a limited space not merely promotes the diffusion of such a poison, but serves even to engen- der it.' It is not improbable that the poison exerts an influence, to some extent at least, through atmospheric diffusion, and that this mode of spread is largely aided by overcrowding and bad ventila- tion. But Pyffimia arises even more frequently from actual inoculation of a ' See on this subject Report on the Hos- pitals of the United Kingdom, by Dr. Bris- towe and Mr. Holmes, in the 6th Report of the Med. Oii5cer of the Privy Council. healthy wound, either by the fingers of those who are engaged in attending on the sick, or by the dressings and appli- ances which are employed upon them. The same remarks, with scarcely any modification, apply to puerperal Pytemia. Puerperal fever has been known over and over again to be conveyed by the clothes, and more particularly by the hands, of nurses and practitioners ; and has been thus carried, not merely from other cases of puerperal fever, but from the poison of erysipelas and other unhealthy inflamma- tions, and from the dead-house. Further, the fact of the heavy mortality from this disease in lying-in hospitals,' compared with the mortality from the same disease in patients treated at home, is well estab- lished ; and the occasional terrible out- breaks of puerperal fever, which blacken the annals of all these institutions bear witness, if not to its spontaneous origin therein, at all events to its virulence of contagion under circumstances favoring its spread. (g) Conditions modifying the Tendency to Pyaemia. — It has been asserted that the presence of organic visceral diseases ; the debility attending convalescence from va- rious acute maladies; the cachexiae which result from intemperate habits, from in- sufficient quantity and quality of food ; untoward circumstances attendant occa- sionally on serious accidents and grave operations and parturition — shock, hem- orrhage, nervous depression, and the like; that tliese, and many other circumstances tending to impair the general health, pre- dispose in various ways to the occurrence of Pyaemia. It is difficult either to prove or refute such assertions ; it is difficult to believe that unhealthy conditions of sys- tem, however produced, should be with- out influence in favoring the attacks of Pysemia and diseases related to it ; but, on the other hand, it may be confidently asserted that the vast majority of pysemic patients have not been suffering from chronic visceral diseases ; that but few of those attacked are recovering from acute diseases ; and that many, very many, vic- tims of Pyaemia have enjoyed the best of health up to the moment of the accident or the operation of the disease which has exposed them to the danger of Pyaemia ; and that even in many cases the wound (if wound there be) has been progressing favorably up to within a few days of the sudden 'onset of pyaemie symptoms. It may be added as regards the subjects of amputations, that many more in propor- tion die of Pya;mia of those whose limbs have been amputated for injuries than of those whose limbs have been amputated 1 Consult again Dr. Bristowe's and Mr. Holmes's Report, and also Dr. Barnes's Lec- tures in the Lancet ot February, 1865. 344 PYEMIA. for disease — many more, therefore, in this particular case of those whose bodily- health has been good until within a short time of the occurrence of Pysemia, than of those who have been reduced by pre- viously existing disease. Time of year, age, sex, have also been considered among predisposing causes. Season has proba- bly no very important influence. No doubt adults more frequently sutler than children, and men than women ; but whatever differences in these respects may be observed are certainly due in an overwhelming degree to the relative fre- quency of grave accidents in the respec- tive sexes, and at the respective ages. Neither infants' nor the aged are exempt. Want of ventilation, and filth, are impor- tant predisposing causes ; but in order to predispose it is necessary that the want of ventilation should co-exist with undue accumulation of traumatic or puerperal cases, or with the presence of unhealthy inflammatory processes ; that the filth should comprise oftensive and other ani- mal discharges. Mere dirt, mere defi- ciency of ventilation, have not, so far as we know, a very obvious relationship with Pysemia ; at least this may be said with certainty in reference to the Pyijemia of puerperal women. IV. Symptoms of Ptjemia. 1. Symptoms coiisidered collectively. The symptoms which usher in an at- tack of Pysemia are generally well mark- ed, unless the condition of the patient, or the nature of the disease under which he is laboring at the time of its supervention, mask the py senile symptoms. In some cases the accidental injury, or the opera- tion, or the puerperal process, seem to be going on quite satisfactorily, up to the very moment when Pysemia manifests it- self In other cases the wound made by accident or operation has taken on for a shorter or longer period some unhealthy action— the discharge from it has become ichorous and offensive, the process of union has become arrested or has retro- graded, or sloughing has attacked the part, and constitutional symptoms in sympathy with these local conditions have appeared; or, in the ease of the puerperal female, the lochia, have become scanty and offensive, or have ceased, the abdomen has perhaps become tender, and high febrile symptoms have shown them- selves. But, whatever the previous con- dition of the patient may have been, whe- ther it have been one of perfect health or ' A child nine months old was recently ad- mitted into St. Thomas's Hospital with "PyEB- mia following on acute necrosis. not, the first symptom to attract attention is almost without exception a sudden, se- vere, and prolonged rigor, followed by profuse perspiration. The patient soon recovers from this, and may for a time appear so well that the fear inspired by the first rigor gives way to the hope that it has been a mere accidental phenome- non, of no serious import. But before long, it may be the next day or at some earlier period, the rigor returns with its after sweating stage ; and again and again, at varying intervals, the rigors and sweats recur. In the course of a day or two the conjunctivae and the skin assume a sallow tinge ; the patient becomes dull and heavy, or it may be restless, and ac- quires very much the aspect and manner of a patient suffering from some form of con- tinued fever. In company with the symp- toms above described, or in succession to them, others of more or less importance show themselves. The pulse, which at the beginning may have been unchanged, be- comes rapid, even exceedingly rapid, weak, and perhaps intermittent ; and these evi- dences of feebleness of the pulse increase as the disease advances. The tongue is often clean at the outset, but soon becomes glazed and fissured or furred, and after a time dry and brown ; the lips also become parched, and sordes accumulate probably about the teeth. The appetite disappears; the patient becomes thirsty ; and often there is nausea or vomiting. Diarrhoea, attended with offensive stools, occurs very commonly. The respirations become shal- low and frequent ; cough often super- venes, attended it may be with pains in the chest, with evidences of consolidation or of excess of secretion into the bronchial tubes, and with expectoration. The skin, in the intervals between the rigors and perspirations, and after they have disap- peared, is generally hot and dry, and may present sudamina, and even it is said a pustular eruption. The sallowness gen- erally increases, and often before death amounts to well-marked jaundice. Pain and swellings in or around the joints, or in other parts of the cellular tissue, often present themselves, and pus may form in these situations rapidly. As the above symptoms develop themselves and the dis- ease advances, the patient becomes exces- sively prostrate, his face becomes shrunk and generally pale, his mental functions become more and more disturbed and im- paired, slight delirium comes on, and pos- sibly coma, or, but very rarely, convul- sions ; and at the end of a short period, generally between four and ten days, he dies. During the progress of the pyemic symptoms the primary seat of the disease (even if it were apparently healthy up to the moment when Pysemia supervened) assumes an unhealthy character. Some- times Pysemia takes a more chronic SYMPTOMS OF PYiEMIA. 345 course ; the symptoms are altogether less pronounced ; the fever attending them resembles hectic fever, and abscesses form in the external parts, as the joints and the cellular tissue ; and the patient sinks, perhaps after a few weeks, of exhaustion; or after a protracted convalescence, during which abscesses cease to form, is restored to health. 2. Symptoms considered in relation to the various Organs, etc. We will consider separately the symp- toms referrible to difterent parts of the system. (a) Aspect, Skin, &c. — The aspect of the Pyoemic patient may vary a good deal ; but for the most part it resembles that of one suffering from enteric fever, or typhus. At first it may be healthy-looking or nearly so, but soon it becomes heavy and oppressed. The face is sometimes highly flushed, sometimes extremely pallid, and these conditions often alternate. Towards the close of the disease, pallor generally becomes established ; and the counte- nance, unless modified in its expression by delirium or other conditions, becomes shrunken and anxious, or settles down into the expressionless dull aspect of the last stages of febrile diseases. The rigors are some of the most marked and promi- nent symptoms of Pysemia. Cases are sometimes observed in which they have either been slight and so have escaped notice, or in which they have been wholly wanting. But in the great majority of cases they cannot possibly be overlooked. They vary much in number and frequency. Sometimes they recur at short and ir- regular intervals ; sometimes they are quotidian, and resemble, and have been mistaken for, attacks of ague ; generally they cease after two or three days, and the subsequent progress of the case is free from them. Their duration varies; some- times each shivering fit lasts for half-an- hour or so, sometimes for only a few minutes. They are always followed by profuse perspirations. The temperature o{ the body rises considerably during the rigors.' In the intervals, the skin is gene- rally harsh and dry. Sudamina, as might be supposed, not infrequently appear and are sometimes surrounded by a zone of congestion. They may then by a careless observer be mistaken for the spots of ty- phus or of enteric fever. A pustular erup- tion has been described as of occasional occurrence, by both Mr. Henry Lee and Dr. Wilks.2 Sometimes livid discolora- tions appear; but these correspond for the ' John Simon, Holmes's System of Surgery, vol. 1. p. 94. ' Op. oit. most part to subcutaneous abscesses, or to tracts of difluse cellular inflammation ; ecchymoses are rare on the surface of the body. In a large proportion of cases the skin and conjunctivae become distinctly jaundiced. This is a very important and characteristic symptom. It generally comes on shortly after the first symptoms of Pyemia have shown themselves, and continues to increase up to the fatal issue. The jaundice, however, rarely if ever be- comes intense, and is often so slight that in a bad fight or from hastiness of obser- vation it may pass unnoticed. (6) Organs of JRespiration. — The respi- ratory movements early become, as in other febrile affections, hurried and shal- low. And this condition generally be- comes more pronounced as the disease advances. Then the respirations not in- frequently amount to forty or fifty in the minute, and are sometimes more numer- ous than this. After a while they are apt to become moaning or groaning in char- acter. It has been asserted that the odor of the breath is in these cases peculiar and characteristic. The respiratory acts assume the characters just described, in- dependently of all pulmonary disease, and in cases where the lungs are not at all affected, or where the affection is so slight as not to have caused special symptoms. But in the greater number of pyemic cases the lungs and pleurte become secondarily affected ; cough comes on, which may or may not be violent ; secre- tion takes place from the bronchial mucous membrane, or fluids get poured out from the air-cells into the bronchial tubes ; and the cough consequently be- comes loose, and attended with expecto- ration, which may according to circum- stances be simply mucous, or purulent, or even distinctly pneumonic. The local phenomena correspond more or less to the morbid processes taking place in the chest. Tracts of dulness may sometimes be re- cognized on percussion, and sometimes uniform dulness at the base ; but partly from the scattered arrangement of the patches of pulmonary disease, and partly from the absence ordinarily of any large amount of effusion of fluid into the pleura, dulness is often scarcely or not at all re- cognizable. Pleural friction-sounds again may occasionally be detected ; but owing probably to the limited extent of the false membranes, and to the shallowness of the breath movements, they are not heard so often as might be supposed. The local signs most commonly present are such sounds as are heard in bronchitis, viz., crepitation, often amounting to gurgling and rhonchus. Pleuritic stitches may be complained of. (c) Organs of Circulation.— The Y>n]se in Pyaemia is specially remarkalile for its feebleness. At the onset of symptoms it 346 PYAEMIA. may differ little in frequency or in any other respect from its previous healthy condition. But generally it becomes from the very beginniiig rapid, or if not rapid at least variable, so that the slightest ex- ertion of mind or bodj' raises it twenty or thirty or even forty beats in the minute. The rapidity of the pulse hovyever is gen- erally considerable, and its rapidity tends to increase as the disease advances ; so that not infrequently the beats of the pulse amount to 140 or 100, and may even rise to upwards of 200, in the minute. With this increase of rapidity, and with this variableness, the pulse also becomes very small and very compressible ; and very often as the patient's general debil- ity increases the pulse becomes irregular and intermittent. There is nothing gen- erally very characteristic in the cardiac phenomena. The action of the organ cor- responds with that of the pulse ; and the sounds, unless they become masked by other sounds, are healthy though feeble. Pericardial friction may be looked for, but will not always be heard even when pericarditis is present. (c?) Organs of Digestion. — The organs concerned in digestion always sympa- thize more or less with the general condi- tion of the system. The tongue in the be- ginning may bo clean ; but it soon assumes an unhealthy character. There is no- thing uniform however as regards its con- dition. Sometimes it becomes morbidly red and glazed, and may be fissured ; sometimes it becomes thickly furred ; but generally its linal condition is one of dry- ness and brownness. Nausea and vomit- ing are frequent but not invariable symp- toms. They are often amongst the first to appear ; but they may arise at any time in the progress of the case, and may persist througliout its whole duration. The appetite mostly fails early, and thirst is generally present. Sometimes however the patient retains his appetite for a day or two, and may be persuaded to take even a good deal of stimulus and nourish- ment tln:oughout the whole course of his illness ; and thirst is by no means neces- sarily excessive, nor is it always com- plained of Diarrhoea often shows itself, and the stools are then described as being highly offensive. This complication be- longs to no particular period of the dis- ease, and may either be persistent or tem- porary. It is interesting to bear in mind, in connection with this symptom, the ten- dency to slight inflammatory changes, and even to pysemic deposits, manifested in cases of Pyaemia, by the intestinal mu- cous membrane. The frequent occurrence of jaimdice has been already spoken of. That the sallow discoloration in these cases is jaundice is proved by its presence in the conjunctiva as well as the skin ; and by the fact that bile-pigment has been recognized in the urine, in the serum of the blood, and in the effusions into serous cavities. The jaundice has no de- pendence on the formation of pysemic de- posits or abscesses in the liver, and is frequently present indeed when the liver seems to be altogether healthy. Frerichs' remarks that "to all appearances the jaundice is here the result of an impaired consumption of bile in the blood, arising from an abnormal condition of the meta- morphic processes which go on in that fluid." Abdominal pain is sometimes com- plained of; but generally it is local, and the result of inflammatory processes going on in the internal organs (as the liver and spleen) and of circumscribed peritonitis in connection therewith. In puerperal Pyaemia, general peritonitis and tympani- tes are more apt to occur than in other cases. (e) Genito-urinary Organs. — There is lit- tle to say in regard to the genito-urinary organs. From the inflammatory processes which so often go on in the kidneys, it is not svirprising that the urine is occasion- ally found albuminous. We might natu- rally expect to find occasionally in it blood or pus. Unless the uterus be the primary seat of disease, there are rarely, if ever, any important symptoms referrible to that organ. (/) Organs of Locomotion. — It is a com- mon thing in Pyaemia, especially in the more chronic cases, to have inflammation and suppuration occurring in joints, and in the cellular tissue, and in connection with bones and other organs. The mor- bid anatomy of these processes has already been considered. It remains therefore only to add that these superficial abscesses are more common in the chronic than in the acute forms of the disease, that they often attain considerable dimensions, that their origin and progress are often at- tended with excruciating pain, and that it frequently happens that pain and swell- ing attack joints and other superficial parts, and subside without leading to any further mischief. Muscular debility is marked from the beginning, but generally soon becomes excessive. (g). Nervous System. — The nervous symp- toms which appear in connection with Pyaemia are almost identical with those which accompany enteric fever or typhus. The patient is at first perhaps a little heavy and dull and drowsy; but generally he becomes ere long (more especially at night-time) restless and somewhat de- lirious ; yet usually he can easily be re- called to his senses, and to this extent remains conscious up to the time of death. The cerebral symptoms vary, however, in different cases. Sometimes the patient ' Frerichs, op. cit. vol. i. 162. SYMPTOMS OF PYEMIA. 347 has little or no delirium, and is perfectly rational throughout his illness. Some- times the delirium becomes violent, and he may become partially or even wholly comatose before death. But generally when coma, and especially when convul- sions or paralysis appear, there is some actual disease going on in the brain to account for these symptoms. The evacuations may or may not be passed unconsciously. 3. Fitrther Considerations in regard to Pymmia. (a) Time at which Pymmia arises, and Duration of Disease. — As regards the time at which Pysemia appears in relation to the state of system on which it supervenes, nothing very definite can be said. In cases of accident and operation Pyasmia may come on at any moment, from the time when a suppurating surface is first established until the wound is perfectly healed. In cases of carbuncle and of erysipelas Pysemia probably does not su- pervene until suppuration has taken place. In cases of acute suppuration connected with bones and acute necrosis, pysemic symptoms are present sometimes almost from the first. In puerperal cases Pysemia usually comes on between about the third or fourth and tenth or twelfth day after la- bor. The disease is generally very rapid in its course ; occasionally its duration is limited to three or four days, more com- monly it lasts from six to eight days, and it may be for a fortnight. In chronic cases, especially such as recover, the du- ration of the disease may be much pro- tracted. (6) Prognosis and Mortality. — The prog- nosis of Pyaemia is exceedingly unfavora- ble. In surgical practice nearly all pyse- mic cases die ; in midwifery practice a larger proportion probably recover. There is much difficulty, however, in arriving at the exact truth in reference to this point ; for, although the symptoms of a typical case of Pysemia are collectively ample proof of the existence of this disease, there is no one symptom, like the rash of typhus or the exudation of diphtheria, absolutely distinctive, and no one symp- tom which is invariably present. Hence the diagnosis of the least well-marked cases of Pysemia is not always to be re- lied upon ; and as cases which are said to have recovered mostly belong to this class, there is generally some, more or less justifiable, room for doubt in regard to the true nature of cases which are re- corded to have got well. Still, there can be no reasonable doubt that of cases of ■Pysemia coming under the care of the surgeon a certain proportion recover. Now and then cases are met with, having most of the usual symptoms of Pysemia, and in which it is at least reasonable to suppose that Pysemia, in a mild form per- haps, exists, which yet escape from the toils in which they seem to be involved. The probability that such cases are truly pysemic is enhanced by the fact that they are apt to occur in a ward in which Pyse- mia is prevalent, and that in some of them abscesses in external parts appear from time to time during their progress, and stamp their real character. But cases of recovery, with or without the formation of external abscesses, are far more common in obstetrical cases; at least it is in lying-in hospitals chiefly that, dur- ing the epidemic prevalence of Pyasmia, re- coveries not infrequently take place after the supervention of symptoms, which in other cases usher in a rapidly fatal illness. Nevertheless, the disease is one of the most fatal with which practitioners have to deal ; its premonitory symptoms are ground for the gravest alarm, and from a fully developed and unmistakable attack recovery is almost quite hopeless. (c) Diagnosis. — The diagnosis of Pyse- mia is not generally difficult, if the cir- cumstances of the case and the symptoms be all considered. Still, its own symp- toms are often so mixed up with those of the disease out of which it arises, or with those of the complications which become developed during its progress, and are often so modified by them, that the Pyse- mia may be recognized with difficulty or even wholly overlooked; and further, there are several diseases with the symptoms of which its own have a decided, and even close, affinity, and with which therefore it is apt to be confounded. It would be impossible to enumerate, still more to discuss, the various condi- tions which mask the onset, and it may be the progress, of the disease. An ex- ample or two must suffice. A patient has had an injury to the skull; after a while rigors come on and perspirations ; and, with these, cerebral symptoms. An abscess has probably formed beneath the skull. Now the symptoms here are al- most, if not quite, identical with those of commencing Pysemia. But whether Py- semia has come on as well is a point that probably cannot be then determined. The further progress of the case may clear up the doubt, but not always. Again, a patient, suffering from a large carbuncle, or from extensive diffiise cellu- lar inflammation, becomes pya^mic ; Ixit it is more than probable, if the paticut be suffering largely at the time from "con- stitutional irritation," that the additional ' ' constitutional irritation" due to Pysemia will be inappreciable. So again in a case of acute deep-seated suppuration connect- ed with some bone (say the femur), and so again in puerperal peritonitis, the 348 PYEMIA. symptoms of the primary disease may be so sudden and so severe, and at tlie same time in many respects so lilie tliose of Pyffimia, that the supervention of the latter disease is very apt to pass unob- served. The diseases, which above all others Pysemia resembles, are typhus and enteric fevers, internal acute inflammations (espe- cially of the lungs), urethral and bladder affections in whicli the kidneys have be- come involved, and acute rheumatism. The resemblance to fever is proved by the fact that even surgeons of experience oc- casionally mistake Pj'Eemia for typhus or enteric fever. The general symptoms and the aspect of the pyfemic patient are in- deed almost identical with the general symptoms and aspect belonging to the fe- vers just named, and the frequent pres- ence of diarrhoea approximates Pyaemia particularly to enteric fever. The liability to error is necessarily much increased when the Pyaemia depends on some deep- seated suppuration, which possibly escapes detection. The differences however are generally well pronounced ; the severe rigors and perspirations of Pysemia have scarcely any counterpart in either form of fever, in which for tlie most part rigors are scarcely marked, and the skin is dry. Moreover, the eruptions cliaracteristic of typhus and of enteric fever are absent in Pj'semia, and the jaundice which generally attends the latter disease is rarely present in either of the former. The morbid anatomy and the progress of the several diseases will suggest other marks of dis- tinction. In pneumonia not only is the general aspect of the patient like that of a patient suffering from Pyaemia, but the rigors, the profuse perspirations, the jaundice, and even the diarrhoea, may all be present ; while in Pytemia more or less of the lung is mostly involved, and there may even be pneumonic expectoration. It is obvious, therefore, that there might be great difficulty, even impossibility, in distinguishing a case of pneumonia, sec- ondary (say) to a compound fracture, from a case of Pj-semia, supervening on a similar injury. 'On the other hand a case of Pyajmia, in which the source of pyfemic affection is not obvious, might without much carelessness be taken for a case of pneumonia. Again, ivhen inflammation and suppuration of the kidney-structures come on as a result of vesical inflamma- tion, or of any other disease obstructing the passage of urine, febrile disturbance with delirium follows, and the combined symptoms differ often but little from those of Pysemia supervening on the same local diseases ; and here the difficulty of distin- guishing between them is often greatly enhanced by the fact that both forms of disease are not uncommon sequelse of sup- puration occurring about the neck and base of the bladder. Further, acute rheumatism has many features in common with Pysemia : in both there are profuse perspirations ; in both inflammation in connection with bones and joints is com- mon (and it must be recollected that joints often inflame in Pysemia without suppu- rating, and that in some cases of Pysemia pain in the course of a bone, with sub- periosteal suppuration, is the first evi- dence of disease); in both, again, peri- cardial complication is not infrequent. We have considered somewhat in detail the resemblances between the several dis- eases above enumerated and Pysemia, partly because they are really striking, partly because we have known them lead to errors of diagnosis. We have not how- ever dwelt generally on the points which serve to distinguish them, for to discuss these completely or even usefully here M'ould be to forestall needlessly descrip- tions of diseases which will be fully given elsewhere. There are yet other affections which, under certain circumstances, Pyse- mia may simulate : such are delirium tre- mens, tubercular meningitis, and other inflammatory conditions of the brain or its membranes, ague, &c. It is needless, however, to do more than mention them. V. Treatment of Pyemia. The treatment of Pyasmia is exceeding- ly unsatisfactory. But, as in so many other instances, although the medical treatment of a case of the disease may be of little avail either to arrest or modify its course, preventive measures are often in the highest degree useful both against its origin and its spread. 1. Prophylactic Treatment.' In considering the subject of preventive measures, the simplest plan will probably be to take the case of a private patient, on whom some grave operation— amputa- tion, for example— has been performed. To take precautions against Pysemia is to take precautions also against those other unhealthy conditions out of which Pye- mia mostly arises. To prevent, so far as may be, their occurrence it is important to maintain both the general health of the patient and the healthy progress of his wound. To this end the patient's strength should be supported by appropriate and adequate nourishment; pain, sleepless- ness, and irritability should be treated with opiates and seclusion from needless visitors and intruders ; ample ventilation should be secured, and in aid of this cur- tams and all unnecessary hangings should ' See Bristowe and Holmes, loc. cit. TKEATMBNT OF PYEMIA. 349 be removed ; further, perfect cleanliness should be uiaiutalned, and especially all evacuations, all offensive discharges, all dressiugs, should be removed at the earli- est opportunity, and never allowed to ac- cumulate in the patient's room. As re- gards his wound, that should be lightly dressed and kept cool, and never treated with the abundant dressings which are employed in some foreign hospitals, and which there promote suppuration and, in our belief, erysipelas and Pyaemia. The dressings should be of the simplest kind, and neither these nor sponges and such like things which have been used for the purpose of cleansing the wound should be used a second time. If erysipelas or sloughing or suppuration ensues, the treatment appropriate to these conditions must be employed ; in the case of slough- ing, charcoal, carbolic acid, and other antiseptics are valuable applications ; but above all things it is essential to allow early and very free escape of pus and ichorous fluids. The same remarks apply to the treatment which should be adopted in the case of compound fractures and other injuries.' And in regard to cases of deep-seated suppurations, acute necrosis, carbuncle, and diff'use cellular inflamma- tion, there is no doubt that free and early incisions are especially important in pre- venting the supervention of PyiBmia. In hospitals, or other places where many sick are accumulated, the precautionary meas- ures above insisted on become doubly im- portant, especially those of ventilation and cleanliness. In discussing these two measures we open up the old subject of hospital construction and hygiene — a sub- ject which, even if in many respects ap- propriate to the present article, is far too extensive to be considered even briefly here. It may however be stated gene- rally, that there should be abundant cubi- cal space to each bed, abundant space be- tween the beds, plenty of ventilation by means of open windows, aided by open fireplaces ; that the walls, the floors, the ceilings, should be kept scrupulously clean; that the wards should be periodically emptied ; that water-closets should be so arranged as in no degree to infect the ward ; that sponges should never be used in the cleansing of wounds — nor anything absorbent in fact which might be used on a second occasion or in the treatment of another case. But the danger of Pytemia, incidental to wards or places in which many sick are accumulated, is less due to mere accumulation of sick than to undue accumulation of such as are suffering from certain forms of sickness, such namely as are suffering from open wounds, whether arising from accident or disease or design. ' See Professor Lister's papers on the treat- ment of compound fractures, &c. The presence of what has been termed a " traumatic atmosphere" would seem to have quite a special influence over the de- velopment of Pyaemia, and for that reason the creation of a traumatic atmosphere should be as much as possible avoided. This may be effected partly by the means just adverted to— viz., free ventilation, and avoidance of overcrowding— but espe- cially by so distributing traumatic cases as to allow of no undue accumulation of them in any one ward of a hospital, or generally in any one spot. The presence of erysipelas, diffuse cel- lular inflammation, phagedena, or any other unhealthy inflammation, and espe- cially the presence or recent occurrence of Pyaemia in a ward, should be the signal for redoubled vigilance in securing that all sanitary regulations are as far as pos- sible systematically carried out. Then, especially, all danger of inoculating the healthy with the unhealthy secretions of the diseased should be most watchfully guarded against ; all dressings, &c. , should be destroyed the moment they are done with ; and neither nurses, nor dressers, nor surgeons, should pass from attendance on those whose wounds are unhealthy, above all from handling their wounds, to attendance on those whose wounds are health}', until by proper precautions their persons, and especially their hands, are thoroughly disinfected. It may be added further that no one should at any time come direct from the dissecting room or post-mortem theatre (especially if he have taken part in the dissections going on there) to the treatment of surgical cases, without thorough purification and disin- fection. Again, when diseases of the kind above specified have been received into a ward, and especially if they have shown any disposition to spread, it may become necessary either to remove them thence, or, still better, to avoid receiving into that ward for a time all accident cases attended with wounds, and to avoid operations on patients who happen to be therein. But notwithstanding all such precautions, these diseases will sometimes be found to cling as it were to a ward. Under such circumstances it becomes ab- solutely necessary to empty and dismantle the ward, to purify it thoroughly, and to keep it unoccupied for a shorter or longer period. Sometimes those forms of disease out of which Pytemia is apt to arise, some- times PytKmia itself, may (dependent apparently on atmospheric conditions, or at least on local conditions of insalubrity) prevail over a district. If such be the case, the importance of temporarily sus- pending the performance of operations in that district becomes obvious. The various precautions, of which the importance in relation to surgical practice has just been discussed, are if possible ot 350 PYEMIA. still greater importance in relation to the practice of midwifery. In sporadic mid- wifery (if the term may he thus used) , as in sporadic surgery, precautions are less absolutely needed than where midwifery is concentrated, as it is in a lying-in hos- pital. But in the former case puerperal Pysemia has been known over and over again to be conveyed by the nurse or the medical attendant, who have brought in- fection in their person or in their clothes either from other puerperal cases, or from cases of unhealthy inflammation, or from the dead-house. In the latter case (the case of lying-in hospitals) the presence, so to speak, of a "parturient atmosphere" intensifles the liability to Pyeemia as it does to other infectious puerperal dis- eases, and leads often to terrible mortality. There is no doubt that no attendant is justified in running the risk of conveying such infection from one patient to another, and that if he have from circumstances become a possible source of danger, he is bound for a while to abstain from mid- wifery practice. As regards lying-in hos- pitals, every possible precaution ought to be systematically taken ; and on the very first appearance of infection they ought at once to be emptied and purified. But we are very strongly of opinion that such in- stitutions are dangerous institutions, and ought not, unless under exceptional cir- cumstances, to exist ; certainly they are not required as schools of midwifery, cer- tainly every poor woman, who has a home however mean in which to be delivered, will be far safer in that home than in a hospital. It must not be forgotten, however, that Pyfemia is not limited to hospital prac- tice ; that even in hospitals it may arise quite independently of hospital influences ; and that many cases originate in private quite independenth', so far as we know, of external deleterious agencies. Against such c'ases prophylactic measures are of course out of the question. 2. lledical Treatment. The treatment of a case of Pyaemia re- solves itself into the treatment of the original lesion, the treatment of the dis- ease, the treatment of tlie complications of the disease, the general hygienic treat- ment of the patient. (a) Treatment of Primary Lesion. — As regards the original lesion, it has been shown that in cases where Pyaemia super- venes on wounds (whether from accident or from operation) the wounds have gen- erally already assumed an unhealthy as- pect. According to the nature of this unhealthy process must be the local treat- ment ; but especially it would seem im- portant that the parts should be kept clean and cool, that disinfectant applica- tions should be employed, that free incis- ions to admit of the escape of pent-up pus should be made. In cases where the wound appears to be healthy, there is probably some deep-seated suppuration in progress ; and here, though the exact seat of suppuration may be diflScult to detect, it is most important that it should be de- tected, and the pus therein thoroughly evacuated. The same rule applies with equal force to those cases where the pri- mary disease is an abscess involving some deep-seated bone, or tract of cellular tis- sue. The reasons, on which the adoption of the above plan of treatment is based, are first, that by this plan the further en- trance of poisonous matters into the blood may possibly be obviated ; second (and most important), that by its early adop- tion the entrance of poisonous matters may be wholly averted and a threatened attack of Pycemia warded off". With the same view it was proposed to cauterize the superficial veins on the proximal side of the diseased part. As regards obstet- rical cases, it has been asserted by some that puerperal fever is mostly preceded by an imperfectly contracted condition of the uterus •, but both by those who hold this view, and by those who do not, the im- portance of securing complete contraction of the uterine fibres and consequent closure of the ruptured uterine veins, by the use of ergot, and other means, has been strongly urged. It has been recom- mended also to cleanse the cavity of the uterus by the injection of disinfectant and astringent fluids. (^) Curative Treatment. — Of the curative treatment of Pysemia we fear little is known. Various plans of treatment have been from time to time adopted, and all probably have by some been supposed to be beneficial, all have by the majority of practitioners been found useless. Some of these plans have been based on the notion of the elimination of the disease ; others on the notion of introducing into the system substances capable of battling with the pygemic poison in the blood it- self, and overcoming it there ; others have been based on analogy ; and others have been wholly empirical. Thus, acting on the assumption that the perspirations and the diarrhoea of Pysemia are efforts of nature to eliminate some morbid poison from the system, warm baths and diapho- retics have been employed by some; by otheis the diarrhoea has not only not been restrained, but has been encouraged by laxative and purgative medicines. Thus, too, from the resemblance which the re- mittent rigors and perspiration of Pyemia sometimes bear to the more regular at- tacks of the same kind which characterize ague, it has been imagined that quinine and arsenic, which are certainly remedial TREATilENT OF PYiEMIA. 351 in the case of ague, might be remedial in the case of Pyaemia. Tims, again, guided we presume by the acknowledged fact that ample ventilation is one of the most im- portant preventives against Pyaemia, some have looked on fresh air as abso- lutely curative, and have exposed their pysemic patients to all the winds of heaven. And thus, others regarding the disease as one of putridity, have treated it with various forms of antiseptic agents. It would be useless to argue seriatim against the above and other modes of treatment ; it would be unwise to oppose a priori the trial of any as yet untried modes of treat- ment ; suffice it to say that, so far as we know, the mortality of Pysemia is just as high now as it ever has been, and the an- tidote to it remains to be discovered. There is, however, one mode of treat- ment, suggested within the last few years by Professor PoUi,' of Milan, which, from the scientific character of the investiga- tions which led to its proposal, and the manner in which the proposal has been brought under the notice of the medical profession, deserves a respectful mention. It will be necessary to go a little into the history of Professor PoUi's investigations, and to trace shortly the steps which led him to his final conclusions. He assumed with most other physicians that septic poisons introduced into the blood produce their injurious eflfects through acting on the blood as a kind of ferment ; and he assumed, as again others have assumed, that if any substance could be introduced into the blood, which, while not acting injuriously either on that fluid or on the system generally, would arrest this pro- cess of fermentation, the exhibition of such substance in cases of septic poisoning would not improbably be curative. Having long studied the effects of sul- phurous acid, he had ascertained that it is not merely a powerful antiseptic, but that it equally prevents the vinous fer- mentation, and those other fermentations by which starch is converted into glucose, by which the pancreatic juice acts on fatty substances, and emulsine on amyg- daline ; and he came to the conclusion that in sulphurous acid we possess a sub- stance capable of arresting every form of catalytic action. But sulphurous acid cannot with im- punity be introduced into the animal economy. Hence Professor Polli sought for other agents which, while having the virtues of sulphurous acid, should be free from its disadvantages ; and he found such agents in the compounds of sulphurous acid with soda, potash, magnesia, and lime. He found that these sulphites, equally with sulphurous acid, prevent all ' See Dublin Journal of Medical Science, vol. xxxiii. p. 367, and vol. xxxvi. p. 470. forms of fermentation ; he found that they may be given safely in large doses over a considerable period of time ; and he fur- ther found that when taken into the stomach they become absorbed, diffused throughout the system and eliminated without undergoing any chemical change, or at most only a very partial chemical change. He assumed therefore that that power of preventing putrefaction and fermenta- tion which they exercise outside the body they would exercise probably equally well within the body. Any further experi- ments made by him upon the lower ani- mals, by the introduction of putrid mat- ters into their blood, and by putting them at the same time under the influence of the sulphites, led him to believe that he had in these agents discovered valua- ble remedies for the various forms of sep- ticsemia. It would seem that large doses of these sulphites (from thirty to sixty grains three or four times daily) may be given with impunity. We are not aware whether this plan of treatment has been so largely tested as the promises it seems to hold out might justify. AVe know of one case of supposed Pyaemia in which it was believed to have wrought a cure, but we know that in the practice of Mr. Si- mon, at St. Thomas's Hospital, it has entirely failed. [The tentative use of salicylic acid, on the same principle, is justified by analogy, No sufficient experience has, however, as yet, determined its positive value in Py- semia. — H.] (c) Treatment of Symptoms and Compli- cations. — When a case of Pysemia is un- der treatment, it always becomes a ques- tion of treating, in addition to the general disease, certain symptoms as they arise, and, it may be, certain of the secondary lesions. On this head, again, we fear there is little satisfactory to be said. Some have recommended, on theoretical grounds, that diarrhoea should be encour- aged. There seem no valid grounds for this course; and certainly if the diarrh«a became excessive, we should recommend that it be restrained, either by remedies administered by the mouth or by opiate enemata or suppositories. Again, the pulmonary symptoms may become some- times exceedingly distressing ; and then, although probably we have no means of either checking or curing the morbid pro- cesses going on in the lungs, we may by opiates or other sedative medicine, judi- ciously administered, render the symp- toms more endurable ; or it may be that expectorants, especially ammonia, may be of benefit. Of course if abscesses form in superficial parts, they should be early punctured. As regards other symptoms, and other compUcations, we have really nothing to say. Many of them will need 352 MALARIAL FEVEKS. no special treatment at all; and generally where special treatment seems to be re- quired, the medical man must be guided by his general knowledge of his profes- sion, and treat them as he would treat such complications arising in the course of fevers and other allied disorders ; bear- ing in mind, however, that where he can- not cure, it is better as a rule to aim at soothing and quieting, than (in the hope of achieving some insignificant advantage over the outposts, so to speak, of his pa- tient's disease) to adopt a fidgeting line of treatment, and so render his few re- maining hours miserable. {d) Hygienic and Dietetic Treatment. — "We come lastly to the general manage- ment of py£emic cases, that is to say, their management as regards diet, stimu- lus, and hygienic observances. It need scarcely perhaps be pointed out that ob- servance of cleanliness and ventilation, which we insisted on as an important prophylactic measure, should be equally persisted in during the whole course of treatment of a case of Pysemia; that, fur- ther, the patient should never be op- pressed unnecessarily with accumulation of bed-clothes — that he should, in fact, be kept cool — and that his comforts should be carefully considered. Pysemic patients, as has been shown, become at an early period excessively feeble ; and in most cases excessive prostration is the most prominent among the symptoms which usher in death. No doubt this debility is- functional rather than the direct result of the waste and degeneration of tissue; the consequence and the indication of blood- poisoning, rather than of the want of either stimulus or food; and theoretically, therefore, is to be counteracted by anti- dotal treatment rather than by nutriment. Whether we possess any mode of treat- ment that can be regarded as really anti- dotal we have shown to be in the highest degree problematical ; but we have in these cases excessive prostration to deal with, and we must deal with it as best we can. To this end, it is manifestly our duty to administer both food and stimu- lus, and to administer them as largely as the condition of the patient will admit. The patient's appetite is generally quite annulled ; and often loathing of food and vomiting are present. These conditions render it, of course, often exceedingly dif- ficult, and sometimes impossible, to carry out the objects we have in view; and they show the importance of selecting for ad- ministration those articles which are least liable to otfend the stomach, and of ad- ministering these in small and if possible frequently repeated doses, rather than rarely and in large quantities at a time. It is not easy to lay down any rule with regard either to the nature or the amount of food and stimulus to be given. These points must be determined in each case according to its requirements. But it is important to give whatever is to be given systematically. As regards food, that which is in the form of fluid is generally most suitable, such as animal broths, eggs beaten up, milk, gruel, arrowroot, and the like. As regards stimulus, per- haps, considering the irritability of the stomach, brandy, sherry, madeira, diluted according to the patient's taste, are the most generally serviceable. But lighter wines will often be found grateful. We protest against that excessive exhibition (that " pouring in" as it is appropriately termed) of stimulus which it has lately been the fashion to practise. We need perhaps scarcely add that when pyasmic cases become protracted, and especially when they show signs of convalescence, and during the progress of convalescence, dietetic treatment becomes of paramount importance, and tonics form important aids to that treatment. MALAEIAL FEVERS. By W. C. Maclean, M.D. Before entering on the description of the remarkable fevers which are to form the subject of the following article, it is necessary to premise a few observations on the peculiar poison which produces them. This poison, which gives a dis- tinctive name to fevers with periodical re- turns, is everywhere recognized by the term Malaria. ' ' When a climate is called unhealthy, in many cases it is simply meant that it is malarious." (Parkes.) In this article it is intended only briefly to summarize the few facts relating to this poison which have been tolerably well ascertained. No chemist has yet been able to demon- MALARIAL FEVERS. 353 titrate the existence of malaria. "We as- sume its existence from certain observed effects on the organism, just as we do in tlie case of other poisons which produce certain specific diseases. Malaria is be- lieved to be the produce of organic de- composition in soils, whatever may hap- pen to be their mineral composition ; water is indispensable to the process, and a high temperature, although not abso- lutely necessary, greatly aids it. It is generated in greatest abundance in marshes, which contain a high percentage of organic matter ; hence the name by which it is familiarly known, viz., marsh miasm. It is often found in sandy soils and arid- looking plains devoid of vegetation ; but in all such cases the soil will be found to contain a considerable proportion of or- ganic matter, and water will be found not far from the surface, either in the shape of subterraneous streams, or detained by a bed of clay below the sand, preventing its free passage and keeping up evapora- tion. Malaria is also generated in hard rocks, such as granite and trap, in a disinte- grating state. A notable example is the island of Hong Kong, which consists en- tirely of weathered and decaying granite. In such soils, so long as they are undis- turbed, the existence of malaria may not be suspected. In the case of Hong Kong, for example, it was not until extensive excavations were made into the disinte- grating granite for building purposes, that violent and fatal remittent fevers ap- peared. Dr. Parkes mentions that the soil of Hong Kong contains less than two per cent, of organic matter, but quotes Frie- del to the effect that disintegrated granite, which is highly absorbent of water, be- comes often permeated by a fungus, and suggests the possible relation between the development of this fungus and the pro- duction of malaria. The air of marshes known for ages as malarious has been examined by chem- ists. Watery vapor and carbonic acid are always found in excess ; and, under cer- tain conditions, sulphuretted hydrogen. "Carburetted hydrogen is often present, and occasionally free hydrogen and am- monia, and, it is said, phosphoretted hy- drogen." (Parkes.) Besides the above, " various vegetable matters and animals, floating in the air, are arrested when the air of marshes is drawn through water, or siflphuric acid, and debris of plants, in- fusoria, insects, and even, it is said, small crustaceae, are found." (Parkes.) Malaria acts with the greatest intensity on the human system in situations which are low and moist, abounding in vegeta- tion undergoing decomposition, e. g. , in jungly districts during or immediately VOL. I.— 23 after the rainy season, at the bases of great mountain ranges, and in those belts of country in India termed terrais, formed by the debris of mountains rich in organic matter, which retain a large quantfty of water and are covered with jungle. It is capable of drifting along plains to a considerable distance from its source, particularly in the direction of the pre- vailing wind. It ascends mountains, espe- cially when favored by ravines and cur- rents of air. The height to \vhich it can ascend from its source is still matter of dispute. Dr. Parkes thinks that .500 feet is the limit in temperate climates, and from 1000 to 1500 in tropical countries ; while others maintain that in the latter we arc not safe from its influence until a height of 5000 feet has been reached. It is probable that when men suffer from malaria at elevations above 2000 feet, it is either derived from unsuspected loca, sources, or it is carried up ravines by cur rents of heated air from tlie unhealthy plains. It is a common belief in India that water is capable of absorbing malaria, and that periodic fevers, dysentery, and even cholera, are produced by drinking water so charged. This absorbing power of water, and especially salt-water, has often a bene- ficial effect, when a sufficient breadth of it, not less than from three-quarters of a mile to a mile, is interposed between our habitations and the source of the poison, which is either absorbed or rendered in- nocuous in its transit. Belts of trees interposed in like man- ner exercise a protective influence. [Liv- ing trees and shrubbery appear to ex- ercise an influence in preventing the development of the malarial cause. The Great Dismal Swamp, on the southern border of the State of Virginia, being cov- ered chiefly by growing cypress trees, is not malarious. The Eucalyptus globulus, native to Australia, has the reputation of special usefulness in this way. Probably it and the Southern Pine do good mainly by assisting, by their vigorous growth, the drainage of the soil. — H.] Malaria disappears before cultivation and subsoil drainage, with free exposure of the soil to the action of the air and of living vegetation. When, however, the cultivating hand of man is withdrawn and the old conditions reappear, malaria again resumes its sway. [Nothing is more evi- dent in the history of malaria than its general disappearance before the exten- sion of closely built cities and towns. Suburbs, in which intermittent occurs, gradually become, in that respect, more healthy as lots are drained and occupied by habitations. Exception to this may, it is true, exist, when houses are built upon made ground, and the drainage con- 554 MALABIAL FEVERS. tinues to be very imperfect for a long time. This kind of exception has been observed to a considerable extent of late yeai-s in the city of New York. — 11.] It is the cause of intermittent and remit- tent fevers, and their sequels ; it " under- lies" the cause of dysentery and cholera ; and by its depraving influence on the con- stitution it often silently undermines the health without the manifestation of any febrile phenomena. Major-General Cot- ton, in his evidence before the Indian Sanitary Commission, very truly observes " that there are many ailments which the natives of India call fever, but which a medical man does not, which are the effects of malaria. " When a person has for some time suf- fered from the toxic influence of miasm, a curious impress of periodicity is sure to show itself in all his subsequent ailments, whatever be their nature ; and I believe, from extensive observation, that this im- press of periodieitj' is never eradicated. Casorati, a late Italian physician of eminence, in his "Treatise on Intermit- tent Fevers, " a posthumous work recently published, has given it as his opinion "that miasm is the cause of an extremely small number of intermittent fevers. " He saj's "that there are pernicious intermit- tents, the origin of which is simply rheu- matic." Casorati further dwells on the fact that, within the sphere of his obser- vation, " nothing is more common than to see pregnant women the subjects of tertian fever, under which they frequently abort ;" and he gives numer(_)us examples of diseases, such as menorrhagia, cephal- algia, &e. &c., all presenting an intermit- ting tj'pe, due, as Casorati supposes, not to the toxic effect of miasm, but to other causes, such as "humidity," "cold, "and the like. The truth is, that Casorati's sphere of clinical observation was in a malarial re- gion : the stamp of periodicity was there- fore deeply impressed on a great number of the diseases that came under his care. The proof of this is not far to seek ; for, by his own showing, no treatment was effective until quinine was given. We do not find, where there is no miasm to com- plicate the case, that "acute rheumatism" or "menorrhagia" or " cephalalgia" de- rive benefit fro'm anti-periodic remedies, itill less that such are indispensable to all treatment. jSTo sooner is the blood poisoned by ma- laria than it acts on the stomach and ali- mentary canal. In all agues, particularly of a severe type, there is from the first great disturbance of the stomach, and in severe remittents this is often the most prominent and urgent symptom. Casorati goes so far as to state that morbid appear- ances in the stomach constitute by far the most constant post-mortem appearance found in fatal cases of intermittent fevers. In the article Dysentery I have given it as my opinion that miasm is also the cause of that disease. In the present state of knowledge, it is not possible to explain why malaria should in one case cause dysentery, and act with intensity on the glandular structures and mucous mem- brane of the great intestine, and in an- other excite an intermittent or remittent fever, with signs of extreme irritation of the stomach and duodenum, going on often to structural changes in those parts. Chemistry may one day reveal to us some difference, at present inappreciable, in the constitution of miasmata to account for the affinities displayed in the different cases.' The structural changes of a more secon- dary kind induced by malaria are, enlarge- ment of the spleen and liver, to be more particularly described further on. INTERMITTENT EEVER. Definition. — A specific paroxysmal fever, the febrile phenomena observing a regular succession, characterized by a cold, a hot, and a sweating stage, followed by a period of complete apyrexia, varying in duration according to the type of the fever. Synonyms. — Periodic Fever, Ague, Paludal Fever. History and Modes of Commence- ment. — When the human system has been exposed to the influence of malaria, sooner or later, according to circum- stances, symptoms of disturbance appear : as already remarked, many have their constitutions silently undermined without suffering from periodical fever at all. It seems probable that in such cases the poi- son is not presented to the system in a very concentrated form ; the blood is so gradually changed that the organs become as it were tolerant of its presence, to such an extent at least that febrile phenomena are not excited at regular intervals for the apparent purpose of expelling it from the blood. On the other hand, people in perfect health may be exposed to the ac- tion of malaria in such a noxious form as to be at once completely overwhelmed by it. The late Lieutenant-General Sir Mark Cubbon informed me that many years ago, when on a journey to the Neilgherry ' I am informed by Dr. E. Goodeve, late professor of medicine in the Calcutta Medical College, that the cases of dysentery which gave him most anxiety in Calcutta were those in which he was at first uncertain whether the disease was to be remittent fever or dys- entery. INTERMITTENT FEVER. 355 Hills, he was compelled to pass a night at the foot of the Segoor Pass, then an un- cleared and unhealthy spot. A party of three German missionaries were also de- tained at the same place, and slept in the same house. These gentlemen were fresh from Europe, and in high health. On the following morning they pursued their journey, and were soon "above fever range." In less than twenty-four hours three out of the four of the party were stricken with fever, and two of them died in a few days. Most frequently the person who has been exposed to malaria suffers for some days from premonitory symptoms. The toxic influence is evidenced by some de- gree of nausea and loss of appetite, with muscular pains in the back and lower limbs, with usually a slight feeling of chilliness, soon passing into trifling heat of skin, scarcely marked enough to excite attention. This may recur for several days before a regular paroxysm of ague sets in. Or, without such prolonged warnings, after an hour or two merely of the above symptoms, the patient may be seized with the cold stage, in the manner to be presently described. In such cases there is almost always a considerable amount of urinary irritation, the patient having frequent calls to pass pale-colored, acid, and irritating urine. "When this symptom is urgent, a severe paroxysm may usually be expected. Then follow in succession the three stages which characterize this fever, viz., the cold, the hot, and the sweating stages, at the end of wliich there is a period of apyrexia, termed the intermission, the du- ration of which varies with the type of the fever. The time occupied by a parox- ysm and the period of apyrexia that fol- lows is somewhat incorrectly termed the interval. The tj'pes of the fever are named according to the length of the in- terval. These are the quotidian, which recurs daily, having an interval, in the above-mentioned acceptation of the term, of twenty-four hours ; the tertian, with a paroxysm every other day, and an inter- val of forty-eight hours ; the quartan, every third day, and an interval of seven- ty-two hours. These are what have been termed the regular types of Intermittent Fever. Physicians recognize others which have been called irregular : such, for example, as the double tertian, which is said to dif- fer from a quotidian only in having on alternate days fits corresponding in se- verity, character, and duration ; the triple tei-tian, which has two fits on one day, and one the next: the duplicated tertian, which has two paroxysms on alternate days, with a fever-free day; the double quartan, which has a fit on one day, a mild one the next, the third being a fever-free day ; and so on. What is it that determines whether the type of tlie attack shall be a quotidian, tertian, or quartan ? It is probable that this is governed simply by the extent to which the blood has been charged by malaria. The presence of a quotidian seems to indicate a liigh degree of saturation, requiring a more frequently renewed effort of nature for at least its partial elimination than either a tertian or a quartan. The tertian is said by many authors to be the primary type of fever, and to be the most common of all. This is certainly not the case in India, where without doubt the quotidian is the most common, and the quartan the rarest of all inter- mittents. According to my experience in India and China, a first attack of ague invariably takes the quotidian form. The duration of a paroxysm of Inter- mittent Fever varies with the type. It is longest in the quotidian, which lasts from eight to ten or even twelve hours ; the tertian lasts from six to eight ; and the quartan from four to six hours. The paroxysms do not always occur ex- actly at the same hour of the day. In the early days of an attack, when the dis- ease, not having been interfered with by treatment, is "waxing," the cold stage will almost certainly appear an hour or two earlier on the days of the second and third paroxysms than on the first. On the other hand, when the system has been affected by antiperiodics, or the poison has by successive paroxysms been to some extent eliminated, and the disease is "waning," the time of attack will be postponed for an hour or two. I have ob- served this in my own person, and have noted it in others as of almost invariable occurrence. The length of time to which intermit- tents left untreated will run on will de- pend much on climate, locality, and sea- son, and the extent to which the system has been charged by malaria. Mild quo- tidians often terminate after ten or twelve paroxysms ; quartans last longer, and may run on for months. When once the system has gone through the phenomena of an attack of ague, par- oxysms are liable to recur quite irrespec- tive of fresh exposure to malaria; an error in diet, exposure to wet or cold, any cause that disturbs the balance of the circula- tion, may bring on an attack, and an im- press of periodicity is apt to be given to any ailment from which the person may subsequently suffer. This disposition lasts always for years, sometimes for life. The type of the disease does not always remain the same ; a quotidian may pass into a tertian or a quartan ; and an inter- mittent may, under certain conditions, as- sume the more grave form of a remittent. 856 MALARIAL FEVERS. I have repoatedljr known sportfsmen in India, and officers of the Forest Conserv- ancy department, wliose amusements or occupations exposed them only to mild intermittents, so long as tliey remained in comparatively cool and elevated regions, suffer from severe remittent fever on de- scending to the plains, a change in many instances apparently due merely to the influence of high temperature, for I have several times observed it A\-hea there Avas no reason to suppose that the sufferers had been exposed anew to the influence of malaria. The direct mortality from Intermittent Fevers in India is small. Even in Ben- gal, out of a strength of 344,152, with 111,087 admissions, the percentage of deaths to strength is 0'24, and the per- centage of deaths to admissions is 0"76. But although it is undoubtedly a rare thing to see a person die in the course of an uncomplicated Intermittent Fever, it is nevertheless, indirectly, an exceedingly destructive disease ; the fatal results must however be looked for under other heads in the death returns of malarial regions. It is undoubtedly true, as remarked hy the Indian Sanitary Commissioners, "that diseases of important organs, the consequences of malarial fevers, occasion much of the subsequent sickness, mortal- ity, and invaliding among British troops serving in India." Judging froni the writings of Casorati and others, Intermittent Fevers seem to he more severe and more fatal in Italy than in India. How far the system of treatment in that country influences the mortality I am not prepared to say. In many cases of simple, and apparently in all complicated agues, Casorati not only highly extols blood-letting, but reprobates its neglect as culpable and dangerous in a high degree. For example, in a case of ague with orchitis, Casorati draws a pound of blood, and does not hesitate to repeat the proceeding ; and in all cases where v; iM-" Temperature in tertian ague.] This sudden rise in temperature is com- mon to all the types of malarial fever. Headache is sometimes complained of, but not always; the mind is inert, and occasionally the patient is drowsy. The dm-ation of the cold stage is variable ; it may last from half an hour to two hours and a half, and in rare cases even three or four hours. "When the paroxysms have been often repeated, and the poison has been, to a great extent, eliminated, thecold stage shortens, until at last the patient is only conscious of a passing chill. ^ Hot stage.— Plushes of heat at first al- ternate with slight rigors. By and by a grateful feeling of warmth steals over the Body; the bed-clothes are thrown off; the increase of temperature is now apparent to the patient and his attendants without the aid of a thermometer. The pulse be- comes full and frequent ; the respiration, although still hurried, becomes more regular. When the hot stage is fully de- veloped, a temperature of 107° or 108° is often noted. The agreeable sensations that accompanied the first feelings of warmth pass away; nausea, and even vomiting, often distress the patient; head- ache and thirst are complained of; and the patient tosses uneasily in a burning fever. Physicians in the malarial parts of the southern States of America look anx- iously for the development of what they call "a good hot stage," regarding pow- erful reaction as conducive to the patient's safety ; whereas a quick and feeble pulse, with rapid thoracic respiration and low temperature, are looked on as dangerous symptoms, as indeed they are. The duration of the hot stage is usually about two hours ; in severe cases it may last four or five, and it has known to be prolonged through ten or twelve hours. Sweating stage. — Perspiration appears first on the brow and face, and gradually spreads over the entire surface, until the patient sweats copiously at every pore. The pulse falls in frequency and strength; the respiration becomes more natural; the temperature rapidly falls to the normal standard; headache first abates, and then passes away. Captain TBurton, the renowned African traveller, writing of the mild Intermittent or Seasoning Pever of East Africa, de- clares "that there is nothing unpleasant in these attacks. The excitiement of the nerves is like the intoxication produced by a plentiful supply of green tea ; the brain becomes uncommonly active, peo- pled with a host of visions ; and the imagination is raised almost to Parnas- sus." This mental excitement I have ex- perienced, and the observant traveller is right when he adds, "the patient pays for it when tlje fit passes off. These agreeable sensations do not recur with the subsequent paroxysms." 358 MALARIAL FEVEKS. During the intermission tlie patient is commonly said to be "well," but this is only true in a limited sense ; and if the paroxysms be allowed to go unchecked, the sutterer, even during the intermission, soon becomes incapable of much exertion of mind or body. Condition of the Urine. — As already mentioned, the urine is increased during both the cold and hot stages, and appa- rently, from the presence of a large quan- tity of free acid, is sometimes very irri- tating. Convalescence is ushered in by a remarkable diminution in its quantity ; it now becomes scanty, alkaline, or neutral, and of a deep orange color. Intelligent patients soon learn to note this, and inti- mate to their physicians the occurrence of what they deem a critical discharge, by informing them that no more quinine is required. In the hottest weather, during the active stages of Intermittent Fever, urine always retains its acid reaction for several days. When the fever intermits, the urine then rapidly undergoes decom- position, and changes from acid to alka- hne. (Jones. ) A person with ague, not actually suffer- ing from a fit, secretes less urea than a person in health. The moment a fit com- mences, the urea suddenly increases, although every known cause of increase, as food and exercise, be avoided. The increase lasts during the cold and hot stages, and then sinks, sometimes gradually, sometimes suddenly, through the sweating stage, or into the commence- ment of the intermittence. The amount then falls below the healthy average. (Parkes.) There is a very close connection between the temperature and the amount of urea. (Ringer.) The amount of urea corre- sponding to a degree of Fahrenheit is greater at a high than a low temperature. The pigment is lessened in amount. (Jones.) Uric acid is greatly increased during the fit. (Parkes. ) The chloride of sodium, according to Professor Einger, is greatly increased during the cold and hot stages. Albumen is found in an uncertain proportion of cases during the fit, with blood and renal cylinders. I can confirm, from personal observations, Dr. Parkes's remark that chronic Bright's disease is a consequence of ague. "Many "old In- dians," who have sviffered from malarial fevers, die of this disease. The Blood is changed from the begin- ning of the attack, and, probably, for some time before. The red globules and fibrin are diminished, the coagulum is larger and more fiabby than that of healthy blood, much darker in color — in extreme cases approaching to black — and on exposure to air, instead of the usual bright red, it only assumes a cherrj'-rcd color. (Jones.) Its serum is dark and muddy, and it has sometimes an oily appearance. The skin, after a time, assumes a dirty pale yellowish hue, a change which is often permanent, and which depends, not on bilious discoloration, but on some of the blood-changes above descriljed. Sufferers from Intermittent Fever are usually depressed in spirits, and are inca- pable of much exertion of mind and body ; their appetites and digestions are bad, and they are prone to diarrhcEa from slight causes. When this anaemic condition is de- veloped, a peculiar cardiac murmur is commonly present, which is prolonged into the great vessels. This is an "anse- mic bruit," due apparently to the watery condition of the blood. If the spleen is much enlarged, the heart is apt to be displaced upwards, and thus to mislead the unwary into a diagno- sis of heart disease, when that organ is sound. (Morehead.) The heat-generat- ing power of all victims to malarfa is im- paired : hence they suffer from atmosphe- ric changes, of which healthy men take no note. Diagnosis.— Eemittent Fever is the only disease which appears to me likely to be confounded with an ague. The regularity of the phenomena, the exist- ence of a distinct period of complete apy- rexia, will suflice to determine the diag- nosis, and in doubtful cases the ther- mometer will settle the point, "for all the types of ague present this characteristic peculiarity of a sudden and speedy rise of the temperature up to 105° or 106° Fahr. and of an equall)' rapid and complete de- fervescence, till the period of another paroxysm comes about. " (Aitken.) Morbid Akatomy. — Death in an un- complicated intermittent is so uncommon that few opportunities for post-mortem examination are afforded. We have seen that one of the eariiest indications of disturbed function after the action of malaria is given by the stomach ; in the mildest agues this disturbance is present, and in severe remittents intense nausea and urgent vomiting are among the most prominent symptoms. Casorati, who has had many opportunities of dis- secting the bodies of those who have died from the " pernicious" agues of Italy, ob- served "that sufiiciently well-charac- terized morbid appearances in the stomach constitute by far the most constant post- mortem appearance of all those observed." {Vide "British and Foreign Med. Chir. Rev." July, 1864.) Hyperemia of the stomach and duode- num, then, is one of the most common of the appearances found post mortem in in- termittents. In some of the cases ex- amined after death at Walcheren, circular ulcers, according to Sir Gilbert Blaue, INTERMITTENT FEVER. were found in addition to the hypersemia above described. The liver and spleen also suffer, the latter more frequently than the former. In recent cases the spleen is generally found so softened in its texture as to breali up under examination ; occasionally it is reduced to a dark-colored bloody pulp, enveloped by its capsule. In more chronic cases the organ is found to be indurated, and often so enormously enlarged as to extend downwards into the pelvis. That the spleen acts as a diverticulum in the cold stage of ague there is no doubt ; by percussion we can demonstrate that it en- larges with every fit, and contracts again when the paroxysm comes to an end. In time the elasticity of its structure is im- paired, and some degree of permanent en- largement results. But there is another cause in operation. Virchow and others have shown that the spleen enlarges not only in intermittent and tj'phoid fevers, but also in most other morbid processes resulting from the presence of noxious matters in the blood. Irritation of the gland ensues, and the result is increased cell-formation in its structure. The liver is found in recent cases in various states of congestion, often soft in texture, and of a dark purple or black color. In more chronic cases it is en- larged, tiie malarial poison acting as a source of irritation, leading, as in the spleen, to increased cell-formation. "WTien the bodies of men who have served long in malarial regions are examined, one of the most common appearances is a deposi- tion of black pigment in the spleen, liver, and kidneys. Prognosis. — I have never seen a per- son die from uncomplicated Intermittent Fever. The prognosis in such cases, under ra- tional management, is favorable. The danger to life is from the malarial cachexia, and the organic changes to which it gives rise. When the disease is about to yield, not only are the paroxysms less severe, but the time of accession is postponed for some hours. The appear- ance of a copious deposit in the urine, and an herpetic eruption about the lips, are also favorable signs : so also are the dis- appearance of prsecordial distress, ano- rexia, and nausea at the commencement of the paroxysm. [In several localities in the Southern United States, especially in the rice-grow- ing region of South Carolina, and some places near the lower Mississippi, a type of Intermittent Fever prevails, which, in the absence of specific treatment, is often ratal. This is best designated as Perni- cious (also called congestive) Fever. In it all the main symptoms of ordhiarj' Intermittent are intensified ; at least in the cold stage. This partakes of the cha- racter of tlie collapse of cholera ; except in the absence of the colorless watery evacuations. The skin is cold, pale, or livid ; the countenance haggard ; thirst is intense ; tlie pulse is small, weak, often rapid or irregular; respiration is oppressed; vomiting is common ; the bowels mostly are loose, with discharges often like bloody water. Sometimes cerebral symptoms predomi- nate ; delirium being present, passing into stupor, with stertorous respiration. Te- tanic rigidity occasionally exists during the paroxysm. After an imperfect reaction, lasting from eight to twelve hours or more, another attack comes on, unless prevented liy treat- ment. A third paroxj'sm is almost always fatal. The diagnosis of such cases is usually not difficult in the localities in which Per- nicious Fever is common. In the North- ern United States, where examples of the same kind now and then are seen, they may present more difficulty. Especially the variety in which a tendency to stupor exists, may not always be easy to discrimi- nate from apoplexy. The previous history of the patient must then be closely inquired into. Tlie coldness of the skin, and gene- rally the character of the pulse, will aid in drawing this distinction. In the morbid anatomy of Pernicious Fever, the attention of Southern practi- tioners was long ago called to the frequency of congestion of the brain, liver, lungs, and other organs ; giving rise to the title "Congestive Fever." There is no doubt, however, that this condition of the organs is the secondary result of the systemic poisoning by malaria. Typhoid pneumonia, the winter fever of the South, is, in many cases at least, de- cidedly a malarious affection, requiring to be treated as such. Dysentery, also, is not unfrequently impressed with the same character, being periodical in the recur- rence and remission of its symptoms. In the treatment of Pernicious Fever, the indications are clearly two: to produce reaction from the cold stage, and to pre- vent its return by specific medication. If the stomach wiU'retain it, quinine maybe given as the first, perhaps almost the only medicine. The amount, when it is given, must be larger than in ordinary Intermit- tent. Five or ten grain doses, repeated at intervals of two "or three hours until thirty (some say sixty) grains have been taken, will do all that can be looked for from this remedy. More than sixty grains of pure sulphate of quinia in twenty-four hours cannot be given with safety to the patient ; and very seldom will more than thirty or forty grains within the same time be appropriate. Should the stomach be very irritable, 360 MALARIAL FEVERS. ice may be given to quench thirst, and, as a stimulant, capsicum, in pills of five grains each. To promote reaction, the patient may be placed for a short time in a hot bath, or bags of hot salt or sand may be placed in contact with the back and limbs ; a large sinapism, also, being ap- plied to the epigastrium. Some physi- cians, instead of capsicum, give camphor, or opium, or ether, duiing the paroxj'sm, to promote reaction. A good combination is of camphor, opium, and quinine, each in moderate doses, in pill, bolus, or pow- der, every half hour during the cold stage. If a comatose condition occurs, the opimn should be omitted. AVhen the stomach obstinately rejects everything, quinine may be introduced by the rectum, or by hj'podermic injection. Calomel is cm- ployed, on traditional evidence, by many practitioners, in this disease. Experience in the North with Pernicious Fever is too limited to afford the moans of concluding absolutely upon its value in this affection. Alcoholic stimulants are more apt to be needful in a second or third than in a first paroxysm ; unless in those whose habits have been already intemperate, with cor- responding feebleness of system. Cerebral symptoms, such as low delirium or stupor, may be treated by the applica- tion of a blister to the back of the neck, cutting short the hair, &c. ; not, however, omitting quinine, if the malarious nature of the attack is evident. — H.] TREAT3IEXT. — " Happily for us," says the observant traveller ]3urton, "the old African treatment is now obsolete. A. B. caught fever — gave him calomel, bled him, blistered him — died on the third day." Happily too for those whose lot is cast in India, "the same may be said ; the anti- phlogistic treatment of malarial fevers is no more heard of there. So completely is this the case, that it seems to me like con- tending with a shadow to say a word in condemnation of it. In Italy, however, this system not only holds its ground, but appears to be carried out with a higher hand than in the darkest days of African practice. Every perversion of normal function occurring in the course of an ague is still looked on as an inflammation, and treated accordingly by general and local bleedings, and a rigorous system of diet. What Dr. Haldane has recently said on this system of treatment generally is, as it appears to me, peculiarly applica- ble to every form of malarial fever that has come under my observation. "For- merly, when an inflammation manifested itself, it was regarded as something super- imposed upon the organism; as an enemy attacking the fortress of life, which re- quired to be attacked by the most ener- getic measures. Its supplies mu»t be cut off by the enforcement of a rigorous diet, [ and it must be attacked ivith the heavy artillery of bleeding, mercury, and blisters. But it was not kept in mind that by these measures the garrison was weakened in an equal degree with the enemy, or rather in a greater degree, so that even if the adversary were overcome and retired from the contest, the patient often succumbed, owing rather to the severity of the treat- ment than to the malignity of the disease." (The Modern Practice of Medicine : a Lec- ture by Dr. Eutherford Haldane, M.D., F.K.C.P.) Most systematic authors direct us to be- gin the treatment of all fevers with an emetic. In Intermittents, when the tongue is very foul or the stomach op- pressed by food, an emetic does good, giv- ing great relief, and hastening the stage of reaction. The longest cold stage I ever saw was not in India but in England. The sufferer was an Indian ofBcer who was subject to ague. He had partaken freely of pickled oysters ; in a few hours he was seized with intense nausea, head- ache, and epigastric oppression, soon fol- lowed by severe rigors. When I saw him he had been nearly five hours in this state, and his condition caused great alarm. I immediately gave him a mustard emetic, which speedily relieved him, and rapidly brought on a short and mild hot stage. It is hardly necessary to caution even young practitioners against the absurdity of giving an emetic to a patient every time he has an ague, without regard to the special circumstances of his case. The same rule applies to purgatives. They are useful if the bowels are loaded ; the action of a purgative tends to relieve the congested condition of the solid ab- dominal viscera, and prepares the way for the action of quinine. But great caution is required in the use of purgatives in per- sons laboring under malarial cachexia, particularly in Asiatics. If there be much urinary irritation, a few grains of bicarbonate of potash with or without a few drops of tincture of opium will relieve it at once. During the cold stage the patient should have a sufficiency of bed-clothes, but, be- yond this, interference is not often called for, and more sufferers prefer to be let alone. If the cold stage is unusually pro- tracted, or it becomes apparent that the vital powers are so oppressed as to be un- equal to the development of reaction, then the external application of warmth and the use of stimulants may be required. In like manner during the hot stage little interference is called for. The bed- clothes should be removed as reaction ad- vances ; cooling drinks may he given if they are relished or called for, which I have observed is seldom. If the patient be in a debilitated state from any cause, instructions should be given to watch the INTEKMITTENT FEVEK. 361 patient when the sweating stage begins, lest symptoms of collapse should appear, in which case support and stimulants should be promptly given. The paroxysm ended, our utmost eflforts should be directed to counteract the poi- son, and prevent, if possible, a repetition of the attack. In cases of first attacks it is of unspeakable moment to the patient to prevent his system from getting, so to speak, into the habit of going through the phenomena of an ague tit. For, although we cannot doubt that the aim and end of the process is so far salutary that it rids the system of a portion of the poison, it is also true that the organism suffers in the process, and that every paroxysm is a step towards the establishment of those organic changes I have described. lu quinine, skilfully used, we have a remedy, particularly in nrst attacks, which almost deserves the epithet "divine" wliich has been applied to it. I always assume that in first attacks the type of the disease will prove to be quoti- dian, and I take my measures accordingly, making sure tliat the patient shall have thirty grains of quinine between the ter- mination of one paroxysm and the hour when we may look for another. The first dose of ten grains should be given towards the close of the sweating stage, and look- ing to the fact that when an attack is, as I have already expressed it, waxing, we may expect the setting in of the cold stage perhaps two hours earlier than on tlie first day, the last ten-grain dose should be given so as to anticipate that time by at least an hour. Quinine in the treatment of agues should always, if possible, be given in solution, with a few drops of diluted sulphuric acid ; its bitterness is best covered by the addition of a little syrup of orange-peel. [Less than thirty grains will suffice for the interval in the type of Intermittent which is usual in the Northern United States ; fifteen grains, given between the end of one paroxysm and the time of its expected recurrence, will, in ordinary cases, almost never fail to interrupt the attack. Pernicious fever, in the South, requires larger doses. In ordinary ague, especially when the sto- mach is irritable, the method of Dr. G. B. Wood is best, in the opinion of many who have tried it, viz., giving one or two grains of quinine at a time, repeated at sufficiently short intervals to get in the amount' required for sufficient " cinchoni- zation" during the interval.— H.] If irritability of stomach be present to such an extent as to lead to vomiting, no time should be lost in giving the quinine by enema. The lower bowel must first be washed out with a little warm water, and fifteen grains should then be given by the rectum in four ounces of beef-tea, if that be at hand, if not, in a little thin starch ; and the irritability of stomach still con- tinuing, this should be repeated twice at proper intervals during the apyrexia. I have been in the habit of administering quinine in this way with advantage for the last fifteen years. [Hypoderuiic in- jection of a solution of sulphate of quinia is resorted to not unfrequently, when the stomach will not retain it. The amount needed is somewhat in the way of this method of administration, and local irri- tation is somewhat more frequent than after other hypodermic injections. — II.] If we are fortunate enougli to prevent the recurrence of the paroxism in this our first attempt, the gain to our patient is great, and it is well to maintain a mode- rate degree of cinchonism for some days, evidenced by " ringing in the ears." This can be eftected by giving three or four grains of quinine in solution every four hours. But our duty to the patient is not yet discharged. We must not dismiss him from our thoughts because we have successfully managed his case so far. In a lunar month from the date of his first attack, even should he not in the in- terval be exposed to malaria afresh, there will be a tendency in his system to repeat the same phenomena as before, and this tendency will be strengthened by every successive attack. A day or two, then, before the time, the patient should again be brought under the influence of quinine, which should be maintained until that time is past. [American experience favors bringing the patient again under the influence of quinine at the end of a ti^eek instead of a month. Many times the attack will, without that precaution, recur on the eighth day following the last chill. — H.] In military and naval practice we have great facilities for carrying out this pro- phylactic plan, by simply keeping the names of the men in a list, and requiring their attendance at the hospital for a few minutes daily at the proper time. Speaking from a large experiencCj I promise those who may try it the happiest results, not only to the men themselves, but to the State, whose costly servants they are. When our object has been attained, and the paroxysms' have been broken, it is well, if cjuinine excites nausea or irrita- bility of stomach, to give what may still be required after food, which will entirely obviate any such unpleasant effect ; and, what is of no small consequence, prevent the patient from being disgusted with the remedy. If we fail in entirely checking the return of the paroxysm, we are nevertheless pretty certain to have made some impres- sion, and it will be a favorable sign if it is postponed for two or more hours, as is almost certain to be the case. Under 362 MALARIAL FEVERS. such circumstances we must proceed as before, slightly increasing the close of qui- nine, if we are not satistied with the ex- tent to whicli cinchonisni was induced. Most American authors describe qui- nine as the antiihte to the poison of malaria. According to Herapath's experiments, not much of the quinine taken into the S3'stem is excreted from it, at all events when disease is present. Out of forty grains given to a man with tetanus, only a fifth part was detected in the urine ; the remaining four-fifths were either assimi- lated in the body, or destroyed in their tran>it through the vascular system. When given in ague it does not appear so soon in the urine as in health. {Parkes; Kinger.) "It has no marked effect on the water, urea, and chloride of sodium, though it may at once arrest the rise of temperature ;" and Dr. Parkes adds, "After ague has been apparently cured by quinine, there occurs in the next two or three days an increase in urea, chlo- rine, and water, at the hours when the fit would have occurred but for the qui- nine. In other words, the quinine disso- ciates these two symptoms, increased temperature and ureal increase ; it stops the first at once, but not the second for some days." [There is no room to doubt the fitness of the designation of ciniUlote, as applied to quinine in the cure of Malarial Fever. How it acts, we cannot know while the nature of the morbid poison is unknown. The "fungus theory" has much to com- mend it as probable, and quinine is found to be destructive of low forms of vegetation ; yet demonstration is here wanting.' A remarkable observation of Dr. "H. Bence Jones, concerning the existence of a fluorescent substance in human blood, was confirmed in 1867 at the Penns3-lvania Hospital by Drs. E. Rhoads and W. Pepper. These observers also ascertained that, in malarial cases, there occurred a notable diminution of this fluorescence, and that it was restored after the administration of sulphate of einchonia in therapeutic doses. ^ — H.] We occasionally meet with cases in which quinine appears to have lost its control over the malarial poison, the paroxysms returning with unfailing regu- larity month after month, in spite of the regular proph5dactic use of the "antifZo(e." In such cases it will be found that the sufferers have been long in a malarious localitj' ; and, whether or not we can de- tect enlargement of liver or spleen by pal- pation or percussion, the miasmatic and [' See, on this topic, Dr. Salisbury, Am. Journ. of Med. Sciences, Jan. 1866, and Dr. H. C. Wood, same journal, Oct. 1868.] [2 Pennsylvania Hospital Reports, 1868, p. 269.— H.] melancholic aspect of the patients, and the presence of bile in the urine, point to the imperfect manner in which the hepatic functions are being performed. In such cases a course of the fluid extract of tar- axacum with small doses of podophyline are most useful ; and if to the above be added the free use for some days of such blood depurants as the bicarbonate, or acetate, or citrate of potash, considerably diluted, it will be found that quinine, be- fore useless, will soon reassert its power. I have seen this again and again, and by this method have cured agues deemed be- yond the reach of art without a change of climate. I have not space to enter into the question of the modus operandi of such remedies. It is probable that they act chemically on the eftete matters in the blood, which in some way interfere with the due action of quinine on the materies morbi. Next to quinine as a therapeutic agent in this disease comes arsenic. It has been used in the East in the cure of agues and their sequels from remote antiquity. Having always been fortunate enough to have access to an abundant supply of quinine, I have not used arsenic much in the treatment of agues. From motives of economy it is much used in the French arm}', and in much larger doses than British physicians are in the habit of pre- scribing. Boudin, acting on the principle that in paludal fevers there is great toler- ance of arsenious acid, is in the habit of giving it in divided doses, and, with the watchfulness always required in the use of this powerful poison, to the extent of a grain and even a grain and a half in the intermission. (Morehead, Clinical Be- searcJics.) Like quinine, its use should be continued for some time after the cessa- tion of the fever, of course in diminished doses. We should carefully look for the earliest signs of its constitutional action ; these are watering of the mouth, a silvery appearance of the tongue, redness of the eyes : and the medicine, as a rule, should be given after food. In the brow-ache and hcmicrania of malarial localities arse- nious acid is very efHcacious — often more so than quinine. I gave an extensive and careful trial of sulphate of bibeerine, prepared by Messrs. Duncan and Flockhart, of Edinburgh, and found it useless in the treatment of all forms of Intermittent Fever. Barberry, a very old remedy in ague, I have also tried in the shape of tincture. I think it possesses some power as a febrifuge, but it is so uncertain in its action, so immeas- urably inferior to quinine, that, in my judgment, to use barberry when quinine is available, is to trifle with the constitu- tions of our patients. Of Warburg's Tincture, as a febrifuge of undoubted effi- cacy, I shall have to speak when I come to remittent fever. INTERMITTENT FEVER. 363 [Various substitutes for quinine have been proposed and largely tried. Among these, opium, chloroform (by the mouth, in fgj doses), and bromide of potassium have had a number of successes. Dog- wood bark (Cornus florida), ! This subject will be found very ably treated in Mr. Lee's Lectures on Syphilis (Lecture xi. page 209). Mr. Lee quotes the important observations of Dr. Ferguson (1812) as to the mildness of Syphilis amongst the Portuguese being explained by the acquisi- tion of hereditary immunity, and adds, "That which Dr. Ferguson observed in his day may be seen at present. A person who has had hereditary Syphilis in his youth, will either not contract the infecting form of Syphilis in after life, or will have it in a modified form." Four years ago I published in the British Medical Journal some cases in which patients who had suffered from inherited Syphilis subsequently contracted venereal sores. These cases were, I believe, the first facts relating to the subject whicli had been recorded. Others had arrived at the same conclusions, but it was by & priori reasoning rather than by deduction from facts. Subsequently I published a case in which a patient who was the subject of inherited taint, not only contracted a venereal sore, but experienced an outbreak of constitutional symptoms. This young man is still under my care, and suffers from inherited Syphilis and acquired Syphilis at the same time. I have recorded a number of facts bearing on this subject in the second volume of the Lon- don Hospital Reports. unmodified, and that if it once produce its own first efteots all the rest will follow. However small the quantity producing it, if once the sore have become indurated, the usual results may be expected. We have no reason for believing that there is any second variety of constitutional Sy- philis, other than that which follows an indurated sore. The questions as to im- perfect contagion therefore concern the surgeon rather than the physician. Un- der its influence a great variety of vener- eal primary sores are produced, hut we have no real variations in the specific fe- ver and its results. ' Lastly, we have to ask the all-important question, whether the ordinary evolution of Sijphilis can be altered in any way by meas- ures of treatment. It will probably be ad- mitted that physicians have abandoned the idea that it is practicable by medica- tion to regulate in any way the course of the other exanthemata. They are gene- rally acknowledged to be diseases which always run their course. With the excep- tion perhaps of cinchonism as a remedy for malarial fever, no single specific in the present day enjoys any repute as to cut- ting short the course of these diseases. But we must not too hastily assume h priori that the same will hold true as to Syphilis. It is possible that the stages of the other exanthemata are too short to permit of the beneficial influence of anti- dotes. Few questions as to therapeutics have been more hotly debated than the efficiency of certain drugs in reference to Syphilis. By some their speciflc power ' If we reflect on the mode in which syphi- litic inoculation is usually effected, the won- der will be not that apparent varieties as to both primary and secondary symptoms occur, but that the disease preserves so close a con- nection with its type as it undoubtedly does. Here, if anywhere, are the conditions under which we might expect a new species to origi- nate. In the first place the virus is constantly mixed with other secretions, and very fre- quently with those of inflammatory origin. In the first place the virus is constantly mixed with other secretions, and very fre- quently with those of inflammatory origin. In a great many instances the person from whom the contagion is received is one whose own body has been previously rendered proof against the disease. Most prostitutes proba- bly suffer from Syphilis early in life, and during the greater part of the period during which they continue their vocation are inca- pable of being themselves again affected by true Syphilis, although still liable to contract and to transmit primary sores of a modified character. Then not only must we make al- lowance for differences in the kind of secre- tion with which the inoculation is effected, but also for differences in the recipient's state as regards it. Hence the differences in the type of cutaneous rash which follows; from a roseola to psoriasis and to rupia. CONSTITUTIONAL SYPHILIS. 429 has been positively asserted, and by others as strenuously denied. As far as the pur- poses of our present argument are con- cerned, we may, I think, admit that there is no proof that the exanthematic stage of Syphilis can be prevented. If the sore have presented well-marked induration, a rash more or less copious is almost certain to follow in due time. A few exceptions occur, but they are as frequent when no treatment has been vised as under opposite conditions. The statistics which have been collected on this point are for the most part valueless, because the kinds of primary sore have not been carefully dis- tinguished. Any conclusions of trust- worthy character must be based on the observation of indurated chancres only. For myself, I may state that I have treat- ed some hundreds of these by the mercu- rial plan, and that in a considerable num- ber of others I have carefully abstained from all medication, and that I am not in a position to record any single instance in which after mercurial treatment no exan- them followed.' That mercury can pro- cure the healing of syphiUtic sores and the absorption of syphilitic lymph, no one who has had opportunities of observation, and who dare credit the evidences of his senses, can doubt ; but that it can prevent the occurrence of one of the stages of the disease, is a very different assertion. I shall discuss the question of treatment in its practical aspects as a further part of this essay; for the present, and in refer- ence merely to the natural history of the disease, it may suffice to observe that there is no more proof that it can prevent the evolution of the exanthem of Syphilis, than that it can do the same in variola. Whether the tertiary symptoms can be prevented or made milder by treatment is again another question, since they, strictly speaking, do not constitute a true stage, but are rather the sequel, more or less ac- cidental, of the secondary one. Any remedy which, although important to pre- vent, is yet able to modify and shorten the secondary stage, may very possiblj' influ- ence the occurrence or otherwise of the tertiary inflammations; and whether mer- ' By this I mean that I have never seen a case in which after a well indurated sore I kept tlie patient continuously under observa- tion, and assured myself that he never had any constitutional symptoms. I have seen many in which the constitutional symptoms were so slight that they might easily have teen overlooked, but these are sufficiently frequent without treatment to make us very cautious in assuming, when such a result follows mercurial treatment, that is a propter ^"c- Many patients whom I have treated by mercury for the chancre have been lost sight pf as soon as the latter was healed, and it is of course possible that in some of these no Secondary stage occurred. cury does so or not, must be determined solely on cliuical evidence. Jlodes of Cdiimiunicuiion. —^yhl\s,t the other exanthemata are for the most part communicable only by direct contagion or infection _ to the individual concerned. Syphilis, in consequence of its very pro- tracted duration, may be conveyed in any one of three different modes. Pirst, con- tagion direct to the individual ; second, contagion indirect through the fostus (pos- sible only in women) ; and third, by he- reditary transmission. The period during which direct conta- gion is possible extends from the first ap- pearance of the indurated chancre to the decline of the exanthem. The primary sore is more actively contagious tlian are any in the secondary stage, but there can be no doubt that under favorable condi- tions the germs of the disease may be con- veyed by the latter. When Sypliilis is communicated to a mother by contamina- tion from the fluids of a foetus with which slie is pregnant, the course of the disease is materially different from wliat it is when received by other means. The ab- sorbed materies seems to be scarcely capa- ble of breeding in the blood of its recip- ient; it merely contaminates it, the degree of the contamination being in exact pro- portion to the amount received. The evi- dence of contamination is greatest during the pregnancy, and increases with each successive one. The symptoms produced are of the tertiary class onfy ; for the most part the secondary stage is wholly omit- ted. A taint thus obtained rarely attains anj^ high degree of severity. When Syphilis is transmitted from pa- rent to offspring, various important pecu- liarities are observed in its manifestations. In the first place the phenomena of the secondary and tertiary stages not very un- frequently occur together, or at any rate we have a superficial rash on the skin re- seml)ling a secondary one, coincident with nodes and with deposit in the viscera. These cases are, however, exceptional, and as a rule the stages occur as in the adult, the secondary rash disappearing after a few months, and there being a pro- longed period of health before the tertiary symptoms show themselves. A few symp- toms are peculiar to the inherited disease, and do not occur in adults who have ac- quired it. Amongst these I may mention, of the secondary'stage, diffuse stomatitis without ulcers, diffuse inflammation of the mucous membrane, of the nares re- sulting in the well-known symptom of snuffles, and of the tertiary ones a form of phagedfenic lupus and interstitial inflam- mation of the cornea. The latter, which is a common and very well marked con- dition in inherited Syphilis, has no parallel condition whatever in the acquired dis- ease. Deafness and amaurosis from nerve 430 CONSTITUTIONAL SYPHILIS. or cerebral disease are both of them far more common iu thu inherited form of tlic disease than they are in that which is acquired. The ell'ect of the syphilitic poison upon the ovum is in many in- stances to destroy its vitality at an early period, and consequently to induce abor- tion. Unfortunately this is far from being its constant effect. In the great majority of such conceptions the tainted fcetus is carried to its full period. In exceptional instances it is then brought into the world with manifestations of its disease apparent in the form of skin disease ; but in most this is not so, and the infants who when a few weeks old will suffer most severely, appear at first to be perfectly healthy. In these a period of from a fortnight to two months usually elapses, and then simul- taneously a rash appears, and the nostrils become stopped by swelling. At this stage the mouth is usually hot, its mucous membrane red and tumid, and the gums swollen. The child wastes, and assumes a shrivelled senile aspect. Sometimes acute, well - characterized iritis occurs. Condylomata are frequentl}' seen. The cutaneous exanthem may vary in charac- ter, much as we find it does in the adult. Many children die during this evolution of secondary symptoms. If they survive they usually in the course of a year get rid of all traces of disease, excepting per- haps an unusual pallor of skin, and certain scars which may have been left in the face by the eruption, and an expanded nasal bridge caused by the long-continued swell- ing of the parts within. I have said above that the tertiary and secondary stages are sometimes strangely mixed in the early symi^toms presented by syphilitic infants. Amongst those which we occasionally meet with under these circumstances are nodes of the long bones, nodes of cellular tissue, of tendon, or of muscle, and disease of tlie liver, kid- neys, thymus gland, &c. Such children are certainly more liable than others to serous inflammations. Serous arachnitis to a slight extent is very common, and pleurisy is not an infrequent cause of death. A condition of extreme anaemia usually results during the outbreak of early symp- toms in a syphilitic infant, and from this death often results. In many cases, how- ever, the child does not emaciate, but re- tains an appearance of good health which is remarkable, considering the nature of the disease. 1 have occasionally seen an infant who was well grown, stout, and strong in an unusual degree, who yet pre- sented well-characterized indications of inherited taint. In the child as in the adult the second- ary symptoms pass away in due time, and a period of health or latency ensues, of variable duration, after which the tertiary phenomena show themselves. These are of precisely the same character as in the adult, with, however, the addition of seve- ral others which are not met with in connec- tion with the acquired disease. There are few more remarkable facts in the history of this most interesting malady than that the disease known as Interstitial, or, ac- cording to Mr. Dixon, as Syphilitic Kera- titis, should never occur as a consequence of acquired disease, but only in the in- herited form. I must also here note a re- markable exception to what I have stated to be the characteristic of tertiary symp- toms in the adult, that they are excep- tionally symmetrical. This form of kera- titis, although it often occurs many years alter the secondary stage, is as a rule sym- metrical. So alEo are the nerve affections, which result in the forms of deafness and amaurosis which we now and then en- counter in these p.atients. As a rule, I believe all sj-philitic symptoms in the in- herited disease, without regard to stage, are symmetrical. In the cases in which tertiary and secondary symptoms in in- fants appear to occur together, the latter are rarely well characterized. Thus I do not know of any instance in which a co- pious scaly or papular rash with acute iritis were coincident with any symptom of a tertiary kind. It has been asserted that a parent transmits to his child the precise form of Syphilis from which he at the time suflers. But to any rule of this kind exceptions are far more frequent than are confirmatory instances. It is very common for a man who does not himself display a single symptom of any kind, and who appears to be in perfect health, to beget a syphilitic child, the symptoms dis- played by the child being usually those of the secondary class. There is no doubt that the nearer to the occurrence of the primary symptoms in the parent is the birth of the offspring, the more certain is the latter to show symptoms of a severe character, and typically secondary in stage. Instances, however, are met with in which infants, born ten years after the original disease in the parent, still dis- played first a secondary rash, with the characteristic snuffles, &c. In several instances I have known a whole family of children, born during a period of from five to ten years, display each one the charac- teristic and transitory rash soon after birth.' The following appear to me to be well- established conclusions as to the transmis- sion of inherited taint. 1st. — In all stages of constitutional Sy- philis — whether during the secondary or tertiary symptoms, or even during a pro- ' For facts on this subject I may refer tlie reader to my paper in tlie London Hospital Reports, vol. ii. p. 184, et seq. TERTIARY SYMPTOMS OR SEQUELAE. 431 tracted period of latency — an individual may become the parent of a taintctl child. The degree of severity of the inherited taint will he in proportion to the shortness of the period whicli has elapsed. 2d. — A child may inherit Syphilis in a severe form from but one parent — from its father alone, or from its mother alone. 3d. — When both parents are the sub- jects of Syphilis a child is more certain to suffer, and also more likely to suffer severely than when only one is so. 4th. — We have as yet no data on which to ground an opinion as to whether a child is more likely to suffer severely when its father is the source of contamina- tion than when it derives the disease from its mother, or the reverse. 5th. — In a large proportion of the cases met with in practice, the taint is derived from the father only. In connection with the hereditary trans- mission of Syphilis, an exceedingly im- portant question arises as to whether any degree of taint is transmissible to the third generation. There is no doubt that persons of marriageable age often present heredito-syphilitio lesions in an active stage, such as keratitis and nodes. I have repeatedly seen patients of various ages, from twenty to eight-and-twenty, become the subjects of syphilitic keratitis for the first time. We might conjecture that such persons would be likely to trans- mit to their offspring some degree of taint, seeing that the taint is still in full activity in their own bodies. I am not aware that any facts have as yet been published on this question. Conjectures abound, and several surgeons have expressed their be- lief, that the influence of Syphilis once ac- quired is felt through several subsequent generations. About eight cases have come under my own observation in which persons, undoubtedly the subjects of in- herited disease, have become parents. With one exception, I have never been able to discover any evidence of disease in the offspring. In several instances the offspring appeared to be in excellent health. I have always made a point of seeing the children for m3'self, never rely- ing upon the parents' statement — a pre- caution which is essential, as I have here occasion to illustrate. The exceptional case just alluded to is strongly in favor of the behef that the third generation may suffer. As no parallel one is on record, I think its details worthy of brief mention. A respectable young woman came to me about six months ago on account of an in- flamed eye. She had interstitial keratitis m a typical form, her teeth were notched, and her physiognomy characteristic. She told me that she was suckling her first child, an infant of two months. I in- quired if it were healthy. She said it was a fine baby and ailed nothing whatever. I asked her to bring it with her at her next visit. She did so, and on having it stripped I found it covered with coppery blotches, with condylomata at the anus, and snuffles in the nose. Under subse- quent treatment by mercury all these symptoms disappeared. There remains of course the source of fallacy that this child's parents, one or other of them, may have had acquired Syphilis. As to its father, I may state that he has been long under my treatment for sycosis, and that I have made the most detailed inquiry of him as to any venereal disease. I believe strongly that ho has never had any. A fact, which is perliaps of more value than his own statement, is, that his sycosis has not been in the least benefited by iodide of potas- sium. Of course I have not ventured to insult him by inquiring as to his wife's antecedents, but there is no reason to en- tertain suspicion in that quarter, whilst the fact that she is the subject of inherited dis- ease makes it probable that she would not be liable to the acquired disease. Having therefore carefully balanced the evidence, I incline to believe that we have in this instance an example of the transmission of Syphilis to the third generation. Tertiary Symptoms or SEQUELiE.— I have endeavored to draw a strong line of distinction between secondary and ter- tiary symptoms. The secondary phe- nomena constitute a stage ; they come on at a certain known period ; they are in their nature transitory, and undergo spontaneous cure ; they affect the two halves of the body at the same time, prov- ing that they depend upon blood-poison- ing ; when once passed they rarely return. The tertiary symptoms are not so properly a stage, but must count rather as the se- quelas, more or less accidental, of the pre- ceding stages. They are as a rule not symmetrical, making it seem improbable that they depend upon blood-taint ; they have no tendency to spontaneous cure- quite the reverse. They relapse over and over again after remedial treatment. The period which intervenes before their out- break is of very different length in differ- ent cases, and in many they never occur at all. From these facts we infer that they are due rather to the ill constitution of the affected structure than to any free virus still circulating in the blood. Let us briefly enumerate the principal tertiary symptoins wliich occur in acquired Syph- ilis. We may conveniently take them in their relation to special organs or structures. First, the sJciii and mucous incmhranes. Tertiary affections of these tissues differ in a most marked manner from those \vhich occur in the secondary stage. With the exception perhaps of pahuar psoriasis, they all involve ulceration of 432 CONSTITUTIONAL SYPHILIS. greater or less depth, and consequently leave cicatrices. "^^erj- frequent!}' the patch assumes a cresceutic form, spread- ing at its edges and healing in its centre the well known horse-slioe or serpiginous ulcer. If the disease commence in the middle line it ma}' spread equally on the two lines, and may thus appear to be symmetrical ; but it is decidedly unusual for symmetrically-placed patches to ap- pear on the opposite limbs or on corres- ponding parts of the trunk. In many cases the skin is involved secondarily to the sub-cutaneous cellular tissue, the dis- ease having begun as a gummous tumor or node of the cellular tissue. A form of lupus attended by rapidly-spreading pha- gedenic ulceration, occasionally occurs in tertiary syphilis, but there is good reason for believing that the common forms of lupus, whether exedens or non-exedens, have no connection whatever with syphi- litic taint. The appendages of the skin, the nails and hair, are frequently affected during the secondary stage, and but very rarely at later periods. The most frequent affection of the mu- cous membranes which we encounter in connection with tertiary syphilis, is a rapidly-spreading ulceration of the palate and pharynx. This again is totally differ- ent from the throat affections which occur in the earlier stages. Instead of being superficial and marked chiefly by swelling and inflammatory deposit, it is character- ized by deep ulceration and loss of tissue. Instead of showing itself symmetrically on the two sides, it commences at one, two, or more points, and spreads quite irregu- larly. The cicatrices left by these deep ulcerations not infrequently narrow the pharynx and occasion difficulty in degluti- tion. In a few cases the ulceration may extend down the oesophagus, and in many the larynx is involved. Every now and then we see cases of tertiary syphilitic ulceration of the mucous membrane of the rectum, and again we must note that it is ulceration, and that it is not attended by the development of condylomata or mu- cous patches, as usually seen in secondary Syphilis. Stricture of the rectum is much to be feared when these ulcerations heal. Several authors have described cases re- sembling dysentery in ah their symptoms, but occurring in syphilitic patients, and cured by anti-syphilitic remedies. Mr. Paget has recently recorded a case of this kind, and have myself seen some very well-marked ones. It is probable that in such cases ulceration of the mucous mem- brane at a considerable distance alwve the anus is present. I have seen several cases in which syphilitic ulceration extended higher than the finger could reach. The cellular tissue is frequently involved in common with muscle, with periosteum, or with fascia. In not a few cases, how- ever, we meet with what are called cellu- lar nodes, in which the disease begins, and is, up to a certain period, confined to this tissue. These may occur in any part of the body, but are much more usually met with in the lower extremities than in any other part. They are very common close to the knee, and especially so in the fe- male sex. It is a very interesting fact in respect to these cellular nodes that they are comparatively very infrequent in men. Whether this is to be explained by the greater abundance of cellular tissue in women, or by the fact that many women obtain Syphilis in a manner wholly pecu- liar to them, that is, by fetal contagion, may be open to some question ; probably both influences have their share in the re- sult. In the early stage of a cellular node we find a small lump of induration, often ex- ceedingly tender. At first it is firm, but as it extends it becomes doughy and softer. When of considerable size there is fre- quently a very deceptive sense of fluctua- tion in it. The overlying skin becomes adherent and of a dusky red color. At length ulceration takes place, and a large core is exposed, consisting of sodden and infiltrated tissues, much resembling in ap- pearance soaked wash-leather. Unless specific remedies are used, this core is very slow in separating, and the ulcera- tion of the skin over it may spread widely. Cellular nodes are not infrequently mul- tiple, but more usually single. The pa- tient frequently has scars of former ones on the opposite limb, but it is exceptional to find them simultaneously present on corresponding parts. A period \arying from four to ten or fifteen years has usually elapsed between the occurrence of primary contagion and the development of cellular nodes. In close connection with syphilitic inflamma- tion of the cellular tissue, we must men- tion that of the subcutaneous bursa. It is not at all uncommon for a bursa to suffer in connection with the disease of the tis- sue around it, and sometimes there ap- pears to be clear evidence that the disease t)egan in the bursa itself. The bursa in front of the patella is the one most fre- quently involved. When ulceration takes place the in- flamed bursa is usually involved in tlia core, and has to be entirely removed be- fore healing can ensue. Iiiflammations of the periosteum and hones have for long occupied the most promi- nent place amongst the tertiary symptoms of Syphilis, and they are still some of the most common. In enumerating the symp- toms which characterize the secondary stage, we have mentioned pains in the bones, attended occasionally by slight and temporary swelling. This kind of perios- TERTIARY SYMPTOMS OR SEQUELS. 433 titis, however, never lasts long, and, as far as my own observation goes, never leads to suppuration. True nodes seldom occur until at least two years liave passed since the first contagion, and generally the period is much longer. Tliey may aflfect almost any parts of the osseous sys- tem, but the bones which are superficial, aud therefore most exposed to external influences, are those most frequently at- tacked ; e. g., the calvaria, tibise, and the clavicles. The bones of the palate, the alveolar processes of tlie maxilte, the vomer, and other bones in the nasal passages, are very frequently afl'ected, and when such is the case, exfoliation of portions usually occurs. Syphilitic periostitis may vary consider- ably in its degree of severity and in its tendencies. In some cases there is but little of acute inflammation, and the result is a great thickening of the bone affected, without the occurrence of suppuration. Tliis fre- quently occurs in the bones of the skull — the whole calvaria acquiring greatly in- creased thickness and density. It is also not uncommon on the surface of the tibia and other long bones, constituting what is known as the osseous node. In other cases suppuration occurs, and in these very frequently large portions of cellular tissue become involved, and we have a swelling consisting in part of periosteal abscess and in part of a cellular node. When the bone is exposed by ulceration, exfoliation of portions often results. When the bones of the skull are at- tacked by syphilitic periostitis it is very possible that inflammation may occur in- ternally as well as superficially, and that we may have symptoms referable either to irritation of the cerebral coverings or to compression consequent upon intra-cranial abscess. In association with nodes on the skull, various symptoms of mental dis- turbance show themselves ; extreme irri- tability of temper, liability to fits of un- controllable passion, melancholia, and sometimes acute mania occur. These symptoms of mental disturbance may or may not be associated with those of local paralysis. They not infrequently result in attempts at suicide. The proof that they really are dependent on syphilitic lesions is afforded by the ease and rapidity with -v^hich they are relieved by the iodide of potassium, bome remarkable instances of this kind have recently been under my care. Periosteal nodes are not very frequently met with on the short bones ; we must, however, be prepared to recognize them occasionally on these also. The patella and the os calcis are not very infrequently affected, and now and then the other bones of the tarsus or carpus suffer. VOL. I.— 28 Diseases of the muscular system occu- chietty amongst the most remote sequels of Syphilis, and they are by no means fre- quent. They usually take the form of nodes or gummata, developed in the sub- stance of some single muscle. The indu- ration is usually very considerable, and in many parts abruptly limited. The diag- nosis from cancer is often very difficult, and many a mistake leading to an unne- cessary operation and to a supposed per- manent cure of cancer has occurred. The muscular substance of the tongue is that most frequently attacked, but they have been met with in almost all the muscles of the body. We may mention especially the sterno-mastoid, the masse- ter, the supra- and infra-spinati, the gas- trocnemius, and the rectus femoris. I have recently had under care an ex- tremely interesting case in which a tumor, which we at first suspected to be cancer, was developed in the left masseter of a lady who had twenty years before suffered from Syphilis. She presented at the time the tu'nior appeared no other syphilitic symptoms, and the correct history was only obtained with much difficulty. The tumor has wholly disappeared under the use of the iodide of potassium. Some forms of syphilitic indurations of the tongue are exceedingly difficult to dis- tinguish from cancer. They are very hard, have well-defined edges, are pain- ful, and when they ulcerate present an unhealthy surface. Iodide of potassium in full doses will usually in the course of a week or ten days clear up the diagnosis. The heart itself 'is sometimes the seat of syphilitic nodes. Of this, M. Eicord' was, I believe, the first to record an example ; but several others have been subsequently mentioned by other observers. The Olandular System.— The chronic enlargements of the lymphatic glands, sometimes resulting in suppuration, are every now and then met with as the se- quels of Syphilis, but it does not appear to me that they occupy any very impor- tant position. It is a remarkable fact in reference to tertiary syphilitic lesions generally that they do not cause any secondary enlargement of the adjacent lymphatic glands. This is true of syphi- litic ulcerations of the skin and mucous membranes, of all the various forms of node, and of syphilitic tumors in muscles and it often constitutes a very useful means of differential diagnosis between cancer and Syphilis. The Internal Fiscera.— Of late years the investigations of pathologists have fully • See Traitg complete des Maladies V^n4- riennes, Planche xxix. In this instance the patient was a man aged 41, who had suffered from a chancre followed by constitutional symptoms eleven years prior to his death. 434 CONSTITUTIONAL SYPHILIS. conflrmeil the conjectures of the older writers on Syphilis, as to the frequency with which the viscera of the trunk, and more especially the liver, suffer in consti- tutional Syphilis. In connection with this subject we must especially mention the very valuable contributions of Dr. Wilks. As to the exact period in the course of the disease at which the viscera are attacked, it is diflicult to obtain any positive evidence. What we discover in the post-mortem examination is usually the result of long past disease, and it is comparatively infrequent to find it in a recent stage. What evidence we have, however, favors the belief that it is not un- til the later periods that the viscera suffer. The liver appears to be far more fre- quently affected than any other organ. [Fig. 15. • »^-',4'i5&*^ The peripheral portion of a gummy growth in the kidney. Showing the small-celled granulation growth in the intertubular tissue. X 200. (From Green.)] Indeed, in the examination of the bodies of those who have suffered from tertiary Syphilis, it is decidedly exceptional not to [Fig. 16. From a gummy growth in the kidney. Showing the reticulated structure occasionally met with in the intermediate zone of these formations. ^ 200. (Prom Green.)] find proof of hepatic mischief. The most common condition consists in large white patches of fibroid thickening on the sur- face of the organ. These patches are evi- dently cicatricial. The liver is knotted and puckered by them, and bands of cica- trix dip from the surface into the sub- stance of the organ. Sometimes, when the destruction has been great, the whole bulk of the organ is diminished. In re- cent disease the affected parts of the or- gan are enlarged, and on section exude a material not unlike bees-wax, or glutinous and gummy. I am not aware that ab- scesses have as yet been met with in the liver in supposed connection with Sj'phi- lis. Virchow recognizes two forms of disease — a capsular hepatitis and an in- terstitial hepatitis. Of these the capsular inflammation is the more common and the less serious. It is probable that the two are generally associated to a greater or less extent. Ascites occurs eveiy now and then in connection with Syphilitic disease of the liver. An instance of it in a woman, the subject of inherited Syphilis with a contracted liver, has recently been under my care. The disease was of sev- eral years' standing, and paracentesis had been repeatedly performed. By a long course of iodide of potassium, with am- monia, the fluid was entirely removed and her health much benefited. Ascites from liver disease is not very infrequent in the subjects of inherited taint. Testes. — Syphilitic sarcocele or syphilitic orchitis has usually been classed by au- thors as a secondary sj-mptom. I feel sure, however, that this" is not quite cor- rect. It is amongst the earlier of the sequelae, but seldom if ever occurs during the secondary stage. It is commonly met with in conjunction with nodes, and with deep ulceration of the skin rather than with the superficial rash of the sec- ondary epoch. It consists of the free ef- fusion of lymph (fibro-plastic material) into the substance of the testis, or, more rarely, into the epididymis. The swelling often attains a very con- siderable size, and when it does so it pre- sents the peculiar feature of feeling very light in the hand. Syphilitic sarcocele is much more frequently symmetrical than any other form of tertiary Syphilis. This circumstance we might expect from the fact that it occurs much nearer to the secondary stage than do most of the oth- ers. ' Still, however, it is only exception- ally symmetrical. Ifervous Systevi. — We come lastly to syphilitic affections of the nervous system itself. I have previously adverted to the occa- sional occurrence of cerebral symptoms in ' On this point Mr. Curling writes, "Sir A. Cooper thinks that in the majority of cases, the disease attacks both testicles. The eight examples recorded in his work do not, however, hear out this remark, for in only two of them does it appear that both organs were attacked. According to my observation, the disease is more commonly confined to a single gland, though it occasionally affects both ; and this also appears to be the opinion of Ricord." TREATMENT OF SYPHILIS. 435 connection with syphilitic inflammation of the bones of the sliull, and to the for- mation of intra-cranial nodes ; but, quite apart from tlie disease of its osseous case, tlie brain itself may suffer directly from the formation of tertiary syphilitic depos- its in its structure. We may also have deposits of like nature into the substance of nerve trunks, producing special forms of local paralysis. To these isolated de- posits the term syphilitic neuromata has been given, and several well-authenticated cases are on record in which the diagnosis has been confirmed by an autopsy. In a far greater number of cases the diagnosis has received an almost equally valuable confirmation in the cure of the disease by iodide of potassium. So frequently indeed is tertiary Syphilis the cause of paralysis, that investigations in this direction ought never to be omitted in cases in which the nature of the disease is in the least doubt- ful. It is, indeed, safe to go further than this and to saj'^ that in all cases of paraly- sis, without evident cause, and in which syphilitic antecedents are even possible, it is advisable to try the effect of iodide of potassium. I allude chiefly to cases of paralysis of the cranial nerves, for it would appear that neuromata of these are more frequent than of the spinal ones. Of the cases of paralysis of the fifth nerve, of the tliird, fourth, and sixth, which have come under my notice at the Ophthalmic Hos- pital, a large proportion of these have been of syphilitic origin, and most of these have been cured by the administration of iodide of potassium. Syphilitic affections of the nervous sys- tem are usually among the late tertiary phenomena. I have rarely seen them at an earlier period than about five years after the primary disease, and in most in- stances the interval is much longer. In many cases the patients have had time to regain the appearance of good health, and almost to forget the malady from which they had formerly suffered. Under such circumstances the diagnosis is often sur- rounded with difficulty. Syphilitic affections of the nerves of special sense do not appear to be common in connection with acquired disease, but they are not infrequent as results of in- herited taint. In the subjects of the latter a form of cerebral deafness is often met with, and also one of complete blind- ness in association with white atrophy of tlie optic nerves. Treatjient of Syphilis. — In ap- proaching the question of the treatment of Syphilis we must always keep clearly in mind the facts which have been estab- lished as to its nature. Not indeed that A priori reasoning is to supersede empiri- cal experience in such a matter, but rather that we shall do well to guide the one by the other. Viewing Syphilis as a disease of the zymotic class, caused by a specific virus which accomplishes its de- velopment within the body of the infected person, and passes through distinct phases or stages, nothing can be more probable than that in order to influence its cause we shall require very different measures in the different stages. The treatment which we should adopt in the onset of variola is not that which we should resort to after the exanthem has disappeared. "We have then in respect to Syphilis to ask : First, what treatment should he adopted in the exanthematic or secondary stage? Second, what should be used against the very various sequete classed as tertiary symptoms ? Third, whether there is any reason for believing that the development of stages, more especially of the exanthem, can be influenced by in- ternal treatment adopted immediately after inoculation ? Fourth, whether the sequelae are rendered less or more severe by interference with the development of the early stages of the complaint ? As the present essay is on the medical aspects of Syphilis, we may suitably leave out of debate a matter of the utmost in- terest to the surgeon, that, namely, as to the prevention of constitutional infection by local treatment of the inoculated part (so-called "abortive treatment"). To cite an array of facts on this exten- sive subject would be wearisome, and without adequate result, nor should we more easily accomplish a summary of the very diverse opinions which have been published by medical authorities. [A general agreement exists among practi- tioners as to the propriety of endeavoring to arrest the specific morbid process of chancre by local applications. Early cauterization with .solid nitrate of silver will sometimes eradicate the disease. If that fail, the alterative action of powder of calomel may be tried. Iodoform is pre- ferred by some. Astringent washes, as lime-water, solution of sulphate of copper, &c., usually do good. When a bubo forms, in the inflammatory stage it may be treated with lotions of lead-water and poultices. If suppuration occurs, it should be freely opened with a bistoury. Should it then be slow to heal, the treatment will be essentially the same as for an indolent ulcer.— H. ] The question as to the treat- ment of Syphilis resolves itself chiefly into one as to the efficiency or otherwise of mercury. We will submit for consideration answers to the following questions : Does mercury in any way influence the course of syphilitic symptoms ? On this point I think almost all are unanimous. When given during the stage of induration of a chancre, mercury causes the absorption of the induration, and the healing of the sore ; when given during the outbreak ot 436 CONSTITUTIONAL SYPHILIS. the secondary rash, it causes the rash quickly to disappear ; it also causes the ulcers in the tonsils to heal. In cases of iritis and retinitis we have the most con- clusive proof of the rapid absorption of syphilitic lymph under mercurial influ- ence, inasmuch as in each of these condi- tions the inflamed structure is directly under our inspection. If we inquire as to the value of mercury against the tertiary symptoms, we obtain a much less positive answer, but we shall still meet with evi- dence in proof that over many forms it possesses a most decided power. Having seen that mercury does, beyond all doubt, possess the power of shortening the duration of the primary sore, or if not used until the secondary manifestations have appeared, of causing these latter to disappear ; we next have to ask whether the mercurial cure of any single stage, whether primary or secondary, influences beneficially the subsequent progress of the disease. The difference between an anti- dote for the syphilitic virus and a remedy for extant syphilitic inflammations, must be clearly recognized. It is one which has been acknowledged from the time of Hunter to the present day. It appears to me that the balance of evidence is in favor of the belief that mercury is a most potent remedy against syphilitic inflam- mations, but that it does not act as an an- tidote to the virus. I fear we have but lit- tle proof that mercury tends, on the whole, to abridge the duration or mitigate the se- verity ofthe syphiliticfever audits sequelae. During about two years in my practice at the Metropolitan Free Hospital, I sj's- tematically abstained from adopting any treatment in my cases of indurated chancre and its consequences. The chancre and the rash were allowed to de- velop themselves and to disappear spon- taneously, and they did so in a fairly satisfactory manner. The duration of each was considerably longer than when mercury is given ; otherwise I could ob- serve no diflerence. The rash did not ap- pear earlier, nor was it more copious than in the cases in which the remedy had been used. On the whole I had no reason to think that the patients suffered from the experiment beyond the fact of a more prolonged illness. As to what may be the relative frequency of tertiary symptoms in these cases it is as yet too early to speak. I have also, in private practice, not infre- quently treated indurated chancres and secondary rashes without giving mercury.' ' I have preferred to speak from my own experience rather than to refer to the large amount of published evidence which exists. My own trial of the non-mercurial plan was made purely as an experiment, and without the slightest sentiment of partisanship. As already stated, I think there is no proof whatever that by giving mercury for the primary sore, we diminish the pro- bability that secondary symptoms will occur. These latter are for the most part inevitable, whatever may be the treat- ment employed. They are sometimes very slight indeed, and in some cases, perhaps, wholly omitted, but their non- occurrence is quite as frequent.when mer- cury has not been given as under the opposite conditions. It is, therefore, un- safe to assume because in any one case in which mercury was given early, and no secondary symptoms ensued, that, there- fore, the treatment prevented them. Such sequences are probably mere coincidences. Thousands of cases may be quoted in proof that mercurial absorption of the chancre does not prevent the secondary stage ; and, further, that the mercurial treatment of both primary and secondary stages does not prevent the occurrence of tertiary sequelse. We might also quote another class of .facts in proof that mer- cury is not in any strict sense an antidote, those, namely, in which relapses occur either during or immediately after its use. These cases must be familiar to all. A patient, whilst actually salivated on ac- count of iritis in one eye, becomes affected by the same inflammation in an acute form in the other, or just after the mer- curial cure of iritis, retinitis occurs. Of the latter occurrence I have seen several marked examples. I admit that these quick relapses are exceptional, but they are still sufflciently common to become of great value in reference to the question under debate. The belief that mercury given in the early stages in any way com- plicates the case or adds to its subsequent severity is, I think, to a very large extent an error ; at any rate it is quite certain that the worst forms of syphilitic symp- toms, whether secondary or tertiary, not infrequently occur in cases in which no mercury has been used ; especially is this a fact as regards tertiary symptoms, such, for instance, as extensive disease of the bones. In former days, when mercury was given so freely, it was not so easy to find cases of tertiary Syphilis without the history of previous mercurial treatment ; in the present day, however, it is not at all infrequent. If I might be allowed to express my own impression, founded as it is on a considera- ble number of facts, but for obvious reasons not easily susceptible of categorical proof, it would be to the effect that the course of Syphilis is on the whole rendered somewhat milder by early mercurial treatment. Quite apart from the questions as to the general influence of mercury upon the course of Syphilis, we must estimate its value in the speedy removal of local in- TREATMENT OF SYPHILIS, 437 flammations. We have ventured to con- sider that it is a proven and admitted fact that this remedy does produce the rapid absorption of sypliilitic lympli. "When the lympli is effused into the skin, or at the base of the original chancre, it may be a matter of little or no consequence whether it is allowed to remain two weeks or two mouths. There is uo material danger as to the integrity of the organ concerned. In the case of the eye and certain other organs, however, the facts are very different. If the iritis be allowed to proceed unchecked, it will in all proba- bility end in obliteration of the pupil, either partial or complete. It will effect but little to use atropine, unless we use mercury also, for in many cases during the acute stage of the inflammation the pupil can be scarcely made to dilate until the lymph effused into the iris is in part ab- sorbed. The longer the lymph is allowed to remain, the longer the inflammatory process is allowed to continue unchecked, the greater will be the risk of disorganiza- tion of the structure implicated. These remarks apply with yet more force to syphilitic retinitis than to iritis. That it is the bounden duty of the sur- geon to administer specific remedies in these diseases, no one who has considered the facts can, I think, doubt. It is not uncommon to see the retina in a case of severe retinitis become almost clear after a fortnight's mercurial treatment, with corresponding benefit to the patient's vision. It is on the other hand very com- mon to see this disease remain unchanged for several months, if mercurial treatment be not adopted. Those anti-mercurialists who carry their doctrines so far as to refuse to employ spe- cific remedies when the eye is attacked, incur a responsibility probably far greater than they suppose. A case has recently come under my own observation so much to the point that I must mention it. A gentleman engaged in the city con- sulted me concerning some symptoms which I easily recognized as the sequels of Syphilis. Amongst others he had mus- C8e and evidences of a past attack of reti- nitis. He gave me the history that he had been treated for the primary disease by a surgeon well known as an opponent to mercury. This gentleman explained to him in very strong terms the evils which he supposed to result from that drug, and so far secured his confidence that he continued under expectant treat- ment for several months. The eyes were attacked, and still specific remedies were abjured. "At length," said my patient, "when I was all but blind, and when for several weeks no improvement had oc- curred, I determined to take other advice, and consulted Mr. Critchett. Mr. Crit- chett assured me that the fear of mercury was all nonsense, and that the only chance for my sight was at once to go home, keep myself in a warm room, and take mercury till the mouth was sore. This I deter- mined to do, and the result was that in the course of a week, I could see very nmch better, and that subsequently I re- gained almost perfect sight." In this case, not only did the mercurial treatment rapidly cure the retinitis, but it removed the syphilitic rash and restored the^ patient's general health in a way which, to him, \vas marvellous. When Syphilis attacks the larynx it be- comes also of great consequence to adopt energetic treatment, on account of the danger to life which may accompany the local disease. Although in the case of the skin we have to deal with an organ not essential to life, and the functions of which may be long interrupted with comparative impu- nity, yet it is still probable that a very ex- tensive cutaneous inflammation, such as occurs in the exanthem of Syphilis, is not wholly without its injurious influence on the general health ; thus there may be some reason alleged for preferring to get rid of a secondary rash in a few weeks by mercury, rather than to allow it to disap- pear spontaneously after several months' duration. We come, lastly, to the question as to the treatment of the tertiary symptoms, or the sequelae which occur several years after the contagion. The marvellous power of the iodide of potassium in the cure of these affections is universally admitted, and has led to the almost entire disuse of mercury in their treatment. The only drawback to its employment is, that cures thus effected are rarely permanent, and that relapses are very frequent in a short time after its suspension. Some surgeons of large ex- perience hold that mercury, even in re- gard to the tertiary symptoms, is more efficient than the iodide in bringing about a permanent cure. This is, however, open to much doubt. Practically, in all cachectic subjects suffering from tertiary symptoms, we usually administer the iodide alone, and if the cachexia be less severe we combine it with a mercurial. Another general rule on this point is, that the earlier in the role of tertiary symp- toms the greater the desirability of mer- cury, and the more remote from the original taint the more likely is the iodide alone to be found efficient. Thus, cases of node, of gummous tumor, of tumors in muscles, and of affections of the nervous system, all of which are among the later of the tertiary class, are usually treated most satisfactorily by iodide of potassium. What little experience I have had of the treatment of tertiary Syphilis, either by the mineral acids or by sarsapariUa, 438 CONSTITUTIONAL SYPHILIS. has not been favorable to these remedies. We must not overlook in the manage- ment of cases of syphilitic sequete, the importance of change of air, of nutritious diet, and general attention to the patient's health. Such sequelae, are especially apt to occur and to become severe in patients whose general health has been broken down. Any debilitating influence brought to bear upon a patient the subject of a latent taint may permit such taint to be- come active. Thus, patients who have for many years enjoyed excellent health, and have be- lieved themselves long ago and completely cured, inay become, at the climacteric pe- riod, or when by any chance underfed and enfeebled, the subjects of tertiary Sy- phiUs. Yet, whilst fully admitting the importance of sustaining the general vigor as a prophylactic measure against tertiary Syphilis, we must keep in mind that these measures will by no means prove always efficient. Many of the worst cases of ter- tiary Syphilis, whether consequent on in- herited or acquired taint, occur in those whose circumstances of life enable them to enjoy every hygienic advantage. With regard to the details of mercurial treatment, differences of opinion still pre- vail among surgeons. The majority still think the stomach the most fitting organ by which to introduce the remedy into the blood. There is no doubt that absorption by the skin, whether by inunction or the moist vapor bath, is very efficient, but there is no proof that it is superior to the other. Under the able advocac}' of Mr. Langston Parker, Mr. Lee, and others, the calomel vapor bath has of late years obtained much repute. I have often used it, and have still more frequently seen cases in which it has been used by others, and have not been able to persuade my- self that it possesses any real advantages. The fact is, that mercury in any form is so prompt in its results against syphilitic inflammations, that whoever is in the habit of prescribing it in one special form is very apt to come to the conclusion that his peculiar mode of use must be superior to others. When there is a rash or ulceration on the cutaneous surface, it is always well to apply mercury directly to the inflamed part in addition to its internal use. This may be done conveniently by prescribing the mercurial ointment when there is no ulceration, and the black wash when the latter exists. Of the various preparations of mercury, I much prefer calomel or the bichloride, and rarely find that these, when used with suitable adjuvants, in moderate dose, disagree to any material amount. For the early forms of second- ary rash I usually employ mercury alone, and for the latter ones mercury in combi- nation with iodide of potassium. A mix- ture containing the solution of the bichlo- ride with the iodide in excess is extremely useful. It probably amounts to bin-iodide of mercury with excess of iodide of potas- sium. The addition of ammonia to this mixture appears to increase its efficacy, and the same is the fact as i-egards its use with the iodide of potassium under all cir- cumstances. In prescribing mercury it is the sur- geon's duty to carefully watch its effects upon the disease, and upon the patient's health. The fact that a given patient is cachectic and feeble is not in itself any reason for precluding resort to specific treatment. On the contrary, it is under such circumstances not infrequently that the value of the remedy is best shown. Nor can we lay down any rule as to the avoidance of mercury in treating certain forms of rash- — ecthyma, rupia, &c. It may be stated in general terms that the more nearly the rash keeps to the scaly type, the more certain is it that mercury will agree ; whilst the greater the ten- dency to ulceration and suppuration, the more is the risk that it may disagree. Should it disagree in any case, the observ- ant surgeon will soon discover the fact. If the ulcers spread instead of healing, and if the quantity of secretion is increased, then mercury should be at once laid aside and substituted by iodide of potassium with tonics. The cases in which this sub- stitution becomes necessary are, I believe, often those in which the patient has in- herited partial immunity, and conse- quently suffers from a modified form of the acquired disease. Although mercury is very efficacious in the infantile stage of Congenital Syphilis, it often disagrees most markedly with the subjects of this taint when they have attained adult age. As a rule, in the management of second- ary Syphilis, it is well to push mercury to a mild degree of ptyalism. Not infre- quently symptoms resist its action until the gums are sore, and then yield at once. I have often observed this in inflamma- tion of the eye, especially in retinitis. With regard to the iodide of potassium against tertiary symptoms, a few simple rules may be given. It is well always to combine it with ammonia. It is weU to begin with a small dose, e. (/., five grains three times a day, and to gradually in- crease, not going beyond ten or twelve unless necessary. If the disease does not yield to the latter, the diagnosis being yet undoubted, then much larger doses should be given ; say, half a drachm three times daily. In a few rare cases, nothing short of these large doses will produce any benefit. The DrAGisrosis of Con-stitutional Syphilis. — The power of recognizing syphilitic diseases when brought under DIAGNOSIS OF CONSTITUTIONAL SYPHILIS. 439 notice is one of tl\e most valuable gifts which the physician can possess. Tlicse diseases meet us at every turn in prac- tice, and present a most bewildering variety of external aspect. At one time we have to distinguish a syphilitic rash from a simple one, at another to diagnose between Syphilis and Cancer, or Syphilis and Rheumatism, or the problem pre- sented may be to form a correct opinion • as to the nature of a paralysis, an ascites, or an attack of mania. The first requisite to success is a mind constantly awake to suspicion, and fully impressed with the all-important fact that diseases of the most diverse character may have their origin in this taint, and that if so they will prove to be curable only by treatment directed against it. This suspicion must be present, whatever may be the position in life or the reputation of our patient. A gentleman, who now at middle age bears the most irreproachable character, may chance to have been less circumspect during college life, and it is not fair that his subsequent purity of conduct should be the means of preventing his relief from the consequences of youthful error. We meet every day with cases in which wo- men, whose characters are spotless, have become the subjects of syphilitic taint without their having the slightest sus- picion as to the nature of their malady. Under many circumstances it is out of the question to make any direct inquiries, and the physician must depend upon his own acumen for the opinion which shall guide his treatment. The recognition of syphilitic symptoms in the secondary stage is not usually diffi- cult. The copiousness of the rash ; its symmetry ; the copper-tint ; the frequent coincidence of several of different types of skin eruption in the same case ; the presence of febrile disturbance ; the ab- sence of cutaneous irritation and the co- existence of sores on the tonsils, and fre- quently on the mucous membrane of tlie cheeks also — are all features wliich help to make the diagnosis easy and certain. To these we may add that the syphilitic exanthem usually appears first on the ab- domen, chest, and fronts of the arms, that it very commonly affects the face, and that it avoids the backs of the elbows and the fronts of the knees, localities which are almost always attacked in cases of common psoriasis. Although syphilitic rashes vary very much in outward charac- ters, yet they have always in the features lust mentioned a basis of close similarity. When mistakes occur they are usually those of insufficient attention. The pa- tient is allowed to show only a small part of his surface, instead of being made to strip, or at any rate to expose the whole of his bust. If the latter course be adopted, the symmetry of the rash and its other peculiar features will almost al- ways arrest the attention of the observer. Amongst minor points which occasionally assist may be mentioned the gyrate or ringed form of the patches, and in some cases of syphilitic psoriasis the compara- tive absence of desquamation. The cases which cause most difficulty are those in which Syphilis occurs in a patient who is already the subject of some other skin disease. In hospital practice it is very common to see scabies and a syphilitic rash coexisting, and in some such it is most difficult to pronounce with certainly as to the nature of the eruption. Examination of the mouth and throat and of the genitals will often remove doubt ; but if not, a few sulphur baths as a measure of diagnosis will usually prove successful. Kext to that of exanthem itself comes the diagnosis of the relapses of eruption, which often occur between the secondary and the tertiary epoch. In these there is rarely any copious outbreak, usually only a few isolated patches. These are most commonly met with in the palms of the hands or soles of the feet, or on the front aspects of the forearms or legs. They are almost dry and attended with peeling of the epidermis. Very frequently there are small sores in the mouth or on the tongue ; at the same time a form of acne, chiefly affecting the forehead, and leaving little pits or scars, is very often seen in this stage. If iritic adhesions are present, or if there are pits in the skin of the face and trunk, left by a former rash, the sus- picion is much strengthened. If the diag- nosis remains doubtful, we may cautiously try the effect of a short treatment with the bichloride or biniodide, and observe the result. Lastly, we must consider the question of the recognition of the various diseases which come into the category of tertiary symptoms. When these occur, it is often many years since the patient has suffered from any other ; and it is quite possible that he may appear to be in excellent health. A few of the tertiary symptoms have been so long recognized in relation to their true cause, and are so rarely met with in connection with any other, that in themselves they almost constitute their own diagnosis, and often also help us to that of more obscure lesions. Periosteal swellings or nodes are the chief of these. To speak generally respecting other forms, we may say that the diagnosis must be founded in part upon the patient's pre- vious history, in part upon any still ex- isting remnants of former disease— such, for instance, as iritic adhesions— and m part upon the peculiarities of the disease itself. As regards the patient's antece- dents, I may just remark, by way of cau- tion, that we must not hastily assume 440 COXSTITUTIONAL SYriirLIS. that he ia syphilitic because he tells us that he has had the venereal diseai^e. A soft chancre with its suppurating bubo, or even an attack of gonorrhosa, although both of them quite innocent as regards constitutional infection, often leave more vivid impressions on the patient's mind than does an indurated sore and its exan- tliem. Those who are most ready to sus- pect a venereal cause, are often those who have never had true Syphilis at all. If, however, there is a clear history of a chancre followed by secondary rash, sore throat, &c. , then we have obtained a fact which, whatever may be the present ail- ment, may be safely permitted to modify our treatment. The majority of tertiary lesions are by conventional usage re- garded rather as surgical than medical, and it would be out of place to speak in detail of the diagnosis of ulcers, gummous tumors, &c. I may briefly remark that the serpiginous form of ulceration, heal- ing in the centre and spreading at the margin, is a feature always to be re- garded with suspicion ; that tumors in muscle, which will only melt away under the influence of the iodide, are sometimes as hard and as defined as any variety of chancre, and have often led to needless operations. In cases of disease of the nervous sys- tem in which Syphilis is suspected, an examination of the patient's eyes, throat, tongue, and tibite should never be omitted. The existence of iritic adhesions, of cica- trices of the soft palate or of periosteal nodes, will often decide the question. The occurrence of nocturnal exacerbations of pain is also always suspicious. If the disease implicate only one nerve-trunk, especially if only one cranial nerve be in- volved, the suspicion of Syphilis becomes very strong. Probably a full half of the cases of paralysis of the third, fourth, fifth, and sixth nerves, when such paralysis affects only one nerve, are due to Syphilis and are curable by specific treatment. In these cases the disease is hardly ever sym- metrical, and the paralysis is usually com- plete. The seventh nerve is occasionally attacked, but not so frequently as the others. The nerves of special sense are not so frequently affected in acquired Syphilis as they are in the inherited form. Nevertheless, cases do occasionally occur in which amaurosis or complete deafness are met with in the subjects of syphilitic taint, and without other assignable cause. In these the loss of function is usually symmetrical, and probably depends upon disease of the cerebral centre rather than neuromata developed in the nerve-trunks. I am not aware of any cases in which paralysis of the branches of the eighth pair have been traced to Syphihs, but no doubt such occur and might be recognized by due search. Paralysis of siugle nerve- trunks of any of the spinal plexuses- more especially those of the brachil plexus — are now and then encountered. In cases of tertiary Syphilis the bones of the calvaria not infrequently increase greatly in thickness and weight without any formation of external node, and un- der such circumstances there is very often a roughened state of the surface in con- tact with the dura mater. Various forms of disturbance of the sensorial functions are usually observed in these cases. In addition to violent headache there is irri- tability of manner, loss of memory, and sometimes actual mania.' The diagnosis must depend upon the facts to which I have already adverted. The Diagkosis of Constitutional Syphilis when consequent upon Inherited Taint. The diagnosis of inherited Syphilis rests on somewhat different data to that of the acquired disease. Indeed, the whole course of the disease, as thus transmitted, presents some remarkable features of dif- ference which I have endeavored to bring into clear contrast in the appended tabu- lar parallel. (See p. 443.) Some local lesions, not infrequent in those who have inherited the taint, never occur at all in those who have acquired it, as for in- stance, interstitial keratis. Others pre- sent important modifications of charac- ter ; thus, when periosteal nodes occur in children, they are much more extensive than is usually the case in adults. Speak- ing generally, the tertiary symptoms of inherited Syphilis, however long may have been the interval of latency, are for the most part symmetrical. We have seen that those of acquired Syphilis are but rarely so. The stages observed in the course of in- herited disease are very similar to those of the acquired form, but they much more frequently run into each other. We must consider the question of diag- nosis in reference to the three different stages : first the infantile period ; second, the stage of latencv ; and lastly, that or tertiary symptoms (usually about the age of puberty). In the infantile period we recognize Syphilis by the peculiarity of cert.iin si;> gle symptoms, or, more frequently, auil ' A youiif; man was recently admitted un- der my care into the London Hospital, hav- ing attempted suicide (by cutting his throat) in a state of mania. He had disease of the alveolus and nasal hones, -whicli led me to diagnose Syphilis. We gave him full doso of iodide of potassium, and he rapidly recov- ered. When his mental faculties had re- turned, he gave us a history vphioh fully confirmed our suspicions as to specllio taint. DIAGNOSIS OP CONSTITUTIONAL SYPUILIS. Ul with greater certainty, by the peculiar grouping of several different symptoms. First in importance is tlie rash on the skin. The rash, as in acquired Syphilis, may vary much in its character, but the commonest are those of erythematous or papular character. If it is erythema, the redness will show itself in abruptly mar- gined patches, and Will be characterized further by its peculiar red or coppery tint, compared by some authors to that of the lean of ham. Sometimes we see instances of dry, scaly rashes in infants, but these are rare. Pustular, vesicular and bullous rashes are also not infrequently witnessed. Condylomata at the anal orifice are com- mon, though less frequent during the first few months than at later periods. At the same time as the rash the little patient almost always displays the characteristic symptom known as "snuffles," and there is usually inflammation of the mucous membrane of the mouth, and sores at its angles. (See p. 429.) Iritis occurs in a few cases and has similar tendencies to those witnessed in the acquired form, and is equally under the influence of specific treatment. It occurs also at the same stage, always amongst the secondary symptoms. Inflammations of the deep- seated structures of the eye — of the vitre- ous, retina, choroid — are as frequent as they are in the adult, and present the same characters. During the stage of outbreak of the ex- anthem, which lasts on the average from the fourth week to the sixth month-, the child becomes fretful, pale, and emaci- ated ; growth is for a time arrested, and his shrivelled face resembles that of an old man. Emaciation is certainly the rule, but it has many marked exceptions, and I have often seen syphilitic infants who were fat and plump and looked re- markably well. At or about the age of one year, if the child have survived, it is usual for the secondary symptoms to wholly disappear. Tlie period of latency now ensues, during which the child enjoys often very good health. Sometimes relapses occur, and especially are such subjects liable to be affected by condylomata. These relapses scarcely ever involve a return of cutane- ous rash. I think that all observers will bear me out in the statement that the characteristic rashes so often seen in syphilitic infants are never witnessed at later periods of life. The tertiary epoch may begin at any period after the fifth year, but it is commonly delayed till at or near the period of puberty. The recognition of the subject of in- herited Syphilis, at or after the age of pu- berty, may be sometimes made with great certainty, and is at others surrounded by difficulties. Our most valuable aids are the evidences of past disease, more especi- ally of the inflammations which may have occurred in infancy. A sunken bridge of nose, caused by the long-continued swelling of the nasal mucous membrane when the bones were soft, a skin marked by little pits and linear scars, especially near the angles of the mouth, the relics of an ulcerating eruption, and a protuberant forehead, consequent upon infantile arach- nitis, are amongst the points which go to make up what we recognize as an he- redito-syphilitic physiognomy. Added to them we have vei-y valuable aid furnished by the shape of the incisor teeth. In these patients it is very common to find all the incisor teeth dwarfed and mal- formed. Sometimes the canines are af- fected also. These teeth are narrow and rounded and peg-like ; their edges are jagged and notched. Owing to their smallness their sides do not touch, and interspaces are left. It is, however, the upper central incisors which are the most reliable for the purposes of diagnosis. When the other teeth are affected these very rarely escape, and very often they are malformed when all the others are of fairly good shape. The characteristic malformation of the upper central incisors consists in a dwarfing of the tooth, which is usually both narrow and short, and in the atrophy of its middle lobe. This atro- phy leaves a single broad notch (vertical) in the edge of the tooth, and sometimes from this notch a shallow furrow passes upwards on both anterior and posterior surface nearly to the gum. This notching is usually symmetrical. It may vary much in degree in different cases ; some- times the teeth diverge, and at others they slant towards each other. The ap- pended woodcut {Fig. 17) illustrates a good Fig. 17. Syphilitic teeth. example of the deformity. In any case in which the malformation was as marked as Fig. 18. Syphilitic teeth. in this sketch, I should feel no hesitation in pronouncing the possessor of the teeth 442 CONSTITUTIONAL SYPHILIS. to be the subject of inherited Syphilis, even in the absence of other testimony. I have never yet seen such teeth, excepting in patients of this class. In the majority of cases, however, the condition of the teeth is sufficient only to excite suspicion and not to decide the question. In a few rare cases only one of the upper central incisors is malformed, the other being of natural shape and size. A good instance of this state of things is shown in Fig. 18. In a considerable number of cases of heredito-syphilis the teeth show no devia- tion whatever from the normal standard, and in such the diagnosis must be guided by other conditions. In addition to the peculiar malformations above described and illustrated, there are others which, although less characteristic, are yet very valuable to a trained observer. They do not, however, admit of description with- out great risk of misleading the reader. Before leaving the subject of dental mal- formations, I may again ask attention to the fact, that it is only in the permanent set that any peculiarities are observed. The first set are liable to premature decay, but are not malformed. In addition to the peculiarities of physi- ognomy and the malformations of the teeth, the diagnosis may be much helped by observing the state of the eyes and of the bones. If there be evidences of past iritis, or if there be clouds in the sub- stance of the cornese, the results of past keratitis, or especially if the corneee be now attacked by this peculiar inflamma- tion in its acute stage, very valuable evi- dence will have been obtained. The phe- nomena of syphilitic keratitis in its acute stage are peculiar and easily recognized. Both eyes are usually affected at the same time. The corneal tissue becomes very extensively opaque by the effusion of lymph into its substance. Its tint may vary from that of ground glass to a red salmon color. There are no ulcers oa its surface. A zone of ciliary conges- tion is usually well marked. The patient is often for several months, whilst the dis- ease is at its height, practically blind. The intolerance of light is usually con- siderable. After the inflammation is passed away the cornea usually clears in a most remarkable manner, but it rarely regains such perfect transparency that the experienced observer cannot detect traces of what has taken place. These traces consist in a somewhat dusky and thin sclerotic in the ciliary region, and in the presence of slight clouds here and there in the corneal substance, there being no scars in its surface. The difference be- tween these interstitial clouds and ordi- nary leucomata is easily observed. In a few cases the existence of nodes on various long bones may help us to a diag- nosis, and in others we may obtain aid from finding that the patient has become deaf without otorrhoea, or that he is par- tially amaurotic from choroiditis. With regard to the general arrest of de- velopment in heredito-syphilis, I may re- mark that it is a very untrustworthy indi- cation. In a few cases this taint dwarfs the whole body in a most remarkable manner, but in most cases no retardation of general growth is observable. A pale complexion is most always met with. It is exceedingly rare to meet with a florid good complexion in a young adult who is the subject of this taint. We do, how- ever, every now and then see a physiog- nomy which neither in shape of features nor in color of cheeks and lips furnishes the slightest clue. I have met in one or two instances with arrest of sexual devel- opment. In one of these, a young woman under the care of Dr. Hughlings Jackson in the London Hospital, there was such an entire absence of all sexual character- istics that I could not but suspect that the ovaries had been destroj'ed by syphilitic inflammation in early life, SYMPTOMS IN ACQUIRED AND INHERITED SYPHILIS. 443 Contrasted Parallel between- the Course of Symptoms in Acquired and Inherited Syphilis. I have endeavored in the following tabu- lar statement to place as clearly as I can the resemblances and differences which we observe in the course of symptoms when arising from acquired or from in- herited taint. To some of these I have already incidentally alluded, and respect- ing the others the statements in the table will, I trust, explain themselves : Primary Stage, — Local or stage of inoculation. The sore appears after an incubation period of from ten to twenty-eight days, and if not treated may re- main from a fortnight to six months. Liable to re- lapse. Secondnry Stage. — Constitu- tional or exanthematic. Usually commences within six weeks or two 'months of the inoculation, and if not treated, may last from three to six months or to a year. Essentially transitory, and will disappear without treatment. Intermediate Stage. — Stage of latency and of relapses. This stage may be said to commence at from a year to a year and a half after the contagion, and to ex- tend over a period which may vary from three to five, ten, or even twenty years. Tertiary Stage or stage of sequel SB. This stage commences at from four to ten or to twenty years after the contagion, and extends indefinitely, very often to the end of life. acquired disease. An ulcer (chancre) usually with indurated base. In- durated lymphatic glands. Induration is to be regarded as the earliest proof of successful inoculation, but the latter is sometimes effected without any hardness of the original sore having shown itself. Febrile disturbance, malaise and muscular pains. Slight engorgement of lymphatic glands in many parts. A symmetrical, and usually copious eruption on the skin, and often on exposed mucous surfaces. Symmet- rical ulcers in tonsils. Iritis, retinitis, &o., usually symmetrical. Loss of hair, loss of flesh and of strength. This stage may be either exceedingly slight or very severe. Its severity appears to bear proportion to the degree of induration of the preceding chancre. It is often noticed that the rash comes out in successive crops. The rash may also vary very widely as to its character, roseolous, scaly, papular, pustular, ecthyma- tous, &c., being modified probably by peculiarity — first, in the source of contagion ; secondly in the state of health of the recipient. The patient may be either wholly free from symp- toms and in good health, or he may remain pale and rather feeble, and liable from time to time to slight re- turns of eruption on the skin, sores on the mucous mem- branes, condylomata, &c. He is protected as regards fresh contagion, and should he beget children they are almost certain to suffer. The relapses during this stage are usually easy to be distinguished from true secondary symptoms. There is little or no febrile disturbance, the rash is not copious, and often not synunetrical. Acute iritis, retinitis, &c., never occur; that is, they do not occur for the first time ; they may occur in the form of relapses. All the symptoms in this sta^e occur, as a rule, with- out symmetry; sometimes multiple, but not infrequently single. They consist of chronic inflammations of deep tisslies, or of the deeper layers of superficial ones, e. g. : —Inflammations of periosteum and bone, resulting in nodes ; of cellular tissue, tendon, or muscle, resultmg in gummy tumors ; ulcerative destruction of tlie_ palate and pharynx ; serpiginous ulcerations of the skin ; in- flammation of nerves, or even of cerebro-spinal centres, inducing various forms of paralysis ; deposits in liver, lungs, &c. Probably but little liability to transmit the disease to offspring. Protection against a new conta- gion incomplete. All the inflammations in this stage are remarkably under the influence of treatment by iodide of potassium, but tend to relapse. Unless so treated, all of them tend to progression and permanent disorganization of the part attacked, none of them to spontaneous recovery. 414 CONSTITUTIONAL SYPHILIS. Primary Stage. The infants usually remain without sj'mptoms for from one week to three months. Secondary Stage. — Constitu- tional or exanthematic. Prom the age of two to four weeks to the end of the first year. This stage is essentially tran- sitorj^ and will disappear without treatment, if the child lives. Intermediate Stage. — Stage of latency. This stage extends from the end of the first year or eighteen months to the second dentition, the time of puberty, or even very much later. IXHEEITED DISEASE. This stage has been passed through by one or both of the sufferer's parents within from a few months to twenty years of the infant's birth. The infant is usu- ally free from all symptoms at the time of birth. Inflammation of nasal mucous membrane causing "snuffles." A symmetrical and usually copious eruption on the skin. Wasting ; fretfulness ; a peculiar odor ; a with- ered, senile aspect ; inflammation of the mouth, and condylomata at anuS ; iritis, usually symmetrical ; arachnitis and slight effusion ; disease of liver (rare) ; nodes (very rare). The eruptions which occur differ from those of acquired disease, chiefly in being more moist, and in preferring the thighs and genitals. These differences may in part be due to peculiarities in the skin of young infants, and to the constant irritation from urine to which the nates are liable. Dry scaly rashes are rare. Iritis is much less frequent than in the adult, but just as well characterized when it does occur. In infants this stage often proves fatal. The patient will probably be wholly free from active symptoms, but will show various indications of his dia- thesis in pallor of skin, sunken nose, protuberant fore- head and premature loss of the upper incisor teeth. Sometimes there will be a remarkable retardation of growth and general development. If second dentition have occurred, the central upper incisors will be mal- formed. Unlike what happens during this stage in ac- quired Syphilis, we scarcely ever observe any tendency to recurrence of the secondary symptoms. Now and then we see condylomata at the anus returning during the first five years, but the rash of infantile Syphilis having once disappeared, I think scarcely ever relapses. A certain degree of nasal obstruction sometimes per- but not often. Tertiary Stage or stage of sequelse. This stage may commence with the second dentition, at the time of puberty, or not till much later. Its duration is quite indefi- nite. Most of its symptoms are symmetrical : — Keratitis (interstitial); kerato-iritis; periosteal nodes; cerebral deafness (not infrequent); cerebral blindness (rare); disease of liver and kidneys ; phagedasnie or serpiginous ulcerations of skin ; cellular nodes (rare). Probably not liable to transmit the disease to offspring. Protection against a new contagion incomplete. The symmetry of the symptoms is in marked contrast with what occurs in this stage of acquired disease. The paralyses of single cranial or spinal nerves, so common from acquired Syphilis, are, I believe, never met with, in the inherited form. Most of the inflammations tfnd, unless arrested by treatment, to permanent dis- organization, but one (interstitial kerati- tis) tends to recovery even without treat- ment. They are much less easily influ- enced by treatment than those of the acquired disease. GENERAL DISEASES, OR AFFECTIONS OF THE WHOLE SYSTEM— oo.vrjiviT-^/). § 11.— Those determined by conditm\s existing within the body: SCOEBUTXTS. PUBPUEA. [Chloeosis.] Rickets. [sceofula.] Gout, KHETJMATorD Aetheitis. Rheujiatisji. Goa^OBEHCEAL EUEUMATISH. SCORBUTUS. By Thomas Buzzaed, M.D. Scttett, or Scorbutus, as it is techni- cally called, is a peculiar state of mal- nutrition, supervening gradually upon the continued use of a dietary deficient in fresh vegetable material, and tending to death, after a longer or shorter interval, if the circumstances under which it arose remain unaltered. The condition is essen- tially marked by a dull leaden pallor of complexion; e.Kcessive bodily debility and mental lethargy ; dyspnrea upon slight exertion, unaccounted lor by the auscul- ■ tatory signs ; spontaneous elFusions of blood-colored fluid into the various tissues of the body, causing petechise and bruise- like patches to appear on its surface ; to- gether with (commonly) a livid, swollen, and spongy state of the gums, and a dis- position for them to bleed upon the slight- est irritation. Synontms. — French, .Scorbut; Oerman, Scharbock ; Italian, Scorbuto ; Spanish, Eseorbuto. These terms, as well as the English Scurvy, take their origin from the Danish Skorbeck, ' ' I')isea3e of the mouth, ' ' of which the word ".Scorbutus" is a bar- barous Latinized version. Etiology.— Very much has been writ- ten upon the subject of Scurvy. Long be- fore the disease was styled by the name which it now bears, and when, indeed, it wasoften called the " unknown disorder," Distorians noted its ravages in armies lo- cated, under circumstances of difficulty, in foreign lands, or in garrisons shut off from obtaining supplies of requisite nutri- ment. In the long sea-voyages which the intrepid navigators of the fifteenth and sixteenth centuries commenced, the crews suffered terribly from a disorder which destroyed the lives of large numbers, and afi'ected the working power of the survi- vors in a manner equalled by no other dis- ease. It is probable, indeed, from the records which have come down to us, that Scurvy, either alone or as influencing the severity of accompanying maladies, has proved more destructive to mankind than any other disorder. There is no more interesting fact in the history of medicine than that this condition, which has been looked upon at various times as plague, as a mysterious infliction of Divine justice against which men could only strive in vain, or as a disease inseparable from long voyages, should have been proved, by evidence of the most satisfactory char- acter, to arise from causes in the power of man to prevent, and to be curable by means which every habitable country affords. Scurvy only occurs when fresh vegetable nutriment has been for some time partially or completely withheld. A variety of forms of impaired nutrition will follow the want of other descriptions of food, but this particular condition is only seen as a sequel of that special privation. Scurvy (445) 446 SCORBUTUS. does not occur when the supply of -whole- some and fresh vegetables is abundant, even though the food generally may not be adequate to perfect nutrition. There is a degree of positiveness about these two assertions which can rarely be ventured upon in the etiology of disease. In this case, so abundant and conclusive are the proofs, that to assert less strongly would be to imply a doubt which cannot be al- lowed to exist. The grounds for these statements are to be found in the volumi- nous records of the circumstances under which the disease has occurred, as related by observers, either unbiased by any theory of their own, or widely differing in their opinions as to the cause of the dis- order. They may be said to form the negative side of the argument. The affir- mative is based upon the fact, universally allowed by those largely experienced in the disease, of the power possessed by fresh vegetable material, and by that alone, in removing the disease. It is not our intention t(5 quote at length the records of Scurvy outbreaks, in proof of these assertions. We shall but glance at some of the more prominent instances in recent times, referring the reader for more elaborate details to the vast biblio- graphy published upon the subject by writers of almost every nation. In the exhaustive treatise upon this disease, by Dr. Budd, in the Library of Medicine, will be found a history of Scurvy, which has served more than any other publica- tion to place the disease in its true light, and the views expressed in it have been remarkably confirmed by the experience of the several outbreaks which have oc- curred since it was written. In 1846 the potato crop failed in the United Kingdom. In the autumn, win- ter, and following spring, numerous cases of Scurvy occurred amongst all classes of society. Dr. Christison has described' an outbreak of the disease amongst the labor- ers employed upon the Scotch railways. Their food consisted of bread, salt pork, butter, cheese, coffee, tea, and sugar. "Potatoes were, of course, out of the question. Fresh vegetables were never thought of, and were, indeed, in most places inaccessible." The quantity of food seems to have been sufficient. In the Eoyal Infirmary of Glasgow, 83 cases were admitted. Dr. Eitchie^ writes: " The general fact in regard of the food of all was that it failed in variety, and in the quantity of its animal constituents, and that in all but a fraction of the cases in which they were very deficient, the pa- tients had been exposed for months to a total deprivation of fresh succulent vege- tables." "In Carlisle and its vicinity," ' Edin. Monthly Journal, July, 1847. » Ibid. Dr. Lonsdale informs us," "the persons chiefly afflicted were weavers and their wives and daughters working in the fac- tories, shoemakers, and comparatively few of any other kind of artisans. Bread, oat- meal, treacle in very small quantities, tea and coffee, with an occasional herring, formed their entire food. None had tasted potatoes after the harvest of 1846, or for a period of seven or more months." Dr. Lonsdale states also that in a great number of the huts occupied by the rail- way excavators, amongst whom there were numerous cases of the disease, some of which proved fatal, he saw the men breakfasting off beef-steaks or mutton- chops and bread. The dinner comprised bread, boiled beef or bacon, pea soup or broth, and suet puddings containing cur- rants. The animal food was taken in large quantities ; there were no potatoes or fresh vegetables. At Workington (a seaport town of seven thousand inhabit- ants) the disease did not show itself. Dr. Dickinson, a resident, assigned as a rea- son, " that vegetable food was more abun- dant there than in many situations, par- ticularly turnips, of which large quantities were used." The same kind of evidence is adduced by Dr. Curran" in his description of the occurrence of the disease in Ireland. " In four-fifths of the cases reported to me, bread and tea or coffee was what the pa- tients had been living on when attacked ; the others had been using grains of vari- ous kinds, or grains and flesh or fish ; but in no single instance could I discover that green vegetables or potatoes had formed a part of their regular dietary." Dr. Shap- ter' remarks, in reference to the cases of Scorbutus observed by him in Exeter, that the only difference from the usual diet of the sufferers consisted in the absence of the potato. There is no doubt that the failure in the potato crop, besides depriving the population of this vegetable, incidentally also rendered their nutrition imperfect, by increasing the price of provisions in general. This circumstance might natu- rally, therefore, be believed to bear its part in the causation of this particular morbid condition, were it not that the dis- ease was not confined to the poorer classes of society. Dr. Shapter relates that many of his patients were persons who had ex- perienced no difficulty in procuring an abudance of the necessaries of life, with the exception, however, of potatoes or fresh vegetables. Dr. Christison notes the occurrence of Scurvy amongst railway laborers " earning ample wages, and whose extravagance in good living was a ' Edin. Monthly Journal, August, 1847. ' Dublin Quarterly Journal, 1847. " Lond. Med. Gazette, vol. iv. ETIOLOGY. 4il frequent subject of remark in their neigh- borhood." The allied armies of England, France, Turkey, and Sardinia suHered severely from Scurvy in the Crimea and Asia Minor during the war with Russia, 1854:^ 56. The disease first began to show itself amongst the British troops iu Bulgaria, when they had been living for some months upon an inferior diet, with but a very scanty supply of vegetables. On their arrival in the Crimea, the men found an abundance of grapes, cabbages, &c., which were eagerly consumed ; and al- though the rations in other respects were most imperfect, no cases of the disease were recorded in September. As the winter advanced, however, and the vege- table food ceased, the affection reap- peared. It was no part of the ordinary duty of the Commissariat to supply vege- tables, which did not constitute a part of the soldier's rations. In consequence of representations, a supply of lime-juice was ordered, and arrived by the Esk on the 10th December. By one of those ac- cidents, of which so many lamentable in- stances occurred during the early part of the war, no portion of the juice was issued until the first week in February, 1855, and then the supply was very insufficient. In March nearly all the sick arriving at Scutari from the Crimea were suffering from Scurvy. The total admissions from Scurvy during the war amounted to 2096, but " the returns convey but a faint con- ception of the disastrous part which it acted among the troops, for although it comparatively rarely presented itself in well-defined forms, and as an independent affection, yet the prevalence of scorbutic taint was wide-spread, and in a vast pro- portion of cases evident indications of it existed as a complication of other dis- eases, especially fever and affections of the bowels.'" As the supply of fresh vege- tables and lime-juice became more con- stant, the disease gradually disappeared, and comparatively few cases occurred during the second winter. The sufferings of the French from this cause were proportionally much greater than those of our troops. This must be ascribed to the fact that the distribution of lime-juice formed no part of their prac- tice. In fact, even at the present time, the French authorities do not appreciate at its full the value of this addition to the diet of either soldiers or sailors. No less than 23,000 cases of Scurvy are recorded as occurring amongst the French troops.^ From the month of February, 1855, fresh ' Med. and Surg. Hist, of the British Army, 1858. By Authority. ' Relation Medico-Chirurgioale de la Cam- pagne d'Orient, par le Dr. G. Scrive. Paris, 1857. meat was supplied to them at first twice and then five times a week. It was of good quality, but lean. Tiie supply of bread was irregular, and fresh vegetables formed no part of their rations. Rice was allowed, and occasionally dried vege- tables, principally peas, beans, and lentils, figured in the diet, but in small propor- tions.' There was this which was re- markable in the outbreak : The disease first showed itself in the winter of 1854- 55, and committed terrible ravages. As the season opened and the earth began to bring forth vegetation. Scurvy diminished. The troops were encouraged to collect herbs, and especially dandoUon, which was very plentiful, and of which the effects are highly anti-scorbutic. The improve- ment which took place under these cir- cumstances was very marked, and there is no reason to believe that it would not have been permanent had the supplies continued. But as July approached, the rays of the sun dried up the surface of the ground on which the troops were en- camped, no more dandelion was to be oljtained, and iu the course of three months, the finest and warmest in the j'ear, no less than 5000 cases of Scur\'y occurred. It may be remarked here, in- cidentally, that this outbreak furnishes a striking contradiction to the theory which ascribes the scorbutic condition to the in- fluence of cold and damp. The Sardinian army, which arrived in the Crimea in the earlj' summer of 1855, was very generally affected by Scurvy. Its ravages were checked by vegetables supplied to the troops as the season ad- vanced. It is most probable that the Turks ex- perienced even more severe losses from Scurvy than our other allies ; but, from the imperfect organization of their medi- cal department, exact statistics are want- ing. There is no doubt, however, that the original force which formed part of the expedition from Bulgaria to the Cri- mea was almost entirely swept off by dis- ease, of which Scurvy formed an important element. Of the fresh troops, under the command of Omer Pasha, which rein- forced these men, and which were posted at Eupatoria during the winter of 1854-5, as many as 1000 were sent down monthly to Yarna, all of whom were suffering se- verely from this cause, and a very large number of whom died upon the passage. During the summer the remainder, amounting to about 20,000, were en- camped in the neighborhood of Balak- lava. We had ourselves the opportunity of observing them narrowly. Their food was very imperfect ; but tliey showed in- genuity in availing themselves of such I L'Union M^dicale, 1857, p. 419 : M. Per- 448 SCORBUTUS. fruits and vegetables as were obtainable, and they were supplied witli onions. They consumed, especially, large quanti- ties of watermelons, which were procured from the Tartars inhabiting the country, or from sutlers. No cases of Scurvy fell under our observation at that time, uor could we detect any scorbutic taint in pa- tients suffering from other diseases. In November they quitted the Crimea, and campaigned in Mingrelia. During the winter all supplies of vegetables ceased, and, with the early spring, shiploads of sick were brought to Trebizond, all of whom were severely affected with this disease. Large numbers died upon the sea-passage, in their transit from the shore to the hospital, and soon after their admission. The sick included numerous examples of Scurvy, developed to an ex- tent which recalled the terrible descrip- tions of the disorder contained in the nar- ratives of our early voyagers. Such cases as these were rare amongst the other allied troops. In explanation of this fact, it must be noticed that throughout the winter fresh vegetable food had formed no part of the rations distributed to the Turks, and, superadded to this, was ab- solute starvation, from the absence of food in sufficient quantity. Their diet, indeed, had consisted entirely of biscuit, a little rice, haricot beans, and "yagh," a coarse butter made from mutton fat. Dr. Hammond informs us that, during the recent war in America, no confirmed Scurvy appeared among the Federal forces, but a scorbutic taint often mani- fested itself. He attributed its occurrence to occasional deficiency in the supply of vegetable food, exposure to cold and damp, and mental depression. He did not find that salt meat had any influence in its production. If the men had vege- tables they could eat salt meat with im- punity. Raw potatoes preserved in mo- lasses were commonly issued to the troops, and were found of signal service in pre- venting the disorder. So also on the Confederate side, Dr. Darby, late medical director, in a commu- nication which he has been kind enough to send to us, says, "The type of the dis- ease characterized by petechiee and spongy gums was rarely known in the Confederate army. Diseases and injuries incidental to army life assumed at times a scorbutic taint, at such seasons and under such conditions as give rise to this malady. The abundance of proper supplies in the early stages of the war prevented scor- butic tendencies. In proportion as a de- crease of supplies took place, there was an increase of the scorbutic type in all disease." Since the year 1795, Scurvy, unless un- der very exceptional circumstances, lins been all but aboUshed from the British fleet, and for this the name of Dr. James Lind, ''the father of nautical medicine," deserves to be held in lasting honor. The combined observation of exploring navi- gators had tended to show that the disease could be cured by supplies of fresh vege- tables, and its occurrence prevented by a similar diet. It was reserved for Dr. Lind, in his celebrated work on Scurvy, published in 1753, to give overwhelming proofs of the eflficacy of lime-juice as a prophylactic in this disease, and forty-two years afterwards (!) the Admiralty took the hint. To Captain Cook, especially, science is indebted for a practical exposi- tion of the influence of vegetable food. By providing his crew with abundance of sauer-kraut, and encouraging them to seek wild vegetables wherever he landed, he preserved their health completely dur- ing a four years' voyage of his ship Dis- covery. The same principle, though in the more convenient form of a daily ration of lime-juice, suffices to prevent the dis- ease in the royal navy. The merchant service still, however, continues to fur- nish cases of this preventable disorder. Although the Legislature insists, under a penalty, that lime-juice shall be issued to the crews, the provisions of the Act are but too frequently evaded, and the Dread- nought Hospital still continues to receive annually an average of ninety cases of the disease — about one in twenty-five of all patients admitted.' Practically, in many cases, no lime-juice is furnished ; or a cheap imitation of the juice, consisting of tartaric acid, sugar, and water, flavored with essence of lemon, is substituted. On the other hand, emigrant and convict ves- sels sailing to Australia, being under more complete Government supervision, convey their passengers without loss from the disease. Now, it may be argued against such facts as we have recorded, that inasmuch as these outbreaks of Scurvy have always occurred amongst persons in an unnatural state of existence, in periods of famine, landed with insufficient provision in an enemy's country, or cooped up on board ship in long voyages, there may be some other special privation to which the occur- rence of Scurvy is quite as likely to be ' There is an excelfent article upon the subject by Dr. Barnes in the Sixth Report of the Medical Officer of the Privy Council, 1863. See also an able report by Mr. Harry Leach, resident medical officer to the Dread- nought in a House of Commons' return, "Scur- vy in Merchant Ships," June, 1865. Mr. Leach ascertained by inquiry that of eighty- three Scurvy patients admitted in 1864, forty-two had received bad lime-juice ; eigliteen had had none at all ; fourteen could give no exact account ; and in the case of nine only was good lime-juice declared to have been taken. ETIOLOGY. 449 due. This argument, in fact, has been repeatedly employed, and even at the present time it is still occasionally urged. In opposition to the view which we advo- cate, several causes of Scurvy have been insisted upon by various writers. Some have attributed the disease to the action of some one noxious agent, whilst others, and this is more common, urge that a combination of circumstances is necessary for its production. The point upon which there still exists the most important dif- ference of opinion is regarding the intlii- ence of salt meat. There is no doubt that, in the great majority of Scurvy outbreaks, salt meat has formed an important part of the food taken by the sufferers. But, in order that this circumstance should be possessed of any weight, it would be neces- sary to show that the disease was never known to occur unless this description of food had formed at least a part of the dietary. There is evidence in plenty to the contrary. During the campaign of Louis IX. of Prance, in Egypt, 124:9, the army was frightfully ravaged by Scurvy, of which a inost graphic description is afforded us by the historian.' During Lent, which was very strictly observed, the troops ate no meat, but subsisted "on eel-pouts, which is a gluttonous fish." During the war in Hungarj"-, in 1720, between the Austrians and Turks, many thousands of the former were cut off by Scurvy. Kramer informs us tliat they ate no salt l)eef or pork ; but, on the con- trary, had plenty of fresh meat at a very low price. 2 The French prisoners confined in Si sin 't- hurst Castle, in Kent, in the middle of the last century, suffered mu_'h IVoia Scurvy. They had eaten no salt provis- ions, but had been served daily with fre^h meat and bread.' At the close of the Punjaub campaign of 1848-49, the troops located in the coun- try suffered from the disease. They had abundance of fresh meat and bread, of excellent quality, but no fresh vegetables.'' For some years after stations for troops had been found in the Himalayas, fresh vegetables were not procurable in suffi- cient quantity. Though the soldiers were provided with good fresh meat and bread. Scurvy was not only present, but was at- tended with its full mortality. 5 In the second Burmese war, a detach- ' Histoire de Louis IX. par le Sieur Join- ville. Bohn's Antiquarian Library. ' Dr. Budd, Library of Medicine, art. "Scurvy." ' Philosophical Trans. Sir J. Pringle's Address, 1776. * Med. and Sure;. Hist, of the British Army, 1858. ' Ibid. VOL. I.— 29 ment at Meanday was dieted for several months on fresh beef in unlimited quanti- ties, biscuit, rum, and rice. The men had, however, no fresh vegetables, nor any substitute for them. After thi-ee months. Scurvy made its appearance. Ijinie-juice was procured and issued freely, and the disease rapidly abated.' Dr. Hammond^ describes having seen many cases of Scur\'y among troops who had fresh-meat rations on fovir days in the week, and game of their own procuring on the others. The Turks, as noticed above, in the Mingreliau campaign of 1855-50, had no salt meat, and suffered much more severely from Scurvy than did their French and English allies at a time when the latter were dependent upon it for animal food. So, also, during tlie previous winter, "They fed on good sound biscuit, boiled rice, fresli meat twice or three times a week ; salt meat was unknown amongst them : they wcrr not overworked or idle, and were in excellent spirits at having beaten the enemy ; and yet I found on examination that, on an average, three men out of four on duty in the spring of 1855 were more or less afflicted with Scurvj'. '" In 1836, above one hundred cases of Scurvy occurred in the 75th regiment whilst quartered in Caffreland, at a time when the men had no harassing duties, and were abundantly supplied with rations of good fresh meat, without having had an ounce of salt provisions. They had no vegetables. The Hottentot troops doing duty with them were served with the same rations, but sought out for them- selves pumpkins, melons, some indigenous wild fruits, and esculent roots. They en- tirely escaped an attack, as also ditl the 27th and 72d European regiments, en- camped at a distance of eighteen miles, fed with the same rations, but supplied also, in addition, with vegetables. Cases of Scurvy occur every year in North Wales, where fresh meat and milk are abundant, but where the cottagers rear little or no garden produce. Not only the inhabitants, but visitors, located in the country for a short time, are known to suffer, we are informed, occasionally from this disease. We have ourselves met with many cases of Scurvy amongst the poor of London who had eaten no meat at all for se\'eral weeks, but had lived on tea, bread, and butter.* 1 Dr Crawford, Med. and Surg. Hist, of the British Army, 1S58. 2 Mil. Med. and Surg. Essays, p. 19-- Philadelphia, 1864. 3 Dr. Bird, On Scurvy. Lond. 1858. * See also Dublin Med. Press, vol. xviii. Dr. Bellingham ; " Observations on the Sour- 450 SCOKBUTUS. The occurrence of Scurvj- so frequently, and in such well-dertued form, in cases when salt meat has l}eeu absolutely want- ing in the dietary, is sufflcient to prove that this substance is not a necessary antecedent of the disease, and cannot therefore be properly termed a cause. But it is alleged, sometimes, that it is to the use of salt provisions, combined with the absence of fresh vegetable food, that the disease is owing. If the facts recorded above are insuffluient to negative this view, there are two other circumstances which certainly leave the matter in no doubt : — 1st, There is no case of Scurvy on re- cord, as occurring in a person who has been adequately t-upplied with fresh suc- culent vegetables of good quality. 2d, The occurrence of Scurvy in persons living upon salt meat may be prevented by the regular administration of fresh vegetables, or the juice of lemon. In connection with this subject there is an important point to be considered, as regards the relative rapidity with which Scurvy will appear in persons fed upon fresh meat, or salt meat, or who have had no animal food at all. There is great difficulty in arriving at conclusions upon this point. In the crews of vessels, for example, which have quitted a port during the winter, it often happens that a scor- butic taint has been acquired on shore, and before the men were exposed to the limited dietary of ship life. So also on land, before the supply of vegetables is entirely cut off by the failure of a crop, or by the poverty of the patient, a certain amount continues to be taken, although insufficient for the preservation of health. From these and other causes, reliable sta- tistics as to the exact interval which elapses before Scurvy makes its appear- ance are wanting. The conclusions at which we have arrived, from a careful consideration of recorded outbreaks, as well as from our own jiersonal observation of the disease, are that under a salt-meat diet. Scurvy will appear sooner than when fresh meat has been taken in the ordinary quantity, and that the disease will show itself more rapidly when the patient has been deprived of all animal food than when he has obtained supplies of salt meat. Liebig has shown that the process of salting deprives flesh of a large propor- tion of its most important constituents, so that the remainder is deficient in nutritive properties, and -the altered and hardened character which it acquires renders .even such nourishment as it contains difficult of assimilation. As a result, a diet of salt meat represents only a less degree of vy," by Dr. Mertans ; Phil. Trans, vol. Ixviii. ; Lond. Med. Gazette, vol. iv. Dr. Shapter; Lancet, 1851, p. 619, Dr. Boyd. starvation than the total absence of ani- mal food, and starvation has been agreed universally to intensify Scurvy. Dr. Kane, ' the Arctic explorer, speaks highly of the improvement in strength which took place amongst his crew wlien they succeeded in procuring fresh walrus meat, as a substitute for their salt provisions. He arrived at the conclusion that raw walrus meat was powerfully anti-scorbutic; but his descriptions of the sufferings un- dergone by his party from Scurvy, even when abundantly supplied with this food, fail completely to justify this opinion. Mr. Whymper^ expresses an equally favorable opinion of walrus and seal meat, but the details which he gives are not sufficiently elaborate for the purpose of scientific dis- cussion. It seems most probable that fresh meat of any kind, although satisfac- torily proved by the instances we have recorded to be incapable of preventing Scurvy, will yet, by its powerful nutritive properties, help considerabty to sustain animal strength and retard the develop- ment of scorbutic symptoms. So a man, deprived of all food, and dying of starva- tion, will have life considerably prolonged if he can obtain water. Water, however, we know to represent only a portion of the requirements of man, and to be inca- pable, by itself, of preserving his existence for more than a short period. From the limited variety of food which so often accompanies conditions in which Scurvy has appeared, such as besieged towns, encamped armies, and on board ships in long sea-voyages, monotony of diet has been frequently urged by writers as an important cause of Scurvy. But probably one of the most monotonous diet- aries in the world is that upon which the poor inhabitants of Ireland thrive,' and which consists almost entirely of stirabout, milk, and potatoes. So long as they can obtain this food in sufficient amount. Scurvy is unknown ; but when the mono- tony was broken by the failure in the potato crop, the disease appeared exten- sively. The relation, indeed, which such an al- leged cause, as well as others which have been most insisted upon — namely, cold and damp, idleness, and mental depres- sion — bears to Scurvy, seems to us simply that which obtains generally in modifica- ' U. S. Grinnell Expedition. Second Voy- age. ^ Travel and Adventure in Alaska. U68. ' ' ' The general conditions of these popula- tions, although wearing an aspect of great wretcliedness to English eyes, is not now unfavorable to health. Throughout the coun- try I found them a fine, well-built, and often athletic race, with children sufficiently fleshy and rosy, and bearing all the marks of health."— Dr. E. Smith, Sixth Report of the Medical Officer of the Privi/ Council, 1863. SYMPTOMS. 451 tions of health. The fact that these con- ditions are certainly not essential to its production must exclude them from the category of true causes. That they are frequent concomitants, and hasten as well as intensify the symptoms of the disorder, is just what is seen in many other diseased conditions which, depending upon a spe- cial cause, are yet capable of being injuri- ously influenced by circumstances known to affect the assimilation of food and the consequent nutrition of the animal eco- nomy. Symptoms. — The earliest symptom of Scurvy is a change in the color of the skin, which becomes pale, sallow, or of a green- ish tint, according to the variety of the natural complexion. Succeeding, and in- deed often contemporary witli tliis, is a peculiar listlessness of mind, an aversion to exercise, and a condition, not so much of anxiety as to the state of health, as of indisposition to take any trouble re- garding it. The patient lounges where formerly he has displayed energy in his occupation ; he does not care to speak un- less addressed. In reply to inquiries he will usually complain of flying pains about the limbs and back, which he generally refers to rheumatism. The change of as- pect, where several individuals are ex- posed to the same circumstances, will be noticed by them of each other, whilst the observer is unconscious that he, too, is presenting the same appearance.' Up to a certain period the appetite remains good, and digestion continues tolerably perfect ; usually, however, there is some constipa- tion. There is no fever. Sleep is ob- tained readily enough. It is sometimes described as accompanied by dreams, in which the luxuries of fruits and vege- tables are vividly pictured.^ Gradually petechias are observed, especially about the legs and thighs. They are small, of a reddish-brown color, fading away at the edges, and are especially apt to occur at the points where liairs perforate the skin. They are usually not elevated above the surface. Besides this there may be larger maculae, apparently formed by the convalescence of several petechise, of ir- regular outline, and particularly common about the lowest part of the legs and on the feet. As the disease advances still larger markings will be noticed, so much resembhng bruises as often to be mis- taken for the results of violence. Like tile eruption of variola, they are apt to fix upon weak portions of the frame for tiieir situation, parts where there has been a blow, strain, or other injury some time previously. Accompanying these ex- ' This phenomenon is graphically described liyDr. Kane: U. S. Grinnell Expedition. ' U. S. Grinnell Expedition, p. 267. ternal signs there is breathlessness, for which the ear applied to the chest fails to discover any adequate cause. The ex- pression of the countenance is dejected, or it wears an aspect of indifterence. The lips are pale. By degrees the face as- sumes a bloated appearance. In some cases, however, about this period, the eye and its surroundings are the only parts exhibiting signs of Scurvy. The appearance presented is then very re- markable. The integument around one or both orbits is pufi'ed up into a bruise- colored swelling. The conjunctiva cover- ing the sclerotic is tumid and of a bril- liant red color tliroughout, " about the eighth of an inch in thickness or eleva- tion above the cornea, leaving the cornea at the bottom of a circular trench or well.'" Tliere is nothing inflammatory about this condition ; it resembles very violent ophthalmia in the color presented, but there is no pain or discharge. We have seen many cases in whicli this ap- pearance, togetlier with pallor of the complexion and listlessness, constituted the only evidences of Scurvy, and they have generally been of the most serious character, often terminating fatally. The gums so generally present a remarkable alteration in Scurvy that their condition has been often described by writers as a perfect test of its presence or absence. Our own experience does not correspond with tills, and other observers have re- corded a similar opinion.* All the other phenomena may be present and yet the gums continue in an unaltered condition, except that they are paler than ordinariIj\ But usually, at an early period of the dis- ease, the gums, first of all pale and con- tracted, begin to show a swelling at their free margins. This gradually increases so that the teeth are encroached upon, and eventually, in some cases, almost dis- appear from sight in the huge fleshy masses which encompass them. The swollen gums are then spongy, of a dark- red or livid hue, not sensitive to the touch, and disposed to bleed, sometimes slightly, at others profusely, when irritated. Under these circumstances the teeth become loosened in their sockets, and often fall out. There is a sickening fetid odor from the breath. Tliis is only observed as an accompaniment of the swollen state of the gums, and is evidently due to the sloughing which usually occurs in them. ' Bird, On Scnrvy, p. 38. See also Dublin Medical Press, vol. xviii., a paper by D. Bel- lingham. 2 Dublin Med. Press, Dr. Bellingham ; "Scurvy in Exeter," Dr. Shapter, bond. Med. Gazette, vol. iv. ; L'Union MiSdicale, 1857, p. 419: "Scnrvy in the French Army in the Crimea," M. Perrin; Diet, de Mede- cine, art. " Scorbut" (Paris, 1865), 12th edit. 452 SCORBUTUS. So severe is the affection of the gums in many cases, tluit tleshy massi-s like huge granulations are often seen to protrude between the lips. Chewing is conipk'tely impossible, and there is some diliiculty even in taking fluid nourishment. It is impossible to describe the fearful appear- ance presented by the sufferer under these circumstances. His skin harsh, dry, dirty-looking, and discolored with bruise marks, bloated and puffed up in parts by swellings, his whole manner apathetic and helpless, the condition appears to a novice more irremedialjle than is seen in almost any other disorder. And yet it is re- markable that these cases, where the ex- ternal manifestations of the disease are so strongly marked, are frequently just those ^vhich yield most rapidly and surely to treatment. The change wrought in a few hours by the administration of lemon- juice or vegetables, coupled with general care, is the most extraordinary thing in therapeutics, and of itself furnishes a powerful argument in favor of the cause of Scurvy existing in the absence of such food. Besides the petechise and other larger ecchymoses under the skin which we have described, a most frequent and highly characteristic symptom appears in the oeeurrence of swellings in the flexures of the joints. A favorite seat of this con- dition is the ham. The well between the insertions of the flexor muscles is filled up more or less completely by a mass which is hard, but not so unyielding as to be incapable of pitting on pressure. It requires, however, more force to produce this effect than in (.edematous swelling, and the impression is retained for a longer period. As this swelling increases, the limb is gradually more and more flexed, doubtless because extension, by stretching the skin over the tumor, is attended with great pain. If the effusion occurs, as it most commonly does, in the lower ex- tremities, the patient is unable to walk. A similar swelling is sometimes noticed at the bend of the elbow, and still more frequently beneath the muscles of the jaw. In" the latter position the move- ments of mastication are very painful. Another common seat of such eft'usion is tmder the muscles in front of the tibia, or between the periosteum and that bone where it is subcutaneous. Such tumors have often been mistaken for syphilitic nodes, and mercm-y has been adminis- tered with the result of increasing the scorbutic condition to an alarming extent. It is one of the facts most universally noted, that mercury has a powerfully in- jurious effect in Scurvy. The skin cover- ing such swellings may retain its color or present an ecchymosed aspect according as the subcutaneous areolar tissue is in- vaded or not by the effusion. The breathlessness ■\\hich we have noted as an early symptom in Scurvy be- comes more conflrmed as the disease pro- gresses. On auscultation we find the re- spiratory nnnnnur louder than natural, but otherwise unaffected. It is very fre- quently- accompanied by occasional faint- iugs, especially when the body is made to quit the horizontal posture. These attacks of syncope are highly perilous. It has happened to us on more than one occasion to witness death from this cause. The patient, previously recumbent, has sud- denly sat up in bed to receive our visit, and speedily fallen back in a fainting fit, from which he could not be restored. At Trebizond, notwithstanding that great care was used in the transport of sick from the ships to the hospital, many died whilst being carried up. The danger from faint- ing Is well known in the Dreadnought hospital-ship ; and Mr. Harrj- Leach, the resident medical officer, informs us that no scorbutic patient who is severely affected is allowed to walk up the steps, but is carefully hoisted up the ship's side in a recumbent position. There is an affection of the chest in Scurvy which, especially when the disease occurs during the prevalence of cold and damp, is very apt to be mistaken for pneumonia. Faint rigors, followed by a certain amount of fevcrishness, and accom- panied by lancinating pain in one or both sides, usher in this condition. The pain is felt only in coughing, and a very viscid mucus is expectorated. The dyspncea in- creases, and a constriction as though from a cord bound tightly round the chest is described. Although it occasionally hap- pens that these pulmonary symptoms are dependent upon true inflammation, they are much more commonly associated with effusion of sanguineous fluid into the cavity of the pleura, or into the substance of the lung itself, these structures sharing with every other organ in that tendency to effu- sion which is the dominant feature of Scurvy. When the lung is thus invaded the expectoration after a short time be- comes dark and sanious, with all the hor- rible fetor which is ordinarily associated with gangrene of the lung, but which is here dependent upon decomposition of the bloody fluid poured into the lung sub- stance. There are now cold sweats, in- creasing dyspncea and anxiety, a pulse small and frequent, softer than in inflam- matory pneumonia, ' and death takes place. In other cases there is no pain or cough ; but the breathing rapidly becomes short and laborious, and death occurs suddenly. Auscultatory signs of mischief in the lungs are usually wanting ; but now and then there is localized dulness on percussion, I M. Aug. Haspel, Gazette Medioale. 1650. p. 70. SYMPTOMS. 453 with bronchial breathing. Or mucous rales are heard ; sometimes also gurgling sounds at certain parts of the chest. ' The symptoms of gangrene of the lung, when it occurs, are indistinguishable from those arising from effusion of fluid which be- comes decomposed. The mere occur- rence of very fetid and dark sanguinolent sputa is not necessarily an indication of either condition, as its source may exist in the sloughing and bleeding gums. But constant and increasing oppression of the breath, frequent syncope, and great anxiety point unmistakably to pulmonary mischief ; and cases in which these occur are amongst the most hopeless which are ever encountered. Dulness on percussion may sometimes be noted under circumstances when it probably maybe correctly referred to san- guineous effusions into the muscles of the chest, and unconnected with lung mis- chief. The diaphragm also is sometimes invaded by effusion, and great difficulty of respiration maybe thus produced. It is not usually practicable to distinguish the dyspnoea arising from this condition from that caused by lesion of the pulmo- nary substance, but its significance is not 60 serious, and it will generally subside with rapidity as the scorbutic state is remedied by dietetic treatment. As regards the digestive system, the tongue is usually clean and moist. The color is sometimes red, at others pale, with a violet tinge. It is often large and flabby, showing the teeth-marks at the edges. ^ In the early stages of the disease there is tendency to constipation. Later there is usually more or less of painless diarrhoea, often sanguineous in appear- ance, but unaccompanied by the other symptoms characteristic of dysentery. Scurvy, when it occurs in camps, is so frequently, if not constantly, complicated with the dysenteric diarrhoea which com- monly prevails under those conditions, that disturbances of the digestive system are amongst the most frequent concomi- tants of the disorder. It does not appear, however, that apart from the exciting cause, dysentery is to be considered a symptom of the disease. The dejections usually consist of undigested food, with a quantity of colorless fluid somewhat re- sembling the evacuations of cholera, or they may be accompanied by a consider- able flow of dark blood. The slimy, bright, blood-stained, and offensive fteces of dysentery are wanting, unless that dis- ' Haspel, op. cit ^ There was in general some ptyalism, and then the tongue was indented on its sides, and the swelling of the parotids and of the gums gave the patient the look precisely of a mercurialized person. "—Ritchie On Scorbutus, Edin. Monthly Journal, July, 1847. ease be present as an accidental complica- tion. A fatal result is not unfrequently due to this exhaustive diarrhoea, the pa- tient becoming worn out by the frequent discharges. The intellect of patients suffering from Scurvy is usually remarkably free from impairment. The listlessness, however, to which we have referred above, is con- stantly present, and is sometimes accom- panied by great depression of spirits. As a rule, there is complete coherence of ideas, but we have seen cases occasionally in which symptoms of excitement of a maniacal character were present. Ritchie notes this, and describes also tinnitus aurium, muscfe volitantes, vertigo, and deafness as being occasionally complained of.' In confirmed Scurvy the slightest pres- sure suffices to open the skin and to give rise to an ulcer, whose edges are hard, thick and shining, and the surface fun- goid and bleeding. Its tendency is to increase rapidly in size, and to invade the neighboring structures. An intolerably offensive odor is emitted from it. Ulcers, such as these, will often eat their way into the soft tissues wdth great rapidity, ex- posing and invading large vascular trunks, from which dangerous hemorrhage may occur. Sometimes the disorganization of the fiesh is sufflcientlj' comnlete to expose the bones and produce caries. The lips and nostrils are occasionally the seat of this ulceration, and the patient then pre- sents a ghastly appearance, much like that of an aggravated case of lupus.* The exhaustion attendant upon these spread- ing ulcers is often fatal. Wounds and even slight scratches become invaded by this process. Its influence in cases of frost-bite is most disastrous. An affection of the sight, to which the title hemeralopia (sometimes also nycta- lopia) has been given, is frequently ob- served in Scurvy. In some cases, recorded by Dr. Bryson,^ it was the first symptom of the disease noticed. The patients can distinguish objects well enough during daylight, and even at night can read a book held close to a candle, but the mo- ment they pass from the influence of the light they become absolutely blind, and require to be led about. Mr. G. Lawson informs us that several such cases have fallen under his notice at the Moorfields Hospital, but in none has the ophthalnia- scope revealed any signs of mischief The pupils he finds sometimes dilated and sluggish, in other casos natural. The condition rapidly subsides under an anti- scorbutic regimen. Mr. Soelberg Wells 1 Edin. Monthly Journal, July, 1847. 2 Bird, On Scurvy, p. 9. 3 Ophthal. Hosp. Reports, July, 1859, p. 40. 454 SCORBUTUS. has met with the symptom in cases of great depression of the nervous system, after severe illnesses, and in badly-fed aud cachectic subjects. It sometimes occurs in prisons. "It ought," he writes us, "to be carefully distinguished from that which depends upon retinitis pigmentosa, in which the ophthalmoscopic appearances are most marked, which is not amenable to treatment, and generally leads, sooner or later, to almost, if not complete, bhnd- ness Diagnosis. — In typical cases of Scurvy, and especially when, from circumstances, the occurrence of the disease is probable, the diagnosis is very easy. Tlie dirty pallor and bloated condition of face, re- markable lethargy and indisposition to exertion, ecchj'mosed state of the skin generally, with contraction of the limbs from effusions, and spongy bleeding state of the gums, form a combination of symp- toms which readily distinguishes Scurvy from every other disease. But in the commencement of an outbreak, in spora- dic cases, or when the attack is slight, the nature of the ailment is very often mis- taken. The patients who present them- selves for medical assistance complain of weakness, of pains in the limbs and back which are almost always referred to rheumatism, or of pain in the stomach. They say nothing probably of the state of the skin covering their legs, or of any sponginess of the gums, so that the con- dition of these structures is not perceived by the attendant, who applies himself ac- cordingly to the relief of the symptoms detailed to him by the patient, and the true nature of the case is consequently overlooked. The color of the skin (espe- cially when dirty) in ordinary chlorosis, strongly resembles that of a scorbutic pa- tient, and in such a case there is often a dull heaviness of manner which might tend to mislead an observer. In fact, the early stage of Scurvy is really a form of chlorosis, produced, however, by special circumstances, and remediable only by a correction of these. A careful examina- tion of the skin and gums and the history of the illness will serve to distinguish the conditions. The red and purple spots, livid blotches, and bruise-like stains wliich occur in pur- pura, and closely resemble those found in Scurvy, may possibly cause some hesita- tion in diagnosis. But there is httle dif- ficulty in distinguishing the two disorders. In purpura these appearances often pre- sent themselves suddenly in a patient pre- viously in fair health. This is never the case in Scurvy. The latter disease is always gradual in its progress, and it will be found, on inquiry, that a period of in- creasing pallor, debility, and listle.-sness, preceded the appearance of petechise or blotches. The very peculiar dirty pallor of complexion so characteristic of Scurvy, is absent in purpura. So also is the ten- dency to effusions about the joints, caus- ing contraction of the limbs, and the spongy and bleeding gums. Lastly, the occurrence of purpura is entirely indepen- dent of the defect in diet which produces Scurvy, and it is not cured by fresh vege- table juices. There would never indeed be any diflBculty in the diagnosis of Scurvy but for its comparative rarity, at least in an advanced form, in civilized life. Un- der circumstances of privation, as in win- ter campaigns of armies, Arctic expe- ditions, and the like, the disease is usually expected and recognized as a matter of course. Not so, however, in ordinary civil practice. Amongst the classes which furnish the out-patients to our hospitals, dispensaries, and unions, pallor and de- bility are more often present than absent. E\en bruise-marks from accidental inju- ries are not at all uncommon, so that un- less the possibility of Scurvy be pretty constantly remembered, and the symp- toms be tested by a reference to that dis- order, there is great probability of a num- ber of cases being overlooked. There would be less liability to such errors if the alteration of the gums commonly attracted the patient's attention, and was expressly pointed out to the medical attendant. This very rarely happens. In persons of the class referred to the teeth are rarely or never brushed, and the gums, conse- quently, are often in a more or less un- healthy condition, so that a little addi- tional discomfort in this respect is scarcely regarded. It is considered a trivial mat- ter in comparison with the so-called rheu- matic pains from which they suffer, and and for which alone they ask relief. Were scorbutic patients voluntarily to tender a history of all their symptoms, and the dietetic conditions under which they have been living, there could be little chance of any instructed person, even though he had never seen the disease, coming to a wrong conclusion. But this, it may safely be said, never occurs. The complaints made by the patients of debility and pains in the limbs are just those symptoms of the disorder which are the most likely to be referred to other causes, and it is need- ful, therefore, that the medical attendant should himself institute the inquiries ne- cessary to prove the presence of Scurvy in his patient. This, of course, he fails to do unless an idea of the probable na- ture of the disease has presented itself to his mind. AVe are induced to dwell upon this point from a conviction that there are still many members of the profession who, because no patient has ever consulted them for a swollen and bleeding state of the gums, are under the impression that they have never met with a case of Scurvy PATHOLOGY. 455 — a conclusion, it will be seen, by no means well founded. Pathology. — Great obscurity still in- volves the question of the ultimate cause of Scurvy. That the proximate cause is an alteration in the quality of the lilood, induced by the absence from the ingested food of fresh vegetable juices, is sulH- ciently manifest irom the history of the ' disease. But we are still in the dark upon three points of importance — 1st. What is the essential element con- tained in fresh vegetable material by the deficiency of which in these case.s such re- markable changes are produced V 2d. Is the inliuence of this element ex- erted upon the chemical or the physical quality of tlie blood '? 3d. By what physical law does the blood so altered in quality exhibit such changes in its relation to the tissues ? The essential feature of Scurvy, upon which is based nearly the whole series of organic lesions which takes place, is this — that the relation between the blood flow- ing in the capillaries and the tissues is so altered as to permit of the diversion of some or all of the blood constituents from their natural receptacles into tissues from which they are excluded in a state of health. Beyond this, liowever, there are the cases of fatal syncope, which do not admit of such an explanation. In such instances it would seem, either that the muscular structure of tlie heart is so weak- ened by mal-nutrition as to lose the power of efficient contraction, or, what is still more probable, the phenomenon is due to emboHsm. It is impossible to offer any certain solu- tion to the second and the third questions. Owing to the absence of a perfectly satis- factory mode of analysis of the blood, not only in cases of Scurvy, but in a state of health, no theory can be safely based upon such accounts of the alterations manifest- ed by scorbutic blood as have been pub- lished. The only positive modification that can be detected in tlie blood is a very considerable diminution in its density.' It is quite conceivable that the exudations of sanguineous fluid may depend upon the increased tendency to exosmose which such an alteration would necessarily produce. With regard to the first question, we are able to arrive, principally by a pro- cess of exclusion, at something which probably approaches the truth. We have seen that Scurvy will occur where there is no deficiency in the albuminous, oleagi- nous, or saccharine elements of food, but where there is a want of something which fresh vegetables can alone supply. Fresh lemon-juice may be taken as a convenient ' MM. Becquerel and Rodier, Lancet, 1847, vol. ii. instance of a material which is able to prevent the development of Scurvy, and to cure it if it has already appeared. Lemon-juice contains free citric acid, mu- cus, vegetable albumen, and sugar,' with small quantities of malic acid, and acid salts, especially of potash.^ The only in- gredients which it is necessary to consider attentively in this analysis are citric and malic acid, and potash. The other sub- stances are found abundantly in food which is not anti-scorbutic. In 1848 Dr. Garrod brought forward a very ingenious view of the cause of Scur- vy, wliich has attracted much attention.' From examinations of food under the use of which Scurvy was capable of occurring, he was led to the conclusions, " that in all scorbutic diets potash exists in much smaller quantities than in those which are capable of maintaining health, ' ' and ' ' that all substances proved to act as anti-scor- butics, contain a large amount of potash. " It is, then, to the absence from the food of a requisite amount of potash that he attributes the occurrence of Scurvy, and it is to the presence of potash in lemon- juice that he ascribes tlie anti-scorbutic power of that material. But for his argu- ment to have been complete, the converse of his second proposition should have been true also. It ought to have been shown that all substances largely containing pot- ash are anti-scorbutic. This is not the case. By reference to Dr. Garrod 's table of analysis, we find that one ounce of boiled mutton contains 0"637 grain of pot- ash, whilst one fluidounce of lemon-juice contains but little more, 0'846 grain. So that two ounces of boiled mutton added daily to a dietary under which Scurvy is occurring should be even more efficacious than one ounce of lemon-juice. The nu- merous instances on record (to some ot which we have referred) of fatal .Scurvy occurring in persons abundantly supplied with fresh meat, and on the other liand the indisputable power of lemon-juice in preventing the disorder, are sufficient to disprove this. Again, in the records ot Scurvy disasters on board merchant ves- sels, pea-soup always figures as a most important part of the dietary of the crew. They have often been driven to subsist almost entirely upon this food, owing to the bad quality of the meat. One ounce of peas, according to Dr. Garrod's table, contains 0-529 grain of potash— a large proportion, considering that in an ounce of white flour only O'l grain is found. Yet peas are well known to be utterly useless in the prevention or cure of Scurvy. > Witt. Chem. Soc. Quart. Journal, vii. p. 44. ' Garrod, loc. cit. 3 Edin. Monthly Journal, January, 1S48. 456 SCORBUTUS. The crucial test of administering:; nitrate of potasli to Scurvy patients lias been ap- plied, and found wanting.' Moreover, Dr. J. O. Grant describes the occurrence of Scurvy amongst the Ottawa " lumber- ers" living upon pork salted with nitrate of potash. In one shanty he found twenty-five men out of thirty-six attacked with the disease.'' We are thus led to the conclusion that it is either to the free organic acids which exist in lemon-juice, or to the acid salts, that the efficacy of this material is owing. Now, the influence of the citric acid of commerce in Scurvy is by no means cer- tainly proved. Statements and opinions on this point are very contradictory, but the bulk of evidence is certainly opposed to the utility of citric, as well as of tar- taric and acetic, acid. There seems reason to believe that the bitartrate and citrate of potash have some influence as anti-scorbutics, though their power is cer- tainly far less than that of fresh vegetable juices. It is probable, therefore, that al- though the organic acids and potash sepa- rately do not represent the requisite material, it is to be found in the chemical combination of the acid and base. Very possibly the form in which these salts exist in lemon-juice renders them more easily absorbed and decomposed by the digestive organs than when exhibited separately. The Materia Medica gives numerous analogous examples of the su- perior efficacy of a medicine in its natural combinations.' jSTo artificial imitation of mineral waters is equal to the supply from their natural source. All anti-scorbutic juices contain salts of citric, tartaric, or malic acids, and we have no evidence of any substances which contain these mate- rials in considerable quantity, and are yet deficient in the power of preventing Scurvy. The mode by which they act is still involved in obscurity. Morbid Axatomy. — The body of a patient who has died of Scurv}- is gene- rally emaciated, but this is by no means always the case. Where the diet has Ix-en absolutely deficient, or of such a nature that its mastication was almost impossible from the condition of the gums, there is much wasting. But Scurvy, as we have seen, may occur when there has been not only no lack of food, but the nutriment has been of a kind easily taken by the patient, although from its quality it has not been able to prevent the dis- ease. Under such circumstances the ' See Med. Times and Gazette, vol. xx, Dr. Murray; Med. Times, March 23, 1850, Dr. Bryson, R. N. ' Med. Times and Gazette, DecemTjer 26, 1863. 2 Parkes, quoted by Aitken. general bulk and weight of the body are preserved, whilst the tissues are found to present the appearances characteristic of the disorder. Externally, the body presents the same general aspect as was observed during life. Decomposition is more than ordi- narily rapid. The extremities are usually rigid. Blood is sometimes observed to flow from the mucous passages. Blood, or fibrinous effusion, more or less strongly blood-colored, is found extravasated under the skin, into the subcutaneous areolar tissue, and into the aponeurotic sheaths of the muscles, sometimes bruising and breaking the muscular fibres. The lower extremities, and especially the hams, are generally the most severely affected, but the same conditii. (From Green.) in the coagula, and their nuclei undergoing enlargement and proliferation. Doichler some years since reported an observation of "knots or buckles" of minute arterial branches in masses of tubercle ; their walls softening as the cells increase in number. Aneurismal distension of the walls of the pulmonary capillaries has [' London Medical Record, June 15, 1878.] A firm Gray Tubercle from the Lun? in a case of acute Tuberculosis. Showing the grouping of the elements around separate centres, tho nodule consisting of several giant-cell eystems. X 33- (From Green.) of equally competent observers, made but a few years since. To resume : we may classify the distinctive opinions concerning the nature of tubercle as follows : 1, that it is an exudation (Eokitansky, An- cell, Bennett); 2, an organized neo- plasm ("VVedl, Vogel, Virchow); 3, a degeneration of tissue elements (Henle, Reinhardt, Van der Kolk, Radclyffe Hall) ; 4, a specific in- fection (Villemin, Colin, Schiippel, Green') ; 5, an abortive formation of tissue, followed by degeneration, from defect of vital energy (Wil- liams, Ziegler," Sir J. Clarke, J. Hutchinson, Aitken, G. B. Wood.) Although Prof. J. Hughes Bennett has expressly designated tubercle as an exudation, he has contributed much towards the establishment of the dependence of its origin upon a defect or perversion of nutrition; which corresponds very nearly with the last named of the above views concerning its nature. That tubercle often does occur in coincidence with local inflammation, and thus immediately in, and, in a sense, from [' Virchow's Arohiv, 1862, p. 183.] [2 Science and Practice of Medicine, vol. ii. Phila. edition, p. 238.] [3 Infective, at least, according to Green, though not specific. See his "Pathology and Path. Anatomy," Phila. edition, p. 184.] [* Deutsche Zeitschr. f. pract. Med., 1874, No. 5.] CAUSATION. 507 inflammatory exudation, is certain. But we hav; already seen reason for dissenting from the views of Niemeyer, Oppolzer', and otliers, that Tuberculosis always fol- lows and depends upon inflammation. It may be deposited, as Latnnec taught, in the lungs or elsewhere, prior to all in- flammatory changes. Against the "neoplastic" view, not much need be said at this time. Tubercle is the pathological opposite of cancer. While, in the Litter, there is a perverted, misdirected excess of formative action, in Tuberculosis all the phenomena exhibit deficiency of histogenetic energy. Nothing is more marked than the absence of vascu- larity in every tuberculous mass. The reverse is true of cancer. That a degeneration of already formed tissue-elements takes place as a part of the tubercular process, is clearly true. But it would appear that this is not the central, characteristic fact concerning it ; and only a portion of the appearances pre- sented by its morbid anatomy can be thus accounted for. . The hypothesis of a specific vims of in- fection has been overthrown by the care- ful investigations of Lebert, Trankel, Burden Sanderson, and Wilson Fox. Buhl's "resorptive" theory is well dis- posed of by Birch-Hirschfeld,' as "ana- tomically improbable, and never demon- strated." It is certainly not impossible that, when the lymph-glands are in an unhealthy state, corpuscles may pass from them into the circulation, then accumu- lating in the lungs or elsewhere, and pro- ducing obstructive disease. But it is at least equally probable, when a constitu- tional predisposition has been shown to lie behind the one local mal-nutrition, that it should also account for the other, especially as the order of succession of the two is variable, and many instances occur of each taking place without the other. It remains, then, for me to express the conviction, that the essence of Scrofulosis or Tuberculosis consists in a defect of tissue- forming power ; showing itself most con- spicuously in the organs of assimilation (digestive organs and lymph-glands), in those of most active chemical change (the lungs, skin, and mucous membranes), and iu those of least vital resistance (bones and joints) on account of their minimum of vascular supply. Even in the absence of inflammatory irritation, these organs may be subject to tissue-abortion, constituting tubercular deposit. But, in the scrofu- lous subject, a special vulnerability is pre- sent, so that slight causes induce inflam- mation, which is low in activity and prolonged in duration, " strumous inflam- mation." Degeneration of the products of this morbid process, with that also of [' Ziemssen's Cyclopaedia, loc. oit.] the tissue-elements afl'ectcd, causes that conglomerate of pathological deforma- tions, whose description and explanation have been the theme of so much debate. Causation.— As an account of the etiology of phthisis is given in the article by Dr. J. Hughes Bennett upon that dis- ease (Vol. II.), a brief summary only is here needful concerning that of general Scrofulosis. Ilcnditary predisposition is universally believed to be a principal factor in the production of all varieties of Scrofula. Every physician must know instances of its occurring in several members of the same family, in successive generations. Yet statistics show that very many cases, especially of pulmonary Tuberculosis, are non-hereditary. Dr. Pollock,' amongst 1200 cases of phthisis, ascertained it to be hereditary in 30-16 per cent. Notwith- standing our acceptance of the view that Scrofula, affecting the skin, glands, mu- cous membranes, and bones, is, constitu- tionally, identical with phthisis pulmon- alis, it cannot be denied or ignored that many children suffering with the former grow up and Ave long lives without laps- ing into the latter ; while many persons die in adult life with phthisis who never had glandular enlargement or other signs of Scrofula during childhood or youth. In promoting the tendency to heredi- tary Scrofulosis, impairment of the health of parents, from any cause, is undoubtedly important. Syphilis has long been be- lieved to bear, in tliis way, a close relation to Scrofula. Some have even asserted the latter to be, so to speak, a descendant, with modification, of the former. Kor- tum, near the end of the eighteeulh cen- tury, vigorously opposed this doctrine ; which is now nowhere maintained. The relation between the two is, clearly, only that belonging to the enfeeblement of vital energy brought on by Syphilis, in common with all other protracted constitutional diseases. Smallpox has been charged with a simi- lar promotive power. Before the time of Jenner, this was, there is reason to be- lieve, largely shown. Dr. Greenhow re- ports that ''during the middle of the last century, before vaccination was known, the scrofulous death-rate was more than five times as great as our present one. " Of course other sanitary improvements may have contributed to this result. Intemperance must be supposed to act unfavorably in preparing the way for every vice of constitution. But it has not been shown to promote Scrofula, in the children of drunkards, so much as it does disorders of the brain and nervous system. [' Second Report of Hospital for Consump- tion, Brompton, 1863.] 508 SCROFULA. Consanguineous marriages are com- monly tliought to favor Scrofulosis in tlie offspring of parents nearly related. Wliether this is really the case when no family taint had previously existed, has been much disputed. At least it is true that such a taint is aggravated, and is more likely to be manifested, in those who issue from parents of the same stock. If two scrofulous per- sons marry, whether blood-relations or not, the probability of an inheritance of the predisposition by their children is four times as great as if only one of the two were scrofulous and the other of a faultless constitution. At least this fol- lows from the assumption, apparently well grounded, that the mingling of "pure blood" in marriage with that which is tainted, tends to subtract from, or an- tagonize, the morbid procreative influence. Climate is more important, apparently, in regard to the prevalence of pulmonary than of glandular Scrofulosis. The sta- tistics of the United States show that the Northern States have more deaths from consumption than the Southern ; but there is no evidence that so great a differ- ence exists in the comparative prevalence of general Scrofula. Probably, however, while no race nor climate is free from it, the artificial conditions of life induced by the need of protection from cold, in the higher latitudes, make all forms of Scro- fula more common, especially in cities, in the temperate and cold than in tropical regions. Change of climate, from a warmer to a colder one, has undoubtedly an effect, in many cases, in promoting Tuberculosis. This is seen in the Negro race, especially, when transported to a northern country. Monkeys, taken to England, not unfre- quently die of consumption. AH domestic animals, however, are liable, much more than the same in the wild state, to tuber- cular disease. This has been abundantly shown to be the case with the cow, when confined in the stable ; also with the sheep and the rabbit. Animals naturally wild and active in their habits, as the lion, tiger, elephant, &c., often die of tubercu- lous disease when confined in menageries. This appears to be irrespective of climate, depending upon the unnatural change in their mode of life. Dampness of locality has been shown, most fully by Dr. Bowditch in this coun- try, and Dr. Buchanan in Great Britain, to ikvor Tuberculosis. A. Keith Johnson recorded the statistical fact that, in the cities of Europe, the mortality from con- sumption is in direct proportion to the nearness of a locality to the level of the sea. This general law has been approxi- mately confirmed in America. Habitually breathing foul air, made so by confinement of persons together in ill- ventilated factories, workshops, and dwell- ings, is a potent agency in generating Scrofulosis. This cause is aided, no doubt, by the exclusion of sunlight ; as among those who work and live in mines. Bau- delocque, Carmichael, Arnott, MacCor- mac, and Parkes are among those who have especially forwarded the demonstra- tion of this practically momentous fact. Nothing could be more cogent in this re- spect than Dr. Parkes's exposition of the excessive mortality from consumption of British soldiers, living in barracks, in various parts of the world. Poverty promotes Scrofula, by almost compelling close habits of living, in cold regions. Also, it involves another very serious cause of vital depression, namely, deficiency of food. Prof. Bennett has em- phasized this as perhaps the most influen- tial of all the causes of Tuberculosis. Impropriety of food for children, amongst ignorant people, whether poor or not, acts, evidently, in a similar manner. Dr. Tanner states" that during the cotton famine in Lancashire, in 1862-63, the mortality of infants among the manufac- turing population diminished greatly. The mothers, who, when at work, ne- glected their children, being then unem- ployed, attended to feeding them in the natural manner ; and could less afford, moreover, to stuff them with unsuitable food. Birch-Hirschfeld ^ cites the state- ment of Huss, that Scrofulosis is very fre- quent in Schonen, the richest province of Sweden, where infants, almost as soon as they are born, are fed on coffee, sour bread, and potatoes. The same author asserts that a similar condition of things occurs in thrifty districts of Bavaria, Saxony, &c. An inquiry is alluded to by Birch- Hirschfeld, in regard to the possibility of the generation of tubercle in human sub- jects by their being fed with milk from cows having the pearl disease. Schiippel is considered to have shown the identity of this affection with Tuberculosis. Gerlach, Klebs, Chauveau, and others,' have found it possible to produce tubercu- lization in animals by feeding them on such milk. The pearl disease is not un- common amongst cattle in many places. It is, therefore, a not unimportant ques- tion, whether there is any proportion, in such localities, between tlie prevalence of pearl disease in milk cows and Tubercu- losis in human beings. At present, there seems to be no actual proof of the occur- rence of such a coincidence or result. Insufficiency of clothing is another of the [' Practice of Medicine, Phila. ed., p. 109.] \} Ziemssen's Cyclop., loc. oit.] [' Bollinger, on Tuberculosis by Inocula- tion and Feeding. Arch. f. exp. Pharm. und Pathol., vol. i. Nos. 4 and 5, 1873.] TRKATMENT. 509 means by which the poor are often, in the colder climates, made to underco depres- sion of vital power, promotive ot Scrofula. Prevention of the healthy action of the skin must Impede the removal of impuri- ties from the blood. The action of cold, too, interferes with the regularity and balance of the circulation, not only of the blood, but also of the lymph and chyle. Thus both the glands and the lungs are made vulnerable, and the whole system suffers damage to its recuperative ca- pacity. Treatjiekt. — This must be adapted, first, to the constitutional cachexia ; and, secondly, to the local disorders present. A tuberculous mother is not likely to furnish perfect nutriment to her infant from her own breast. Many authors ad- vise, therefore, that such should never suckle their offspring. This counsel is judicious, if an alto- gether healthy and reliable wet-nurse can be obtained. If not, it may be best for the mother, when her milk is abun- dant, to nurse the child through the ear- lier months of infancy, and then gradu- ally to wean it. Much experience shows that even very feeble women often give the best of their substance to their babes, which thrive upon it while the mothers waste. When it is weaned, cow's or goat's milk, little if at all diluted, is the nourishment to be preferred for the infant. Care is needful that solid food be not given too soon, and unsuitable, indigestible articles never. If the child's appetite be poor, and especially if it rejects milk, concen- trated animal food, as beef-tea, should be afforded to it. The indication for a highly nitrogenized diet is never more clear at any time of life, or in any con- dition, than in a growing infant whose powers of assimilation are low. Fatty food, moreover, as we have already seen, is especially pointed out as desirable for the scrofulous in early life. Cream and good sound butter are its most available examples ; but beef and (more doubtfully) mutton gravy are sometimes also accepta- ble and useful. Fresh air is a cardinal requirement in the hygiene of those having the tubercu- lous predisposition. The country will be, for them, better than the town, and active out-of-door interests and pursuits better than those which are sedentary. Too long confinement in the nursery or school, or, worst of all, the workshop, factory, or mine, may entail the doom of early death or lingering disease upon those whom the life of the harvest-field or the mountain-side might have made robust and of good lon- gevity. Bathing is another hygienic measure of much prophylactic value. During in- fancy, tepid bathing is usually the best ; reaction against cold being then uncertain or imperfect. Later, as resistance is shown to increase, moderately cold or cool water, especially by the shower-bath, or salt water, as of the ocean surf, may be used. But the notion of hardening deli- cate children by severe exposure of any kind, is a mistaken one, fraught with danger. It is only such degrees of cold as can be fully overcome by the natural calorific processes of the body, that are ever salu- tary. Clothing, for scrofulous children, or persons of any age, ought to be suffi- cient to protect the body, and, most of all, the chest and the feet, against ever being chilled. In a climate of extreme and sudden changes, like that of the Northern United States, such persons should wear ttamiel througli the whole year ; lighter in summer, and heavier in the winter, spring, and autumn. The protection afforded by silk next to the skin is probably quite as great, against vicissitudes ; but the stimu- lus of flannel to the circulation of the skin, and its absorbent porosity, are advan- tages. Careful avoidance of dampness of dwellings and localities, is, of course, of great consequence. Of medicines believed to be anti-scrofu- lous, iodine was, thirty or forty years ago, the most trusted. Lugol's essays on the effects of iodine in Scrofula were trans- lated from the French and published in London in 1831. "Lugol's Solution" be- came the standard remedy, for a long time, for Scrofula as well as for goitre. Its external use for tumors of all kinds was mucli relied upon. Like other over- rated medicines, it has now fallen into undeserved neglect. Iodide of potassium, however, holds its place in the treatment of many disorders, especially constitu- tional syphilis ; but it is seldom mentioned by authors at the present day in connec- tion with Scrofula or Tuberculosis. Chloride of calcium and chloride of barium have both been advocated by a few practitioners, as having anti-strumous power. In consumption, particularly, the phosphate and hypophosphite of calcium have been much lauded and largely used. Dr. Churchill, of Paris, attracted general attention to this medication about twenty years ago. Dr. W. Minor Logan, of Cin- cinnati, has emphasized the significance of the well-known pathological fact, that phosphate of calcium is always present in tubercular deposits in large amount. The result of the trial of the phosphates and hypophosphites by the profession has been their failure to sustain general confidence in their value in Tuberculosis. My own use of them in the treatment of consump- tive patients in the Episcopal Hospital of Philadelphia, some years ago, as well as in private practice, has convinced me that 510 SCEOFCLA. they cannot, at all events, compare with cod-liver oil in analeptic power. Dr. W. M. Logan reports a number of cures of phthisis by the use of nitric acid internally (30 or 40 drop doses) after meals, with tincture of chloride of iron ; alonjr with suitable hygienic measures. Cod-hver oil, which had been for a long time a common remedy for chronic rheu- I matism, in the coast-regions of German}-, Holland, and Great Britain, came into ' use for consumption first in Germany, be- tween 183U and 1S40. The introduction of it to the knowledge of the profession in Germany is credited especially to Schuette ; in Great Britain to Percival, Donovan, and Hughes Bennett ; in America to G. B. Wood. Its value in the treatment of phthisis has been placed beyond doubt ; and no one has so well expounded the ra- tionale of its analeptic action as Prof. J. Hughes Bennett.' Numerous other remedies have had a temporary reputation in the general treat- ment of different forms of Tuberculosis. One more may be mentioned : koumiss, a fermented drink made from mare's or cow's milk, used of late years by the physicians of Russia. Eeferring to the article by Dr. Bennett on Phthisis (Vol. II. ) for the special therapeutic^ of that nialadj', our attention may be given now, in part retrospectively, to the treatment of other forms of .Scrofulous disease. Iodine has certainly disappointed the hopes of many of those who have used it, both internally and externally, with the hope of its dissipating' glandular or other tumors. Yet it would seem reasonable, from the evidence accumulated, to employ it in moderate doses, especially the iodide of iron, in the early treatment of scrofu- lous glands. Externally, in tincture or ointment, it appears to act simply as a stimulant to the circulation of the part, without other specific effect. Indeed, the expectation of finding any spedflc against Scrofula has now very much passed away. If scriifulous glands are inflamed, they may be treated like other local inflamma- tions ; seldom with the prolonged applica- tion of cold, as the "phlogosis" is not apt to be intense ; but with soothing poultices of bread, slipperj'-elm bark, or flaxseed meah In all strumous inflammations, of the glands, conjunctiva, and bones, I have bec'ime convinced that the local application of carbonate of lead is more ser-\iceable than it is in other inflamma- torj- afiections. It is best applied in the forin of an unguent, made by adding two drachms of the carbonate to an ounce of simple cerate. Cod-liver oil has not shown any remark- able power in removing glandular tumors. Its recuperative influence, however, in all [I Vol. II. loc. cit.] states of defective nutrition, gives reason for employing it in general Scrofulosis. It certainly does good in cases of caries, ire. , of the bones. Children dislike it less, proportionally, than adults. Beginning with small doses, they may be increased, until a child of ten years of age may take two tablespoonfuls or more in a day. Iron is indicated, particularly in the feebler cases of Scrofulosis. The B3-rup of the iodide, already mentioned ; or Blan- card's pills ; or the citrate, lactate, pyro- phosphate, or other chalybeate prepara- tions may be used. It should be remem- bered (as mentioned in the article on Chlorosis) that iron will not always agree well, even with anaemic patients. Head- ache and indigestion, and sometimes feverish symptoms, will, in such cases, show that the dose is too large, or that it had better be withdrawn for a time. The measures of local treatment of scrofulous otitis and otorrhoea, as well as of ophthalmia, ostitis, and periostitis, fungous arthritis of the knee, coxalgia, and Pott's disease of the spine, are, in detail, most appropriate!}' set forth in works on Surgerj', general and special A few suggestions only, from the stand- point of the medical practitioner, will be in place here. Scrofulous inflammation, in any part, undoubtecllj- requires and bears less active depletory treatment than that of any other type. Leeching inflamed strumous glands, for instance, is rarely to be thought of ; and local abstraction of blood is only likely to do good in a few cases of scro- fulous inflammation of the ears, ej-es, bones, or joints. Emolhent applications are, in the early stages, usually the most suitable. For continued discharge from the ear, lime-water (poured into the ear, gently, rather than injected with a sy- ringe) i« an excellent appUcation. Solu- tion of Castile soap ; gljxerin and rose- water (one part in five) ; and, if the discharge be copious and obstinate, solu- tion of acetate of lead (one or two grains in the ounce of water), are among the lotions available in this complaint. For an attack of earache, a drop or two of laudanum, with two or three drops of olive or almond oil, or glycerin, may be : poured into the ear. j LeaA-ing strumous ophthalmia to the ! surgeon and oculist for particulars of treatment, mention may be made of my own experience of the benefit obtained from the nightly application of cerate of carbonate of lead on the outside of the eyelids, upper and lower ; this treatment i being persevered with for a considerable : time. "WTiite precipitate ointment is an old application, and a favorite with many physicians, in similar cases. I in scrofulous periostitis of the tibia, I I have been in several cases surprised with TREATMENT. 511 the improvement following the free appli- cation of the cerate of carbonate of lead, attended in more than one instance by the subsidence of the swelling, tender- ness, and pain, which, in the same pa- tients, had on previous occasions heralded prolonged troubles, with caries and ne- crosis. In one case of "cold abscess" of the hypogastric region, attended with febrile symptoms, the application of the lead cerate freely over the abdomen was fol- lowed by recovery in about three weeks from the commencement of the treatment. Surgical management of these aljsccsses need not be here discussed ; but reference may be made to Lister's assertion of the safety and advantage of opening them freely in many cases, using the antiseptic method of operation and subsequent dressing." For coxalgia, the treatment by pro- longed rest, by aid of a car\'ed splint, is associated in American practice with the name of Dr. Playsick, of Philadelphia. Dr. Henry G. Davis, of New York, claims, apparently with reason, to have been the first ^ to add an important principle to this, in the management of all chronic in- flammations of joints, namelj', the removal of pressure through separation of the ends of the bones, by extension of the limb, or other part affected. Elastic extending bands serve an excellent purpose here ; and not only great relief of suffering, but cures, otherwise improbable, have been obtained by skilfully constructed and watchfully used apparatus. Dr. L. A. Sayre, of New York, has made known to the profession, within a few years, his successful application of this principle in the treatment of Pott's disease of the spine, by a suspending ap- paratus and "plaster jacket." Dr. B. Lee, of Philadelphia, and others, use a porous felt jacket instead. For chronic arthritis of the knee, wrist, &o.. Trousseau and Dieulafoy have in- sisted on the great value of the prolonged application of cataplasms. Trousseau's cataplasm is made by preparing a poul- tice of soaked and steamed bread of a _'' plum pudding" consistence, over which is spread a liquid mixture, composed of seven parts of camphor, five parts each of extract of opium and extract of bella- donna, and alcohol q. s. This is appUed to the joint, covered with oiled silk, and se- cured by a flannel bandage over the whole joint, over which is bound a calico band- age of the same length. It is intended to he left on for eight or ten days at a time. Returning to Scrofulosis of the glands, [' Med. Times and Gazette, Nov. 1878.] [' Boston Med. and Surgical Journal, Au- gust, 1852.] mucous membranes, and bones, the ad- vantageous effect of soft soap upon glandu- lar tumors has been asserted by Kapesser ;' in two cases their disappearance resulting, followed by rapid recovery also from strumous ophthalmia. Dr. J. Moleschott, of Turin,= after an expurience with it of many years, has re- ported that iodoform exhibits remarkable power in promoting the removal of scrofu- lous glandular enlargements, as well as of other accumulations of "formative ele- ments and exuded fluid." He prefers the application with a brush at nii^'ht, or night and morning, of a combination of one part of iodoform with fifteen of elastic collodion, or an ointment of the same strength.^ Lastl}-, allusion must be made to the benefit often obtained from massage, with inunction, in the management of general Scrofulosis. Massage alone, while no doubt sometimes beneficial in various conditions of debility, has been, in some quarters, overrated and overdone. But S3-stematic inunction of the whole body, in like states of torpor and debility, has not received full justice on the part of the profession. The wisdom of the ancients has, in this, been too little esteemed. "While it is true that no large amount of oleaginous material is absorbed through the skin, experience shows that the dispo- sition to excessive waste is thereby les- sened ; and this is no small part of the pathogeny of advanced or advancing scrofulous disease. Diminution of general irritabilitj' of the system is also thus pro- moted. Simpson, Inman, E. Wilson, W. Taylor, and other British writers have favored this practice ; as well as W. R. Fisher, W. H. Thompson, E. C. Ansell, and others in this country.^ Dr. S. Weir Mitchell, who strenuously advocates mas- sage in cases of nervous debility, encour- ages inunction with cocoa oil or vaseline.* For scrofulous patients, as well as others, olive or cocoa oil may be recommended ; although, but for its odor and comparative cost, the preference might be awarded to cod-liver oil.] [' Berliner Klinische Wochensclirift, Feb. 11, 1ST8.] [2 Giornale della Reale Accademiadi Torino; cited in London Medical Record, Nov. 15, 187S.] [' The odor of iodoform is somewhat un- pleasant ; but, if used only at night, it can be removed by soap and water in the morn- ing. Its preparations should be protected from the light, wliich causes their decompo- sition.] [< See the Sanitarian, New York, Novem- ber. 1878.] [5 Fat and Blood, and How to Make Them. Phila., 1877, p. 54.] 512 GOUT. GOUT. By Alfred Baring Garrod, M.D., F.R.S. Definition. — 1. Regular Gout. — A spe- cific form of articular intlamination inva- riably accompanied with uric acid in the blood, and the deposition of urate of soda in the affected tissues. 2. Irregular Gout. — (a) The same spe- cific inflammation of non-articular tissues, or (Jo) disturbance of the functions of vari- ous organs, accompanied witli the same abnormal state of the blood. Synonyms.— Of Begular Gout. — Poda- gra (jtoiJf, the foot, and tiypa, a seizure) ; Chiragra (x^lp, the hand) ; Gonagra (ywu, the knee) : the first only of these syno- nyms has been much employed. Arthri- tis (dpSpoi/, a joint), a term used for general gout by the ancients, has been applied also to other joint afl'ections by both ancient and modern writers: Goutte, French; Gutta, Latin; Gota, Spanish; Gicht, Ger- man; terms probably derived from the idea of the dropping (Gutta, a drop) of a morbid fluid into the joints — first used in the thirteenth century by Radulphus. Of different forms of Irregular Gout. — Non-articular Gout, Anomalous Gout ; Podagra larvata, Goutte larvee, Goutte vague ; Misplaced Gout, Ketrocedent Gout. History. — Gout was well known to Hippocrates, and his account of the dis- ease shows that he was well acquainted with many of its salient phenomena ; his remarks upon the seasons of the year at which it is most likely to occur, the sub- jects which it more commonly attacks, the alterations in structures it induces, the probable nature of the malady, and the difficulties experienced in effecting its cure, are well worthy of careful study. Prom the time of Hippocrates almost every ancient writer on medicine has made reference to the subject of Gout. Galen speaks of the difference between the times in which he lived and those of Hippocrates, in respect to the character of the subjects aflilicted with Gout. Seneca also alludes to the same topic; and ac- counts of the disease, more or less com- plete, may be found in the writings of Cel- sus, Aretseus, Coelius Aurelianus, Alex- ander Trallianus, Aetius, Paulus ^gineta, Demetrius Pepagomenos, and others. Nearly all these authors were humoralists, and of opinion that the disease depended upon the retention of certain matters in the blood (as bile, phlegm, &c.), caused by imperfect digestion or deficient excre- tion ; and that these humors, or even the diseased blood itself, were thrown upon the textures of the joints, and thus gave rise to the production of inflammation, and the frequent formation of tophi, or chalk- sto)ies. Divisions and Classification of Gout. — It is stated in the definition that Gout may manifest itself, simply, in the form of in- flammation of one or more joints, or as inflammation of some non-articular struc- ture ; or by causing an alteration in the functions of certain organs ; and these latter manifestations may either be inde- pendent of, or accompany the articular affection. AVhen the joints are solely or princi- pally involved, the disease may be conve- niently designated regular or articular Gout, which may be either acute or chronic; but when severe affections of in- ternal organs ensue, or when inflamma- tion of tissues, other than those pertain- ing to the joints, arises from the presence of Gout, tliese affections are known by the name of irregular or non-articular Gout. The whole phenomena of the disease can be conveniently discussed under these two heads. Description of an Attack of Acide Gout, and of the Progress of the Disease. — Under this heading will be included first a sketch of an early and uncomplicated attack of Gout, as ordinarily met with in practice ; next, an account of the progress of the disease when unchecked by hygienic or medicinal means ; and this task being ac- complished an analysis will be made of the different symptoms exhibited during the paroxysm, and of any structural al- teration caused by it. In many instances the first attack of articular Gout comes on without previous warning ; or, if there be premonitory symptoms, they are so slight as to pass unnoticed by the patient. This absence of warning, however, is by no means so common as is usually supposed, and I have met with several cases in which the premonitory symptoms have been very distressing ; although before the seizure they were not suspected of being the precursors of any joint affection. Under ordinary circumstances, an indi- vidual retires to rest in his usual health, but early in the morning, usually from IIISTOIIY. 513 two to five, awakes with an uneasy feel- ing, probably conflned to one of his great toes ; on attempting to place his foot on the ground, he finds himself unable to support the weight of his body, or, if capa- ble of so doing, the act is accompanied with great pain. • If the painful part, generally the ball of the toe, be examined, it is found to be swollen, red, hot, and exquisitely tender, and sometimes to such an extent that the mere weight of the bed-clothes is intolera- ble, and even the vibration of the room causes discomfort. The veins proceeding from the toe are turgid with blood, and the joint stiff. Although occasionally no constitutional disturbance is present, yet more frequently there is evidence of slight fever ; the patient has a feeling of chilli- ness, followed by heat of skin and perspi- ration, some thirst and loss of appetite, a white tongue, and conflned bowels, with great restlessness, and is unable to find an easy position. The urine is usually small in quantity, high-colored, and de- posits, on cooling, a sediment varying in color from pale buff to brick-dust red ; occasionally when febrile disturbance runs high the fur which encrusts the vessel is of intense pink color ; cramps of the legs are often present during an attack, and add much to the sufferings of the patient. If moderate precautions are taken, and the foot kept in a horizontal position, the inllammation usually subsides in the early part of the day, but at evening an exacer- bation takes place, and for the greater part of the night the patient is kept awake by the pain, which again subsides as morn- ing advances. After a day, or as soon as the swelling increases, considerable relief is experi- enced, and in a few more days the tension becomes diminished, as well as the heat and livid redness, and slight sustained pressure will then cause distinct pitting. Subsequently, as the cause disappears, desquamation of the cuticle takes place, and occasionally the skin peels off in flakes of considerable size. Not all cases, even of first attacks, assume this sthenic form; in weakly subjects, and especially in wo- men, the fit may have an asthenic charac- ter ; the pain and heat may be slight, the redness and swelling by no means well marked, yet as far as ultimate mischief is concerned, this variety is often much worse than the other. The duration of the joint inflammation varies considerably in different cases, and is much influenced by the diet and regi- men adopted, and ■ likewise by the medi- cines administered. If no material change is made in the diet, and no remedies taken, the inflammatory action seldom subsides under a week or ten days, and occasionally it lasts two or three weeks : tut, under more favorable circumstances, VOL. I.— 33 the duration of the fit is usually limited to four or five days. After the complete subsidenceof the joint aftection, the pa- tient not infrequently expresses himself as feeling lighter and altogether better than before its occurrence. It will be seen that the ball of the great toe has been mentioned as the joint especially chosen as the seat of the gouty seizure, and it is a remarkable fact, that a patient may experience repeated attacks of Gout in this one joint, without either the tarso- metatarsal or the phalangeal articulations being_ in the shghtest degree implicated. It is not an uncommon occurrence for both great toes to be attacked, even in a first fit of Gout, sometimes simultaneous- ly, but more frequently alternately, the inflammation rapiilly subsiding in one toe, and as quickly appearing in the other. Sometimes other joints, as the ankle, are affected at the same time as the toes, and occasionally the knees, or more rarely some joints of the upper extremities. In many instances, some two or three years elapse before the occurrence of the second attack, but in the majority of cases not niore than twelve months ; and then either the same joint as in the flrst seiz- ure, or the corresponding joint in the other foot, is usually affected. Similar intervals elapse between the next few pa- roxysms, and again the same joints are implicated, or the inflammation extends along the foot, involving the articulations of the arch and the ankles. As time goes on, the disease becomes more general, and almost every joint of the extremities suffer, those of the lower usually taking precedence of those of the upper limbs. The hips and shoulders are perhaps less liable to be attacked than the rest, although they do not necessarily es- cape. In exceptional cases, other articu- lations, as the spine and jaw, become the seat of gouty inflammation. In the course of years, the intervals be- tween the attacks diminish still more — the yearly visitations become half-yearly ; afterwards the attacks recur every few months, until at length the patient can scarcely calculate upon being free, so nu- merous and uncertain are the visitations of his malady. Phenomena occurring during an Ancte Oouiy Attach.— It will be interesting to examine a little in detail the phenomena which present themselves during an acute paroxysm of Gout, for our diagnosis must be founded in part upon the pecuUarities exhibited at such a time. 1. Febrile Disturbance.— The febrile dis- turbance, indicated by heat of skin, tem- perature of axilla, thirst, loss of appetite, and rapid pulse, is almost invariably in close relation to the number of implicated joints, and the intensity of the inflamma- tory action ; in other words, the fever is 514 GOUT. secondary, and dependent on the joint affection. It is important to remember tliis fact, because it will be found that in some other diseases — for example, in acute rheumatism — a patient may exhibit all the symptoms of intense febrile excite- ment, at a time when the joint affection is scarcely apprecialjle. 2. Local Ap^xarances, — The appearance of the inflamed joint is usually character- istic ; there is much swelling present, and enlargement of the veins proceeding from the joint, also great tension of the skin. As the inflammation subsides, pressure produces distinct pitting, indicating the presence of oedema. After a further in- terval, desquamation of the skin almost invariably occurs, usually in a marked degree. There is a point connected with gouty inflammation which is not without inte- rest — namely, the fact, that however acute in character, it never leads to the forma- tion of pus. An inflamed joint may he intensely red, even scarlet, the skin shining from the distension, and it may altogether exhibit the appearance of suppuration; yet all these symptoms quickly subside, and by resolution merely. When it is stated that a part affected by gouty in- flammation never suppurates, it should he added, unless previously the seat of chalk-like deposits; in which case it is not uncommon to find matter formed around such concretions, this formation of pus being probably due not to gouty, but to common inflammation set up around pre- viously existing deposits, which have by their presence acted as foreign and irri- tating bodies. In enfeebled conditions of the system, such an occurrence is fre- quently met with. The pain which attends the joint affec- tion must not be overlooked. It is a com- mon opinion that gouty pain is very in- tense, a degree more so than that arising from other articular inflammation. Doubt- less this is often the case, but it sometimes happens that an acute attack of Gout may be nearly painless, the amount of suffering depending much on the rigidity of the structure of the affected articulation as well as the peculiarities of the patient. The first attack of gouty inflammation in a joint — for example, in the wrist — may be attended with exquisite pain, but in subsequent seizures this symptom may be comparatively slight. CEdema of the affected part has been specially mentioned among the peculiar symptoms of gouty inflammation ; and although it now and then occurs in other forms of inflammation, yet is it scarcely ever absent in Gout. It is owing to the presence of the oedema that so great ten- sion usually accompanies the swelling, and probably the subsequent desquama- tion of the cuticle is also partly due to it. Not only does effusion occur in the tex- ture of the skin, but, when a synovi.al membrane is inflamed, a largo amount of fluid is generally poured into the joints, or, when bursas are implicated, they be- come rapidly filled ; this copious effusion frequently causes considerable alteration of shape in the joints. Joints affected in Gout. — In giving a sketch of the progress of Gout, allu.'-ion has been made to the order in which dif- ferent joints are affected as the attacks become multiplied, and it was then stated that the great toe is commonly selected as the first seat of the disease. The extreme frequency of the selection not only of the great toe itself, but even of a particular joint of this toe, is a fact so peculiar as to make it desirable that a few lines should be devoted to the consideration of the subject. The joint of the great toe, so commonly the early seat of gouty inflammation, is, as before stated, the mctatarso-phalangeal joint, ordinarily termed the ball of the great toe : and from a table collected by the late Sir C. Scudamore, it would seem that in 512 cases of Gout, at its first seizure, the great toe was implicated in 373 cases ; and in 341 out of 512 cases, one or other, or both, great toes were affected, to the exclusion of other parts. My own experience full3' confirms the general ac- curacy of these numbers ; but it should not be forgotten that this joint occasion- ally escapes altogether, and cases of se- vere Gout, accompanied with excessive deposits, have come under my care — cases of at least twenty years' duration — in which the great toes have throughout remained free from disease. The occur- rence of inflammation confined to the metatarso-phalangeal joint of the great toe always convej's suspicion of the exist- ence of a gouty habit : but it requires cau- tion before making a diagnosis from this symptom alone, as the joint may be for a time exclusively inflamed in other and more serious conditions of the system. It is not, however, the great toe which is always first attacked ; for it often happens that an injury to the knee, caused b.y.a fall from a horse, will induce the first de- velopment of Gout in that joint, although after a short time the great toe may be likewise affected. Even an old injury will, as it were, attract Gout to the dam- aged part, and cause it to linger there longer than in other localities. It is a very common remark that Gout differs from rheumatism in implicating the smaller articulations of the body. This is doubtless true, if it has reference solely to the earlier attacks, but after a time the larger and smaller joints appear to be indiscriminately affected. It is not uncommon to hear a patient cafling his disease Gout as long as it is confined to HISTORY. 515 the feet, but rheumatism or rheumatic Gout when tlie upper extremities become attaclced, althougli the same condition of the system which causes the one gives rise to tlie other also. There are certain joints of the extremi- ties which appear to be less liable to suffer from Gout than others. Of these the hips and shoulders are the chief : still, it must not be thought that even these joints are unassailable by the disease, for they are sometimes severely affected. After-effects of Acxtte Gout. — It has been stated above that, after an attack of acute Gout, especially if an early one, the pa- tient not unfrequently expresses himself as feeling even better than before the seizure, the affected joint recovers, to all appearance, its natural size, the tender- ness entirely subsides, and its power of movement is not perceptibly interfered with. To explain this improvement is not difficult. During the occurrence of the inflammation, the blood, as we shall find, loses to a great extent, if not entirely, the morbid condition which previously existed, and hence the disappearance of the malaise ; and the joint, although, as will be proved, decidedly altered by the attack, may yet be not sufficiently changed to interfere with its normal functions. This favorable termination is by no means constant, for as the disease continues to make progress, and the joints have been more frequently attacked, some little re- maining stiffiiess is commonly expe- rienced, due in part to mischief which is irremovable, in part to thickening of the tissues and enlargement of the vessels, which are long in recovering their natural condition. At times, even an early attack of Gout may lead to much mischief; when, for example, the feet are allowed to remain inflamed for any lengthened period, either from want of treatment, or from treat- ment injudiciously applied, considerable oedema may remain long after all pain and heat have subsided — a state often requir- ing special treatment for its removal. This result I have several times witnessed in patients who have allowed the disease to run its own course, and also after ho- moeopathic treatment. Occasionally an- chylosis of a joint occurs even after a few attacks ; in some of these cases it is prob- able that disease of the joint previously existed, although not in itself sufficient to produce appreciable inconvenience ; in others, active and injudicious treatment, as the application of "leeches to the joint, has been the cause of the mischief. Number of Joints affected. — In our de- scription of an attack of acute Gout, we have taken as an illustration a case in which only the metatarso - phalangeal joint, or the ball of a great toe, has been affected. This often happens in the first seizure, and may even occur for several years in succession ; but sooner or later, if the disease continues to make progress, not only are other joints implicated, but several are affected either at the same time or in the course of the same attack ; and it is not uncommon to find many joints, both large and small, of the upper and lower extremities, simultaneously iu a state of acute suffering. When such is the case, as the accompanying fever is in proportion to the joint affection, the pa- tient's malady may easily be mistaken for one of acute rheumatism ; and unless the history is carefully inquired into, the diag-" nosis is somewhat dithcult. Premonitory Symptoms of Ooitt. — Some of these are referable to an altered condi- tion of the digestive organs ; a form of dyspepsia is induced, and tlie patient ex- periences flatulence, often to a very un- comfortable degree, accompanied with heartburn and acidity. Many gouty sub- jects, from the unusual prevalence of these symptoms, can predict the advent of the acute seizure. In some the func- tion of the lower bowel becomes altered, and either constipation or diarrhoea en- sues. The character of the alviue evacu- ations may also be changed. A crampy state of the muscles is another very common forerunner of a gouty parox- ysm, usually in the lower extremities, and more especially in the calves of the legs. Palpitation of the heart is experienced by some patients on the eve of a gouty seizure, and this may or may not be ac- companied with dyspeptic symptoms. In some individuals the respiratory function is implicated under like circum- stances, and a species of asthma produced. At times the urinary secretion undergoes a very visible change in character ; from being copious and clear it may become scanty and turbid. On the other hand, the urine sometimes becomes unusually abundant and limpid a few hours before the establishment of the articular inflam- mation. In other persons, derangements of some portions of the nervous system are pro- duced, the temper becomes very irritable, unusual drowsiness, or headache, grinding of the teeth during sleep, starlings of limbs, and various other phenomena, may be experienced. Lastly, it now and then happens that a feeling of unusually good health, with ap- parent increase of both mental and bodily power, is a prelude to a gouty attack. All these phenomena are probably de- pendent on the altered state of blood which always exists previously to the develop- ment of articular Gout, and the cause of the diversity of the symptoms in different persons must be sought for rather in indi- vidual peculiarities, and the proneness of certain functions to be disturbed, than in 516 GOUT. any variation in the proximate cause of sucli symptoms. When any organ or function is implicated in a very marlved degree, a form of irregular Gout is estab- lished, which we will afterwards describe. Phenomena of Articular Gout ivhen it asswnes a Chronic Form. — In Gout, as in other inflammatory diseases, it is difficult to draw an accurate line between the acute and chronic stages ; but it is not difficult to establish a boundary sufficiently well marked for all practical purposes. It has already been remarked, that acute attacks may come on so frequently, and apparently from such slight causes, that the patient can never calculate upon being free ; but when, in addition to tlie fi-e- quency of the attacks, their duration is prolonged, and a notable change has taken place in the structures of the arti- culations, the case has assumed the cha- racters to which the name of Chronic Gout is commouly applied. It is a somewhat remarkable fact, that although the feet and the joints of the lower extremities are usually the seat of gouty inflammation, often for many years before the hands ; still the latter arc fre- quently seriously injured when the feet have as yet escaped appreciable damage. The explanation of this tendency of Gout to cause greater mischief in one part than another, will be attempted when the pathology of the disease is investigated. Chalk-stones, or Tophi. — The principal changes which take place in parts aflectcd with gouty inflammation, are due to the deposition of a peculiar chalk-like matter in the different structures ; and as such deposits are not only peculiar to Gout, but when capable of being seen become a pathognomonic sign of the disease, it will be interesting to describe somewat fully their nature and origin. White spots often appear upon the helix of the ear, and an opportunity is occasionally afforded of observing the whole train of phenomena exhibited from the commencement to the full develop- ment of the Httle chalk-stone. The earliest appearance presented is that of a small vesicle under the skin of the helix, as if situated between it and the fibro-cartilage ; the contents of the vesicle are at first opa- lescent, or milky, but afterwards become white and opaque, and acquire the con- sistence of cream. After some months, the vesicle assumes the appearance of a small, hard, and white bead, closely re- sembling a pearl, and it may remain as such for years ; but occasionally the thin skin is worn off", and the bead itself be- comes detached from the cartilage, leaving only a slight indication of its presence. If the vesicle is punctured in the early stage, a milky fluid exudes, which pre- sents under the microscope the appearance of a transparent liquid, in which are float- ing a large number of very fine crystalline needles ; if the contents are examined at a later stage, the crystals are found ag- gregated into small bundles ; if the bead is solid, it is difficult to separate them, as they adhere strongly togetlier, and form a closely-interlaced crystalline mass ; if, instead of the little chalk-white bodies in the ear, the formation of deposits in other situations is observed, very similar phe- nomena are exhibited. It will be found as we proceed that al- though chalk-stones, or white deposits visible upon the surface of the body, are far from being constant in cases even of long-continued Gout, yet deposition of urate of soda invariably occurs within some of the structures in every paroxysm ; and thus stiffening and deformity are often induced. When the deposition is confined to the cartilages, unless very ex- treme, the injury to the mobility of the joint is comparatively slight ; but when the ligaments are infiltrated, they are made rigid, and the play of the parts is consequently seriously interfered with. Much distortion is caused when the bursse become infiltrated ; this infiltration, at times, takes place to an enormous extent ; but it may be well to state, that the amount of secretion of urate of soda has no necessary relation to the acuteness of the inflammation. Without the aid of drawings, it is not an easy matter to give even an idea of the extent of crippling and deformity which occurs in some subjects who have suffered from severe chronic Gout. The hands be- come greatly altered in appearance : some- times, when the deposits are chiefly located in the ligaments and tendons, extreme stiffening takes place, without any im- portant amount of bulging ; many of the phalangeal joints become rigid and flexed, others equally rigid but extended beyond the straight line or curved backwards: thus the metacarpo-phalangealof a fino;er may be flexed, the first phalangeal joint curved backwards, and the second phalan- geal articulation shai-ply flexed ; one or several fingers may be thus affected. At other times, not only is there anchylosis of several joints, but likewise great depo- sition of matter, which causes bulging at different points, from the formation of concretions more or less hardened. In extreme cases, an appearance is presented by the hand very closely resembling a bundle of French carets with their heads forward, the nails appearing to take the place of the stalks ; sometimes the toes are affected, though usually in a less de- gree. The bursfe over the elbows are often distended till they attain the size of small oranges ; the bursse over the patellse may likewise become enlarged. Deposits of different sizes are found along the shafts of bones, apparently originating in HISTORY. 517 tlie periosteum ; also on the tendinous sheaths of some of the muscles ; in fact, every bursa may be affected, as lilcewise every tendon and membranous structure, and thus no limit can be set to the de- formity which chronic Gout can produce. When external deposits are visible in any patient, no possible doubt can exist as to the nature of the case, for, as the de- position of urate of soda in the tissues oc- curs only in Gout, its presence constitutes a pathognomonic sign ; but, as before ob- served, the occurrence of visible chalk- stones is not constant, and it was asserted by Sir C. Scudamore that not one gouty case in ten exhibited them. This state- ment, however, is not correct, for the small concretions we have described in the ear are extremely frequent, and may constitute for many years, or even during life, the only visible deposition of urate of soda throughout the body ; and as they produce no amount of inconvenience, they may altogether escape notice unless spe- cially sought for. Some few years since, having been able in some difficult cases to make correct diagnosis from the presence of these aural deposits, the writer was in- duced to investigate the matter, and, in thirty-seven cases examined within a short period, they were found to be pres- ent in sixteen cases ; in seven no other concretions could be seen; in nine there existed deposits around the joints ; and in one case onlj^ were chalk-stones visible elsewhere without being present in the ears likewise. Small chalk-like deposits are found in other situations than those above men- tioned ; sometimes they can be felt under the skin along the tendinous aponeuroses of certain muscles, especially those of the leg and thigh, varying in size from a flat- tened pea to a small bean ; they have been observed on the sclerotic coat, likewise on the tarsal cartilage at the angles of the eyes. It is questionable if they ever originate in a very vascular tissue such as the skin, although it may subsequently become pressed upon and involved. It has already been stated, that the original condition of these deposits is that of a liquid, rendered more or less milky or opalescent from the presence of acicular crystals ; that as the fluid part is absorbed, the consistence becomes creamy, and at last a solid concretion is produced. If the effusion has taken place in a bursa, the resulting chalk-stone is free and of uni- form composition ; but, if it has been infil- trated in a tissue, the structure of the part becomes mixed up with it when solidifica- tion occurs ; hence the discrepancies which have arisen in different statements re- garding the composition of chalk-stones. Several analyses have been made of chalk-stones which have either been re- moved during life, or obtained from the body after death, and from these it will be seen that, omitting the animal matter and the soluble salts derived from the structures in which the concretions have formed, urate of soda is practically the only salt which they contaiu. Possibly in some instances, as in a concretion ana- lyzed by L'Heretier, the phosphate of lime ibund in large amounts was derived from the tissue ; but it is not improbable that it may be occasionally secreted as the re- sult of common inflammation set up by the presence of the urate of soda, whicli latter salt has acted as a foreign body in the same manner as tubercular matter often becomes infiltrated Mith bone earth. Offuty Abscesses. — When gouty deposits increase in size and approach the surface, the skin over them becomes gradually thinner, and often gives way; a discharge takes place, either of a white solid suli- stance, should the concretion have been of long standing, or of liquid matter, if the deposit is more recent ; but not unfre- quently, however, a mixture of both solid and liquid chalk occurs, and thus a gouty abscess is established. Such abscesses are usually difiicult to heal, and may re- main open for months, and even years ; and this is especially the case when the morbid matter penetrates to any consider- able depth, as, for example, in the neigh- borhood of joints ; but when in a bursa, as that over tlie olecranon process of the elbow, this difficulty is not experienced, in fact the healing takes place witli as nuich facility as in the case of an ordinary abscess. The discharge from these ab- scesses may be unaccompanied with pus, and consist simply of urate of soda ; but in exceptional cases, when concretions have become very solid, and the patient is reduced to a very weak state of health, inflammation and suppuration may arise, and pus mixed with white fragments is then freely discharged. It is not uncommon to And that patients, in whom chalk-stones have been freely formed, have a great number of abscesses discharging at one time, and it is aston- ishing to see how little disturbance of the system is produced by them. Occasion- ally five or six such abscesses will be open on each hand, and nearly as many on the feet ; the free outlet thus given to the matter appears, in fact, to give rehef to the system. Cmistitutimal Symptoms in Chronic Forms of Gout.— It remains, before com- pleting the description of chronic Gout, to speak of the symptoms which accompany the changes of structure above descril^ed. It may be here assumed (a fact which win be afterwards proved) that the blood in chronic Gout is always in an impure state, and we should expect, therefore, that symptoms indicating its irritating action upon various organs would be prcs- 618 GOUT. ent. This is often the case, and chronic dyspepsia, accompauied with acidity, heartburn, flatulence, pyrosis, and pain after food, are common accompaniments ; the bowels are apt to be disordered, and the function of the liver impaired, palpi- tation and irregular action of the heart may be present, and occasionally symp- toms referable to the nervous and mus- cular systems, as cramps, twitchings of limbs, nervous depression, and so forth. Although the patient is apt to be afflicted ■with some or even several of the above- named miseries, yet it is not always the case, for it would seem that in many such subjects the system gets gradually accus- tomed to the impurity of the circulating fluid, and it is only when there is an ex- cess of such impurity that they become sensible of its presence. The urine of patients suffering from chronic Gout, with extensive deposit of chalk-stones, is generally pale, of light weight, and often contains a little albu- men ; the occurrence of deposits is rare, except about the time of a paroxysm of a more acute character. Irregular Gout. — The subject of irregu- lar Gout is one of no small difficulty, and requires careful handling in order to avoid falling into error. Some pathologists ap- pear to assume that all the ailments which happen to patients subject to Gout neces- sarily owe their origin to that diathesis, and hence the descriptions given of gouty pneumonia, gouty hepatitis, and many other inflammatory affections ; but a closer investigation of several so-called gouty complications has led me to believe that they are nothing more than ordinary forms of inflammatory disease, modified, indeed, to some extent by the diathesis of the pa- tient. A man with a gouty diathesis may be exposed to cold, and have pneumonia developed from such exposure, and yet the lung inflammation may not differ in its essential character from what occurs in a previously healthy person. Such a sub- ject is, in fact, as liable to be attacked with inflammatory disease as any other individual ; it is necessary, therefore, that good proofs should be shown that a mal- ady is truly gouty in its nature, before we are justified in coming to the conclusion that it is so. On the other hand, it is equally important that, the possibiUty of a disease being dependent on a gouty state, the habit should not be overlooked, for upon a correct diagnof^is of such cases success in treatment mainly depends. As yet we have only described Gout as implicating the structure of the joints, or at least tissues similar to those of the ar- ticulations, and situated near the surface ; but it must be remembered that like tis- sues exist in the deeper-seated parts of the body, and it is a question of interest to know if they often become affected ; in the case of acute rheumatism, in which inflammation of the membranes of the heart so frequently happens, such occur- rences are looked upon as ordinary phe- nomena of the disease. Betrocedent Gout. — There is a popular belief that a patient when laboring under gouty inflammation of any joint, if ex- posed to cold, is liable to have the local malady suddenly checked, and to be at- tacked with some acute affection of an internal organ, as the stomach, heart, or brain ; and when this takes place, the term Ketrocedent Gout is applied. Gout affecting the JS'ervous System. — When the brain or its membranes become implicated, the sj-mptoms may be exhib- ited in the form of intense pain of the head, epilepsy, &c., or the intellect may be impaired and delirium ensue. Apoplexy has been said to have been caused by retrocedent Gout. If the pa- tient is suffering from any chronic brain disease liable to induce apoplexy it can easily be imagined that the suppression of articular Gout might cause its rapid de- velopment. Serous or congestive apo- plexy may possibly result from gouty in- flammation ; but these cases are rare : the author has not yet witnessed one which could be fairly classed under such a head ; those he has seen have always been accompanied with albuminuria. A severe form of headache is not very uncommon in Gout ; sometimes it occurs prior to the development of the joint in- flammation, and then it usually vanishes at once on the occurrence of the latter, and now and then the alternation between the headache and toe affection is charac- teristically and unmistakably marked. At times when a patient is suffering from Gout in some joint a cessation of the ar- ticular pain suddenly ensues ; but this, far from being the termination of the disease, may be followed by delirium, attended with more or less febrile disturbance. This condition may last for hours, days, or even weeks ; it may be relieved by the reappearance of the joint disease, or it may gradually disappear without such re- development. "When these symptoms arise in the course of articular Gout, to what patho- logical condition must they be ascribed ? It would seem probable that they may be ascribed to the sudden occurrence of gouty inflammation about the membranes of the brain, or the lining of the skull ; and, although I am unaware of any trust- worthy post-mortem examination proving the existence of deposits of urate of soda in these structures, still such may arise, and the proof of their existence or non- existence is a point of much interest and importance. Deposits of this kind can readily escape notice, unless specially sought for ; and even those which occur HISTORY. 519 in the joints in early attacks of Gout were not observed till within ihe last few years. Epilepsy is not uncommon in gouty subjects, and appears to be closely de- pendent on the diathesis which gives rise to the articular affection ;. it sometimes distinctly alternates with the joint afl'ec- tion ; at others, the two may occur simul- , taneously. Mania is frequently the result of retro- cedent Gout. I have seen numerous cases : gout often leaves a joint suddenly from exposure to cold or an intense men- tal shock and after a short time distinct mania is developed ; this may last for days or weeks, but generally terminates favorably. Spinal affections, probably with inflam- mation of the meninges, with startings of limbs, hypersesthesia and other charac- teristic symptoms, occasionally result from the sudden suppression of articular Gout, or occur along with the joint in- flammation. Acute neuralgia of different nerves is at times closely connected with Gout. Sciatica of this character often occurs, and facial neuralgia occasionally. These aifeotions probably depend on gouty in- flammation affecting the sheath of the nerves. Forms of local paralysis have also been observed apparently due to the same cause ; and cramp sometimes be- comes so excessively developed, and so permanent, as to justify its being looked upon and classified as a form of irregular Gout. Oout affecting the Digestive Organs. — When the stomach is affected by gouty metastasis, which sometimes occurs from the apphcation of cold to the extremities, there is usually sudden intense pain and spasm in the epigastrium, oppression, and vomiting of bilious matter ; at times the heart's action is involved, and a feeling of great anxiety, with palpitation, produced. Many of the cases reported as examples of retrocedent Gout will not bear a close investigation ; still there is no reason to doubt the possibility of such an occur- rence. True retrocedent Gout affecting the stomach is probably of an inflamma- tory nature, though no direct proof has been afforded in support of this state- ment. Sometimes the upper extremity of the digestive tube, as the pharynx and oeso- phagus, becomes distinctly affected in Gout, producing difficulty of swallowing ; at other times the rectum is implicated, and the patient is troubled with piles or tenesmus. Constipation is very common, but, on the other hand, diarrhoea may prevail, apparently of a conservative character, and cases now and then are seen in which articular Gout appears to be warded off" by the discharge from the intestinal canal. Qout affecliyyg ihe Circulating Organs. — When articular Gout suddenly recedes and the heart becomes affected, the symp- toms experienced by the patient are a sensation of extreme anxiety, difficulty of breathing, constriction of the chest, much palpitation, often accompanied with in- termission, weak thready pulse, and syn- cope. The heart's action occasionally becomes exceedingly slow, or it may be unusually rapid. The subject of heart affection in relation to Gout is one of considerable interest, more so from the fact that the organ is so frequently affected in acute rheumatism. No conclusive evidence has yet been ad- vanced proving the existence of true gouty inflammation of the heart ; the ex- amination of the surface, the lining of the organ, and the valves in gouty subjects, has not shown the presence of deposits ; but it must at the same time be allowed, that in cases where the heart has been implicated, they have not been specially sought for. It has been asserted that the post-mortem examination of gouty sub- jects has frequently revealed the presence of white patches upon the surface of the heart, and Dr. Begbie fancies that these are often the results of gouty inflamma- tion ; he is also inclined to think that the endocardial vegetations and puokerings are due to the same cause ; no proof, however, has been brought forward in confirmation of these views, and the writer of the present article can state positively that his examinations have failed to detect urate of soda, either in the white patches, the endocardial de- posits, or the atheromatous spots. It must also be remembered that the causes which lead to the production of Gout are such as are likely to induce chronic val- vular diseases of the heart. Oout affecting the Hespiratory System. — Acute inflammation of the lungs or pleuras, if it ever occurs from retrocedent Gout, is certainly very rare indeed, al- though some authors have described these forms of disease ; but functional affec- tions of the respiratory organs are of very frequent occurrence in gouty habits, and so probably is a form of bronchitis ; the most common manifestations of such disturbance being shown by asthmatic breathing and cough. Occasionally these symptoms are unaffected by ordinary remedies, and yet yield at once to the de- velopment of articular Gout, or to the administration of medicines calculated to give relief in ordinary Gout. Oouty Conditions of the Urinary Organs. —The different parts of the urinary tract appear peculiarly prone to be affected by Gout. The kidneys are undoubtedly im- 520 GOUT. plicated in very many instances, and structural alterations are frequently pro- duced, which will be described under the " Morbid Anatomy" of the disease. From many observations and post-mor- tem examinations, I am of opinion that gouty inflammation of the structure of the kidney is by no means rare, and that a true deposition of urate of soda takes place as its result. That this may occur early in the gouty life of a patient is cer- tain ; possibly it may at times even pre- cede the joint affection. It must be borne in mind, when investigating these cases, that renal calculi are somewhat common in gouty subjects, and the symptoms must therefore be carefully analyzed ; in irritation of the kidney from a calculus, the pain is more likely to be confined to one side of the loins ; albunien is not so frequently present, and if so, it is prob- ably due to a little blood ; and, lastly, there is the absence of febrile disturb- ance. The bladder and urethra may also be- come affected with Gout, and a species of chronic cystitis and urethritis induced, especially in old people. "Where the irri- tation of these surfaces is simplj' the result of this diathesis, the symptoms are greatly relieved or altogether removed when the joints are attacked ; but in many instances some organic urinary mischief exists, the sj'mptoms of which are aggravated hy the gouty habit. Gout affecting the Eye and Ear. — Oph- thalmia, appears to be occasionally of a gouty character, although many of the cases recorded have been the result of purulent urethral affection. I have recently seen two cases of gouty sclerotitis accompanied with the white deposits of urate of soda on the surface of the tissue. The occurrence of the little bead-like chalk-stone on the helix of the ear has already been fully described ; it has been supposed that the surfaces of the drum and of the ear-bones are at times the seats of like deposits ; those I have examined have consisted simply of bone earth, and have not occurred in gouty subjects. The external ear is at times painfully affected by acute Gout, even to the extent of preventing the patient from resting on it when in bed. Gouty Affectioiis of the Sl:in. — If inquiry is made it will be found that skin erup- tions are very common in those who are the subjects of Gout, and if they are not absolutely produced by the state of the system which leads to the articular affec- tion, still they are evidently kept up by it. Psoriasis is, perhaps, the most frequent form in which the cutaneous disease man- ifests itself, and there are records of many cases in which the skin and joint-affection are alternated. Eczema is likewise not an infrequent accompaniment of tlie gouty diathesi.'- ; sometimes it assumes an acute, sometimes a chronic character. Prurigo is also met with in connection with Gout, either in the limited form of prurigo ani, or as a more general afl'ec- tion. Acne, in the face and other parts, is sometimes found to be closely dependent on the gouty diathesis, and I have known one case in which the patient could pre- dict the advent of a gouty paroxysm from the appearance of these spots. Diseases occurring in Gouty States of the System. — There are certain diseases to which gouty subjects are especially liable, and amongst these gravel and calculus may be particularly mentioned. When the pathology of Gout is consid- ered, the occurrence of uric acid gravel cannot be a matter of surprise ; from a very early stage deposits of urate of soda take place in the tubules, and Dr. Prout has remarked that occasionally patients void this salt in considerable quantities. Some patients suffer in early life from calculus, in after periods from Gout ; in other subjects calculus and Gout alternate, and occasionally the two affections are present at the same time. Oxalic acid, which is so readily pro- duced from uric acid, not infrequently occurs in the urine of gouty subjects, and maj- lead to the formation of calculi. The existence of a gouty diathesis has been regarded as antagonistic to the de- velopment of phthisis ; I have, however, seen instances in which phthisis and Gout have run a simultaneous course. Gout and diabetes occasionally occur in the same individual, but the development of the latter is usually followed by the cessation of the former disease. Condition of the Blood in Acute and Chronic Gout. — The blood undergoes im- portant alterations in Gout, changes which are almost in themselves pathog- nomonic and which require to be care- fully studied and clearly understood. In the writings of the ancients, nothing defi- nite is found on this subject ; and even until the past few years our knowledge of the state of this fluid in Gout maybe said to have been of little value. The blood-corpuscles, as far as yet known, undergo no necessary change either in number or quality ; they be- come lessened in chronic forms of disease, when the general nutrition of the body is impaired, but not more so than in other maladies. Many of the poorer subjects of chronic Gout, it is true, are pale and anajmic , and among painters and other gouty patients who work in lead, this is often due more to the influence of the metal which has been imbib . d than to any other cause. HISTOKY. 521 It is in the serum of the blood that the chief deviation from the liealtliy standard is discovered ; and in tliis portion it is not so much that the normal constituents are affected, as that excretory substances which should have been eliminated are retained — an effect due to the imperfect action of certain of the excreting organs, more especially the kidneys. In healthy blood, it is impossible by or- dinary tests to discover the presence of uric acid, the quantity being so extremely small — in fact almost inappreciable ; but in Gout one can easily not only show its presence, but even obtain it in a crystal- line form. It was first proved to be pre- sent by the author in 1847.' The follow- ing process can be adopted for its detec- tion : — The serum of the blood is first dried over a water-bath, then reduced to coarse powder, and treated with hot alco- hol ; the spirit being removed, the residue is afterwards to be digested for some min- utes in distilled water, and raised to the boiling point ; the watery solution is then filtered and evaporated to a thin syrupy consistence. A drop or two of the solu- tion, when heated on a piece of porcelain, with uitric acid and ammonia afterwards added, exhibits at once the murexide test, i A small portion of the same solution, if acidulated strongly with acetic acid, and allowed to evaporate spontaneously, gives rise to the crystallization of uric acid, the crystals exhibiting its characteristic form; and lastly, the syrupy solution, if merely allowed to evaporate without the addition of any acid, exhibits upon its surface, after a few hours, small white tufts of acicular crystals of urate of soda ; the nature of the base being determined by the examination of the white alkaline ash left after incineration ; the acid by the murexide and other tests. In the clinical examination of the blood, this process would be too elaborate and tedious ; but another method,^ which an- swers admirably for practical purposes, is to put about two drachms of the serum in a flat glass dish, somewhat larger than a watch-glass, acidulate slightly with acetic acid, and having placed in the fluid an ultimate fibre from a piece of linen cloth (unwashed huckaback answers well), set it aside in a safe place until the evapora- tion has proceeded suflaciently far to cause it to become of a gelatinous consistence. If there is uric acid in any abnormal .quantity in the serum, the fibre becomes studded with crystals of uric acid, which can be at once recognized by placing the glass under the microscope with a low power, or by the use of a small pocket magnifying-glass. I have never yet, after ' Medico-Chirurgical Transactions, 1848. ° Medico-Chirurgioal Transactions, vol. xxxvii. 1854. very numerous trials, failed to discover uric acid in the blood of gouty patients by this method, and the test has an especial advantage in only requiring the abstrac- tion of a very small quantity of so impor- tant a fluid. It may certainly be stated as a fact, absolutely proved, that the blood in Gout always contains an abnormal amount of uric acid, and that this acid exists as urate of soda. Besides uric acid, urea is frequently found in varying quan- tities in the blood in this disease, especi- ally when the affection is of long standing, and the kidneys have become much in- volved and their excreting powers im- paired. In 1849' the writer discovered the pre- sence of oxalic acid in the blood, and since that tune has, in several instances, detected it in gouty subjects ; its presence appears due to the decomposition of the retained uric acid. The other alterations in the serum of the blood occasionally met with in cases of chronic Gout, are, the lessening of its specific gravity, due to the loss of albu- men, as well as to the impaired nutrition of the body ; and the diminution of its alkaline reaction. With the exception of collapsed cholera, and perhaps certain cases of albuminuria, the reaction of the blood is found to be nearer the neutral point in severe forms of chronic Gout than in any other disease ; this lessening of the alkaline condition probably depends on the deficient action of the kidneys and the retention of acid products, as it is only when the kidneys are much afl'ected that such a state of the blood is observed. The amount of fibrin is always increased when active inflammation of the joints is pre- sent, and the augmentation appears to be in the ratio of the inflammatory action ; in fact, the fibrin follows the same laws as in other forms of inflammation ; hence, in acute Gout, if blood is abstracted, the surface of the clot exhibits a bulled and often a cupped appearance. Condition of the Blood in the intervals be- tween the Attacks of Gout. — It is a matter of some importance to ascertain the state of the blood in gouty subjects, when no inflammatory action is present ; that is, during the complete intervals of the at- tacks. Although a somewhat difficult task, from the unwillingness of patients to be bled when not suffering from pain or fever, I have been enabled, in a few in- stances, to collect some facts of importance on this point. 1. In the intervals between the early attacks of Gout no appreciable amount of uric acid was found in the blood. 2. A very marked decrease of uric acid was observed in the blood of patients par- tially recovered from an acute attack. ' Ibid. vol. xxxii. 1849. 622 GOUT. 3. In chronic Gout the blood, even in the intervals betv^een the exacerbations, was always rich in uric acid. 4. In some cases wlien symptoms of ir- regular Gout were manifested, without any accompanying joint disease, uric acid was present in the blood. State of the Urine in different forms of Gout. — Much error prevails in regard to the alterations which the urine ot gouty subjects exhibits during the progress of the disease, and such misunderstandings have partly arisen from the prevalent idea, that the appearance and non-appearance of certain principles in the urine necessa- rily indicate their presence orabsence in the blood ; and partly from a want of accurate knowledge of the reaction of healthy urine. It must be remembered that healthy urine exhibits a strongly-marked acid re- action, and that this is, in all probability, due, not to the presence of a free acid, but to the existence of an acid phosphate, probably the phosphate of soda, a salt containing two equivalents of water and one of soda to each equivalent of tri- basic phosphoric acid {2HO, NaO, PO5) [Na2HP04.12H20]. The acidity of urine varies much at different times of the day, and is in close relation to the state of the digestive functions. The fact of the acidity of healthy urine has been specially insitited upon, because the application of litmus papers is not infrequently made both by medical men and patients, and very wrong deductions drawn from the indications thus obtained. It must be remembered that a strong acid reaction is no proof of the presence of any abnormal state of the urine; and that urate of soda is one of its constituents, a salt which can exist in a solution of the acid phosphate without decomposition, and hence the possibility of the coexist- ence of the urate of soda with an acid con- dition of the urine. The amount of uric acid passed by a healthy subject during twenty-four hours is from eight to ten grains — a quantity capable of existing in solution when the urine is in a healthy state. Having premised thus much, we are better prepared to speak of certain changes which are observed in the urinary secre- tions in Gout, changes the import of which has been often misunderstood. It has already been proved that the blood in all stages of Gout is invariably rich in uric acid, and, as the kidneys are the only organs which can be shown to eliminate this body, it follows that these organs must be inefficient for their required task when such a condition of the blood ensues. It becomes, then, a matter of some interest to discover whether these organs in gouty oases lose any of their normal power of excreting uric acid, or whether the forma- tion of this acid in the system is increased. In acute gouty seizures of a sthenic character the urine usually becomes scan- ty ; it is then high-colored, and not infre- quently gives rise, in cooling, to an amor- phous deposit, varying in tint from pale yellowish red to dark red, or at times an mtense pink. The color varies under different circumstances, such as the amount of febrile disturbance which is present, the state of the portal system, and that of the biliary secretion also. If a judgment is formed from the inspection of a small specimen, without taking into consideration the limited amount passed in the twenty-four hours, it may readily be supposed that a great excess of uric acid is secreted; and such, in fact, has been the prevalent idea. However, a more careful examination of the urine in these cases leads to a different conclusion; for example : in a set of observations, taking the averages in seven acute cases, the daily secretion of uric acid was found to be under four grains, an amount far below the normal amount, which is from eight to ten grains. The cause of the prevalent idea that in Gout the uric acid exists in the urine in excess has probably arisen from the following circumstances : During the febrile stage there is usually a deficient flow of urine, the acidity of the fluid is augmented, thus causing the pre- cipitation of the whole of the urates ; at the same time the increase of coloring matter in the deposit gives the appear- ance of a larger amount than actually exists. It must not be concluded from the above that in any given amount of urine passed in a gouty paroxysm there may not be a larger amount of uric acid than that which is found in health— often it is so ; but our remarks apply not to the relative, but to the absolute weight elimi- nated in the twenty-four hours. The question whether the deficient ex- cretion of uric acid is due to a loss of renal function, or to a diminished formation of the acid in the system, is at once deter- mined ; for it can be demonstrated that at the time that the urine is deficient in this principle, it exists in the blood in ab- normal quantities. It is also known that in some otlier diseases, in which uric acid is formed in augmented quantities, the kidneys are found equal to the task of eliminating such excess, and the blood is thus kept free from any contamination. Tlie excretion of the urea also is proba- bly somewhat diminished during the fe- brile excitement of acute Gout, but by no means in the same ratio as the uric acid. As Gout assumes more and more a chronic character, so it will be observed that the excretion of uric acid becomes gradually lessened, even in the intervals between the attacks ; showing that the kidneys are permanently injured, so far MORBID ANATOMY OF GOUT. 523 as their uric-acid excreting power is con- cerned ; and in the advanced stages of the disease, wlien the clialk-Uke deposits are thrown out in various parts of the body, and when the blood is permanently loaded with the acid, the renal organs often lose entirely, or all but entirely, their elimi- nating property for this principle. The results obtained from a large number of examinations of urine, and in numerous cases of chronic Gout, may be thus summed up:— The urine is generally paler than in health, lighter in specific gravity, and often passed in augmented quantities. There is, for the most part, an absence of any deposits on cooling; at times, how- ever, such may occur, especially when an exacerbation of the disease is passing off. The quantity of uric acid eliminated in the twenty-four hours is notably dimin- ished, and not infrequently it is reduced to a mere trace. The kidneys sometimes tlirow out uric acid in an intermittent manner ; for ex- ample, for several days the uric acid gradually decreases, until scarcely a trace 18 present, then suddenly a large elimina- tion takes place ; this has been clearly made out in several cases. Even in the intervals between the fits, the urine of patients suffering from chronic Gout is deficient in uric acid. The urea also, in many cases, is slightly diminished, but not in any remarkable degree, if the diet of the patient at the time of examination is taken into ac- count. A small amount of albumen is very fre- quently met with, also granular casts ; and, in some cases, waxy or fibrinous casts are likewise found. Secretion from the 8kin in Govt. — It is a common opinion that the production of excessive perspiration is the means of get- tiug rid of gouty matter from the system, and the value of hot-air and vapor baths, and other modes of increasing the cuta- neous secretion, have been thus accounted for. There are also to be found, in differ- ent works, statements to the effect that uric acid is capable of being eliminated by the skin, and that a white, powdery matter is occasionally seen upon the sur- face of patients suffering from a paroxysm of Gout. I have made many observations upon this subject, which have led me to doubt the accuracy of such statements, and within the last two years have had an opportunity of putting the question to a severe test. A gentleman, suffering from a very decided attack of Gout, went into a Turkish bath, and took precautions to enable him to save a considerable amount of the perspiration which flowed from his body during the operation. To this fluid rectified spirit was at once add- ed, iu order to prevent decomposition, and it was afterwards carefully examined by the following process : It was first evapo- rated to dryness, then heated with abso- lute alcohol, and the residue afterwards treated with hot water. The alcoholic solution yielded a notable amount of urea, which was obtained as the crystallized nitrate ; but no trace of uric acid could be discovered in the watery solution by the most careful search. This observa- tion, coupled with many others above re- ferred to, leads me to believe that the healthy skin does not possess the power of eliminating uric acid, even when it ex- ists in normal quantities in the circulating fluid. It must, however, be remembered that the liquid thrown out from blistered surfaces in like cases is rich in uric acid, and it is not improbable that in some cu- taneous eruptions, as in the secretion in eczema when occurring in gouty habits, it might be detected. Allusion has been made to a white deposit seen on the sur- face of patients sufiering from Gout ; on one or two occasions, when I have had the opportunity of examining such mat- ter, it has been found to consist of epider- mic scales, together with dry salts, but to be entirely devoid of uric acid. Other Secretions in Gout. — It has not been determined whether uric acid is con- tained in the secretions from the mucous membranes of the bowels in subjects laboring under Gout, and, when evidence of its presence in the blood is beyond doubt, it would be worth seeing if it is contained in the watery excretions pro- duced by the action of saline or other purgatives. In morbid secretions uric acid is often present : thus it is found in the fluid effused in cases of pericarditis, also in ascites, when these diseases occur in subjects in which the blood is contami- nated with this principle. It is also found under like circumstances in the fluid effused by the action of blisters, and we can sometimes make use of this fact in diagnosis, employing the blister fluid in lieu of the blood serum. There is, however, one precaution necessary to be observed, which is, to avoid taking the fluid from a part affected with gouty in- flammation, as it would appear that in- flammation has a tendency to destroy the uric acid in the blood of the part. This fact, if well established, would be of great value in elucidating the pathology of the disease. The thread experiment may be em- ployed for the detection of uric acid in the blister fluid, as in blood itself. Morbid Akatomy of Gottt.— Gout is seldom fatal, yet opportunities for inves- tigating the morbid appearances produced by the occurrence of the malady, even in its slightest forms, are not difficult to obtain, provided that the gouty history of 524 GOUT. cases be carefully taken for a considerable period of time in any great public medical institution. It is only by this method that the writer has been enabled to collect the materials of which he now gives a short summary and which he hopes will go far to elucidate many of the phenomena of the disease. In one case there had been only two very slight attacks of Gout, affecting the nietatarso-phalangeal joint of the right great toe, the first attack occurring two years, the second only one year, before death. The condition of the joint was as follows : On the head of the metatarsal bone was a white patch made up of minute aggregations of a white deposit, occupying altogether about a tenth of the articulating surface ; on tlie cup-shaped surface of the phalanx, the same sprink- ling of white matter was observed upon the cartilage, occupying a greater extent of surface than on the metatarsal bone ; on the inner surface of the ligaments the same substance was here and there ob- served ; the surfaces of the sessamoid bones were free from any deposits, and, although the same joint on the left side, as well as many other small and some large joints were examined, no deviation from the normal state was observed in them. The gouty attacks, it will be re- membered, had been confined to one articulation, and this joint only was found to be altered after death. In another case, only one attack of Gout had occurred, afiecting the right great toe very severely, the left but slightly ; and similar appearances in tho cartilages and ligaments were discovered, but exceedingly slight in the left toe-joint. In this case, also, several other joints were examined, but found to be free from any morbid alteration. We thus see that even a single attack of Gout leaves marks behind, which ap- pear to be very ncarljf, if not altogether, indelible ; for, in the second case, at least thirteen years had elapsed from the time of the gouty seizure to the death of the patient. Before proceeding to speak further of the morbid appearances produced by gout}' inflammation it will be necessary to point out the nature of the alteration we have already noticed — that is, the na- ture and situation of the white deposit. "When the alteration in the joint is slight, no appreciable elevation of the surface can be discovered ; and if we pass the finger over it, nothing abnormal is de- tected, nor can we remove the deposit by moderate friction, nor, in fact, by any means short of removing the surface of the cartilage itself. On the other hand, if we immerse the bono for some hours in water at the ter.ipcratnrc of the body, or keep it in a cold and weak solution of carbonate of potash, the white matter is slowly disfaohed out, and on afterwards drying the bone, the articulating surface appears to be restored to its healthy con- dition. We can thus show that the de- posit is not on the surface of the cartilage, but within it, and that it consists ot a material soluble both by warm water and in a weak alkaline solution. A further insight into its nature may be obtained from a microscopical and chemical exam- ination ; if, for example, we make a verti- cal section of the cartilage over the seat of the white deposit, we at once see, either with the naked ej'e or a simple lens, that the infiltrated matter is most dense near the free surface, and gradually diminishes as it approaches the bone, sel- dom, indeed, extending half-way into the substance of the cartilage. K we place the thin vertical section under the microscope, using a quarter- inch objective and low eye-piece, a very beautiful appearance is exhibited ; the opaque white matter is observed to con- sist of very fine crystalhne needles or prisms closely interlaced, and according to the density of the network, so is the amount of opacity produced. As the de- posit becomes more sparse, many separate crystals are seen, which appear to project into the substance of the healthy cartilage. If we examine horizontal, in lieu of verti- cal, sections of cartilage, we find that, after we have removed a few slices, the deposit becomes sufflciently thin to allow light to pass freely through it, and the crystals are for the most part seen to be arranged in little clusters radiating from centres, the interspaces being nearly free, or with only scattered crystals. If, in- stead of using ordinary light, we employ the polariscope, the appearances above described are much intensified, the crys- tals become strongly illuminated, and more or less colored ; at the same time, the healthy portion of the cartilage, if sufficiently thin sections be made use of, gives a black background. The chemical nature of the deposit can be readily demonstrated. If slices of the altered cartilage be first washed with a little cold distilled water, to remove any soluble matter, and afterwards digested for some hours in hot water under 200° Fahr., the infiltrated matter is dissolved, and a soiution is obtained which, treated with a little nitric acid and afterwards evaporated in a porcelain capsule, and. when nearly dry exposed to the vapor of ammonia, exhibits an intense purple color from the formation of murexide ; ou the other hand, if some acid, as acetic, be added to the solution so as strongly to acidulate it, and the whole allowed to evaporate spontaneously to a thin syrupy consistence, crystals of uric acid, more or less colored, are slowly deposited, and the MORBID ANATOMY OF GOUT. 5-25 forms they exhibit under the microscope at once distinguish them ; again, if the watery solution, without the addition of any acid, be slowly evaporated to a syrupy consistence, and then allowed to cool, urate of soda, in bundles of crystaUine needles, will form on the surface, which can be readily collected, and, if necessary, chemically examined. If a thin vertical section be obtained from any articular surface which has not been much worn — that is to say, from a joint which has not been often attacked, or is not liable to injury from friction — a distinct orgauin layer devoid of crystals can be seen by the aid or' the microscope, superficial to the deposit, aud probably consisting of flattened cartilaginous cells. As yet we have only spoken of very early cases of Gout, in which merely the ball of the great toe has been attacked ; if we take ixiore advanced cases, where the disease has lasted for several years, and in which many of the larger as well as the smaller joints have been impli- cated, opportunity is afforded of investi- gating still further the changes effected by the disease. If a knee has been but slightly attacked, only a few spots or small patches can be detected upon the articulating surfaces of the femur, tibia, and patella ; but if it has been severely affected, a large portion of the surfaces may exhibit the peculiar alteration ; the condyles of the femur are often completely incrusted, except at their margin, in the situation of the syno- vial fringes, the vascularity of which ap- pears to protect this part from the de- posit ;' the concave surface of the tibia is usually less covered ; the patella is often extensively coated ; and in many in- stances the flbro-cartilages and crucial ligaments are more or less implicated. In such a knee-joint the synovial fluid is thickened, and in extreme cases contains tufts of urate of soda ; the synovial mem- brane is also seen to be speckled with little white points looking like amorphous granules. When these are placed under the microscope, they are found to consist of acicular crystals radiating from a cen- tre, and forming with polarized light a very beautiful object. In cases of Gout in which the disease has so far advanced as to cause considerable stiffening or com- plete anchylosis, the ligaments are found to be much infiltrated and thereby ren- dered rigid ; and, as a rule, the movement of the joint is impeded more by the liga- mentous than the cartilaginous altera- tion. Instances are not uncommon in which the movements of the great toe- ball are but partially interfered with, al- though the ends of the bones are com- ' Dr. W. Budd, Hodico-Cbirurgical Trans- actions, 1855. pletely covered ; but the ligaments in such cases have escaped. Tile shoulders and hip-joints often re- main free from disease when most of the other articulations of the body are impli- cated, but occasionally they present simi- lar appearances to those above described. I have a specimen in which the head of the fenmr is almost completely incrusted ; the ligamentum teres, however, is free, and the movements of the joint are con- sequently preserved. The carpus and tarsus are often severely attacked by gouty inflammation, and it is not unusual to find every articulating surface of these bones completely coverecl with the deposit ; also the surfaces of the metacarpal and metatarsal bones, and frequently of several of the phalanges. There is, however, one point of interest in relation to the joints of the great toe, worthy of being borne in mind ; it is the fact that, although the metatarso-pha- langeal articulation is so constantly atiect- ed, the tarso-metatarsal and the pha- langeal joints on either side are for the most part free from morbid alteration. Sometimes urate deposits are found in other articulations. I have met with them even m the arytenoid cartilages, but it requires a special search, not usu- ally made in post-mortem examinations, to discover their presence. It has been asserted that urate deposit has been seen in bone itself; Cruveilhier found it in the astragalus, os calcis, and patella. Although I have carefully searched for it in bone, 1 have not yet succeeded in finding evidence of the de- posit having originated in this tissue. It is true that deposits lie in contact with bone, as they often originate in the peri- osteum, and sometimes acquire sufficient size to press on the osseous tissue and cause its absorption. Dr. Charcot, in conjunction with M. Cornil, has recently (18t)4) published an account of the post- mortem appearances in the case of a female, aged 84, who had suffered from Gout for many years, and had been long crippled and deformed ; a full description of the appearances presented to the naked eye is given, as well as those seen in the microscopic examination ; in every important respect the results are the same as, and confirmatory of, those above described. Condition of the Kidneys in Gout. — From the earliest time it would appear that an idea prevailed that Gout and renal dis- eases were in some way allied ; Aretteus held that opinion, as also Sydenham, Morgagni, and others. The idea was de- rived from the fact that gravel and calcuh are so frequently met with in gouty sub- jects. In the e^r^y stages of Gout, should an opportunity be aCbrded of examining the 526 GOUT. kidneys, little or perhaps no alteration will be observed, but occasionally an ap- pearance indicating the action of the dis- ease may be presented to the eye, and the first change usually noticed is found to be due to the occurrence of some crystalline deposits in the organ. In 1849, the writer, when examining the kidneys of a man who had suffered from Gout, but who had died of another disease, found small white streaks which appeared to follow the di- rection of the tubes of the pyramidal por- tion of the organ ; he also discovered that at the extremity or mamilla of each cone there were certain white points ; — Dr. Todd and Mr. Ceeley had previously no- ticed this fact. On placing a little piece of the substance of the kidney under the microscope, the above-mentioned white streaks and points were found to be caused by the presence of numerous crystals, prismatic in shape, and consisting of urate of soda, that is, identical with those which form ordinary chalk-stones, and which are found in car- tilaginous and ligamentous tissues, but the crystals are usually larger. Shortly afterwards, the same condition of kidney was discovered in numerous other sub- jects, some of whom had been but slightly affected with Gout, and in one only eight seizures had occurred, and no external deposition or deformity had been pro- duced. At first it was thought that the white streaks were due to the blocking up of the uriniferous tubes, but afterwards the conclusion was arrived at that many of the crystals were imbedded in the struc- ture of the tubes themselves. M. Charcot, in an exceljent paper, entitled " Contribu- tions a I'Btude des Alterations anato- miques de la Goutte, et specialement du Kein et des Articulations chez les Gout- teux," has investigated this subject very thoroughly, and has given good drawings: he comes to the conclusion that, as far as the kidneys of the subject examined by himself were concerned, the deposit, which at first sight appeared to be situ- ated in the intervals or between the tubes, was in reality in part contained within them, and in a great measure amorphous; there were, however, crystals not within the tubes which appeared to radiate from the above matter into the intertubular structure. It would appear from the observations which have been made both in this coun- try and abroad, that even in the early stages of Gout the kidneys become imph- cated, probably in some cases much sooner than in others : that deposits of urate of soda take place in the tubes, which after- wards extend into the renal tissues. Causes of Gout.— The causes of Gout may be conveniently treated of under two heads ; first, those depending on the age, sex, hereditary and other peculiarities of the individual ; secondly, those indepen- dent of the aflected subject. Causes dependent on the Individual. Hereditary Ivfliiencc.—Some individuals are undoubtedly more disposed to Gout than others, and in such the disease is liable to be induced by agencies which would be comparatively harmless if ap- pUed to other people. There is, in short, a proclivity to Gout which may be in- herited ; and it is certainly true as regards this malady, that the sins of the fathers are visited upon the children to the third and fourth generation. Instances illus- trating the hereditary predisposition to Gout are so frequently met with, that no one who has had the least acquaintance with this disease can have failed to have observed it. My own experience would show that moi-e than half the gouty sub- jects can distinctly trace their ailment to hereditary taint ; and if patients in the upper class of society are exclusively se- lected, the percentage is found to be con- siderably greater. There exists a popular idea that Gout frequently skips over a generation, and that it has a peculiar ten- dency to attack the grandchildren rather than the children : this idea I beUeve to be erroneous, but at the same time ac- knowledge that there are often apparent grounds for it. Occasionally the child of a very goutj^ patient, having the fear of suffering before his eyes, will live such a life as to keep the disease at bay ; his children, however, may be fully under the hereditary influence of their grandparent and liable to a development of the malady from the ordinary exciting causes. "When true Gout is met with at an early age, the existence of hereditary taint may be sus- pected, and in the case of children this cause is certain to be powerfully opera- tive. However, it must not be forgotten that Gout may be acquired at a compara- ti^'el}' early age, by the influence of causes other than that of hereditary predisposi- tion. [Modification of the gouty diathesis often occurs in the course of hereditary transmission. The children or grandchil- dren of a person subject to regular Gout, may have it in its "flying" or irregular forms ; or they may have gouty neuralgia; or a proclivity to attacks of indigestion, which may be called gouty dyspepsia. Another modification not sufficiently ap- preciated by systematic writers, is goicty rheumatism: an affection which may in- volve the digestive apparatus as well as the larger joints, muscles, and fibrous tis- sues, ill attacks which differ more or less from typical rheumatic fever ; which are CAUSES OF GOUT, 527 attended U3uall3' by symptoms of indiges- tion ; and wliich are especially more" re- sponsive to the remedial action of colclii- cum, than is the case with ordinary articu- lar rheumatism. — H.] Influence of Sex. — Men are much more frequently the subjects of articular gout than women, and the causes of the com- parative exemption of females is not diffi- cult to understand, when we are acquaint- ed with the pathology of the disease. As far as hereditary causes are concerned, women are similarly circumstanced with men ; but there are many reasons explain- ing the immunity enjoyed by women. Some of these are intimately connected with the functional peculiarities of the female sex ; others depend upon the habits of life more commonly adopted by women. The occurrence of the catamenia during a long period of female life is doubtless a great safeguard against the disease, and, as a rule, whenever Gout does occur in the female, it is only after the cessation of this function. There are, however, striking exceptions now and then met with — instances of the most severe Gout attended with great crippling and deform- ity, in comparatively young women ; these cases are extremely rare, and most of them capable of explanation. Influence of Age. — Children are usually free from Gout ; and, although I have been assured of some being attacked when very young, yet, in every case where there has been an opportunity of strict investi- gation into the nature of the affection, there has been good cause to distrust the accuracy of the diagnosis which had been made. Many patients have informed me of their having had Gout when at public schools, and I have no reason to doubt the correctness of their statements, more especially as they have afterwards become the subjects of Gout in its severe forms ; I have myself seen the disease fully de- veloped in the great toe at the age of six- teen, but always in youths who have strongly inherited the affection, and who at the same time had not been altogether abstemious. As a rule, the stronger the hereditary predisposition, the earlier Gout develops itself in any individual, and it is rare to find it before tlie age of thirty unless some well-marked hereditary pre- disposition exists. From a table made by the late Sir O. Scudamore from a large collection of cases it appears that, dividing the period of life from twenty to sixty-five into intervals of five years, by far the greater number of first attacks occur from thirty to thirty- five years of age ; below twenty they are exceedingly rare ; and after sixty-five they are likewise very few in number. As there appear to be exceptional cases in early life, so also are there in old age, and I have known Gout make its first ap- pearance after the age of eighty, and in one instance when the patient was in her ninetieth year. Influence of Temperament. — Little that is positive can be asserted in regard to the influence of what is called the tem- perament of the individual upon the de- velopment of Gout. The more acute varieties of Gout are usually found in those of a sanguine temperament and full habit of body ; whereas the asthenic and irregular forms occur chiefly in spare sub- jects of a nervous temperament. Causes indepeistdbnt of the Individual. Alcoholic Beverages. —No one who has paid attention to the clinical study of Gout can doubt the influence of alcoholic drinks, both in laying the foundation of the gouty diathesis, and likewise in ex- citing attacks of the disease ; and, more- over, no one who has carefully analyzed the causes of this malady can fail to per- ceive that different kinds of spirituous liquors differ greatly in their power iu this respect. This subject is of so much importance that we shall not hesitate to dwell shortly upon it. Distilled spirits have certainly less tendency to induce Gout than either wine or malt liquor : the truth of this remark can be proved by in- vestigating the cases which occur in the large cities of England, and, more clearly, by noting the prevalence of the disease in other countries where little of any other spirit is taken. Among the laboring classes of London, Gout is very frequently met with ; wliereas, among the same class in Edinburgh and Glasgow, it is scarcely ever seen : the former partake largely of porter and beer, the latter almost entirely of whisky, and in no inconsiderable quan- tities. The same fact is illustrated in the almost entire absence of Gout in many cities on the Continent, especially in Poland and Eussia, where a distilled spirit is almost exclusively made use of. As predisposing to Gout, I cannot from experience say whether all distilled spirits are equally innocuous : brandy, whisky, and gin have certainly little predisposing power : rum has been asserted to cause Gout in the West Indies, but the state- ment is old, and there is no good clinical evidence in support of it. In countries where the lighter kinds of wine form the chief or sole alcoholic bev- erage of large classes of the people, the occurrence of Gout is comparatively rare : as, for example, among the working popu- lation of Trance, most parts of Germany, and, I believe, also of Italy ; but it is asserted that in certain parts of Germany, as in Berlin and Munich, where malt liquor is largely consumed, the disease is much more prevalent. 628 GOTJT. It must not be thought, however, that these light wines can be taken with im- punity, for although their gout-producing tendency is small, compared with some of the stronger Avines and malt liquors, still it is very decided. Light claret, hock, and moselle are probably the best of light wines. The stronger wines, as port, madeira, and sherry, probably also marsala, are much more potent as gout-producers, and a free indulgence in their use for several years will very often bring on the disease in those not known to have derived any taint from their ancestors. Port enjoys a very marked reputation in this respect ; it is doubtless as we receive it from Portu- gal, a wine very likely to cause Gout — per- haps more so than any other. Sherry, however dry and pure, is by no means the innocent beverage, as far as Gout is con- cerned, that many people imagine ; I have met with several cases of severe Gout brought on solely by this wine, and have also known attacks of the disease kept up for an almost indefinite period by the patient continuing the use of it, even in small quantities. Madeira is fully as in- jurious as sherry to the gouty suljject, and doubtless, if freely partaken of for any length of time, would be capable of in- ducing the malady in those not previously disposed to it. The same remark applies to several other wines, possessing charac- ters closely allied to those of the above- mentioned class. That malt liquors predispose strongly to the production of Gout is made evident by the frequency of this disease among the laboring classes and artisans of the large cities of England, where porter is so freely indulged in : thus Gout is very com- mon with brewers' men, ballasters, and many others. Even the pale bitter ales, though to many so grateful and useful, will, when too freely partaken of, give rise to the development of Gout, and sev- eral cases in which such ale was the sole cause have occurred in my practice. It only remains for us to investigate the influence of one other alcoholic drink — that is, cider — which forms so favorite a beverage in many of the counties in Eng- land, niore especially in Herefordshire and Devonshire ; also, of the United States of America. Concerning its gout-producing powers many and diverse opinions have been held. Dr. Wood of Philadelphia in- formed me that, as a predisposing cause of Gout, cider cannot be very potent, else the disease would have been more preva- lent among the people of New England and the Middle Atlantic States, where it is very commonly drunk. Having taken some pains to investigate the question in this country, the results I have arrived at are as follows : — 1st. That fully fermented cider — that in which the whole of the saccharine mat- ter has been got rid of, and which consti- tutes genuine rough cider — has but little power in inducing the gouty diathesis. 2d. That sweet and partially fermented cider, when taken in large quantities, pre- disposes to Gout. 3d. That the latter variety, and even the former, when taken by gouty indi- viduals not much accustomed to its use, is apt to excite an attack of the disease. Having enumerated the relative powers of different alcoholic liquors in common use in this and other countries, in indu- cing Gout, it becomes a question of inte- rest to endeavor, if possible, to get some clue as to the cause of such diflercnces ; or if unable to accomplish this, at any rate to point out the known peculiarities of each class of such beverages. The distilled liquors consist of alcohol, more or less diluted, and combined with very small amounts of volatile oils or ethers : thus, brandy contains cenanthic ether, the peculiar principle of all wines ; gin, a little oil of juniper; and so on. They should not hold in solution any non-vola- tile substances, and should be free from saccharine matter and acidity. The per- centage of real or anhydrous alcohol in the different distilled spirits varies greatly, ranging from 70 per cent, in undiluted rum, to about 30 per cent, in gin. Wines consist of diluted alcohol, com- bined with certain soluble compounds, as cenanthic and other ethers, free acids antl salts, and, besides these, coloring, astrin- gent, and saccharine matters. The amount of alcohol varies, from about 18 to 22 per cent, in ports, sherries, and madeiras, to 7 to 9 per cent, in clarets and hocks. The acids and salts consist chiefly of tartaric acid and the acid tartrate of pot- ash : there are also small amounts of other salts, as phosphates of lime, magnesia,' and iron. The amount of alcohol in port wines varies from 17 to 21 per cent. ; in made- ria it is about the same ; in sauterne it varies from 12 to 15 per cent. ; in red Erench wines from 9 to 14 per cent. ; in champagne 10 to 11 per cent. ; in Rhine wines 6 to 12 per cent., usually from 9 to 10 per cent. Measured by the amount of acidity. Dr. Bence Jones has arranged wines and spirits as follows :— Sherry, port, madeira, champagne, burgundy, hock, and moselle. The least acid of all alcohohc spirits are geneva and whisky, then rum and brandy, afterwards ale, porter, and stout ; all wines are found to be more acid than malt liquors. Measured by the amount of contained saccharine matter, commencing with the lenst sweet, spirits, wines, and malt liquors may be thus arranged : geneva, CAUSES OF GOUT. 529 rum, whisky, claret, burgundy, Khine wines, and moselle have no sugar ; then brandy, sherry, madeira, champagne, port wine, cider, porter, stout, malmsey, ale, tokay, samos, paxarete, and Cyprus. The knowledge of the composition of the different kinds of alcoholic fluids has not thrown much light upon their varying powers of inducing Gout, and the follow- ing summary includes nearly all that can be clearly made out on the subject : — ' 1. Diluted alcohol, in the form of dis- tilled spirits, has little power in causing Gout, at least in those who are not pre- disposed to it. 2. Alcohol, when in combination with other substances, as in wines and malt liquors, becomes a potent cause of Gout, and the greater the amount of contained spirits in such beverages, the more power- ful their influence in producing the disease. 3. Neither the acid, sugar, nor any known principle contained in these liquors, can as yet be proved to impart to the al- cohol its predisposing influence ; for wines the least acid, and liquors the least sweet, are among the most baneful. i. Alcoholic drinks which have little tendency to cause dyspepsia, and those which more especially act as diuretics, can, as far as Gout is concerned, be taken with greater impunity than beverages of an opposite character. Influence of the Solid Food in causing Omtt. — It is matter of much difficulty to assign the share that different articles of solid food have in the production of Gout, and likewise to separate the effect of indi- gestion caused by any article of diet from the secondary influence of the same food after its absorption into the system. Cul- len remarked that Gout seldom attacked persons who lived much on vegetable diet, but he added, or persons who were employed in constant bodily labor ; and doubtless the disease is rare amongst those who live in the country, working hard, and living abstemiously. Experi- ence, moreover, has pretty well estab- lished this fact — namely, that an excess of food, more especially animal food, fa- vors the production of Gout, and it proba- bly does so by causing an increased for- mation of nitrogenized compounds, more especially uric acid. Vegetable substances have comparatively little direct influence, unless they cause dyspepsia from their mechanical structure, or other peculiari- ties. As far as composition is concerned, it is probable that articles of food contain- ing a considerable amount of saline prin- ciples, as for instance the salts of potash, are useful in keeping up the activity of the secreting organs," especially the func- tion of the kidneys, and many such sub- ' Nature and Treatment of Gout. Second edition. VOL. I.— 34 stances, even if acid to the. stomach, yet tend to alkalinize the blood and urine from the decomposition of the vegetable acid,and the formation of a carbonate of the alkali. Pie-crust and sweet substances probably are injurious rather from the indigestion they induce than from containing any noxious principles. Made dishes, and those which are very rich and complex, are liable to upset the stomach, and thus act rather as exciting than predisposing causes of Gout. Indigestion as a Cause of Gout.— In in- vestigating this subject, great difficulty is experienced in discriminating between the dyspepsia leading to Gout and that which arises from an already formed gouty dia- thesis. Many persons suffer from dys- pepsia all their hves, and yet never ex- hibit a gouty symptom ; on the other hand, some of those most severely afflicted with Gout have scarcely ever felt the sen- sation of indigestion. Indigestion, if it causes the production of an increased amount of acidity in the sys- tem, can easily be i-upposed to aid the de- velopment of Gout, by causing a less alka- line state of the blood, and hence favoring the insolubility and deposition of the urate of soda in the tissues ; it may also act as a predisposing cause by promoting the formation of uric acid itself. The form of dyspepsia which seems most injurious is that which is connected with congestion of the portal system, and increased vascu- larity of the mucous membranes of the stomach. Although observations have not shown that exercise has any marked influence upon the amount of uric acid excreted in a given time by a healthy person, still it is certain that want of exercise soon leads to a sluggish performance of the more im- portant functions of the body, and the production of dyspepsia indirectly favors the development of Gout. Influence of Neriv/us Depression. — Any circumstance which lowers the tone of the nervous system tends very greatly to the development of the gouty paroxysm, al- though it is questionable if this cause alone can produce the gouty diathesis. The effect of the mind upon the function of the kidneys, is well known and easily appre- ciated, and upon the other secreting or- gans, although less readily observed, it is doubtless equally potent. Any severe mental labor is often followed by an at- tack, and so is prolonged sorrow ; and venereal excesses probably act by lower- ing the tone of the nervous system. Infljuence of Climate and Season.— There is no doubt that Gout is much less preva- lent in hot than in cold or temperate countries, and it would appear from the reports of travellers that the disease is un- known among the natives of the interior j of Africa ; it' is rare, if not unknown, in 530 GOUT. China, Japan, the East Indies, and Tur- key, and much less frequent in the south of Europe than in this country. Great stress, however, must not be laid on these facts, for Gout is scarcely seen among the laboring populations in Poland, Russia, and other cold climates. The character of the beverages used by these different peoples has probably more influence upon the production of Gout than the climate under which they live. As far as regards the development of an attack, climate and season have a very decided influence : for example, a gouty man may often escape his accustomed winter attacks by removing from England to Malta or Egypt during the cold season in this country; and the histories of gouty patients afford abundant proof of the com- parative frequency of gouty seizures in the winter months. In the early stage of Gout the attacks are most frequent in spring, and are often confined to that season ; after a time an autumnal seizure is added ; but when the disease has becouie further ingrafted into the system, the fits may occur at any sea-, son, and at most irregular intervals. There are occasionally found exceptions to the above rules ; for some patients, ow- ing probably to individual peculiarities, suffer far more in summer than in winter. In warm climates and during hot sea- sons the function of the skin becomes more active, and this fact affords an ex- planation of any influence dependent on these circumstances. Influence of Lead Impregnation in causiiig Gout. — About fifteen years since I was struck with the fact that a large percent- age of the gouty patients who had come under my care in hospital practice con- sisted of painters, plumbers, or other workers in lead, and a more careful inves- tigation of the sub j ect forced the conclusion on my mind, that the influence of this form of metallic impregnation in inducing a gouty condition of the system was very considerable.' Since that period I have made many observations on the point, and the conclusions may be summed up in a few words : — 1. Among the patients in London hos- pitals, a very large proportion of the gouty (about thirty per cent, in my hospi- tal practice) have been subjected to the influence of lead : many of these have had painters' (lead) colic ; some have suffered from wrist-drop or more severe f6rms of lead paralysis ; and all have exhibited the peculiarly characteristic blue line on the gums. On careful inquiry into the habits of these men, nothing remarkable has been eUcited ; they have been about as temper- ' Transactions of Medico-Chirurgical Soci- ety, vol. xxxvi., 1854. ate as other men employed in different occupations. It is not painters alone who form this high percentage, but plumbers, composition doll-makers, workers in lead mills, and others whose trades have caused them to be exposed to the use of lead. It may be considered as estabhshed, that the metal lead acts as a powerful pre- disposing cause of Gout. 2. Many cases have occurred which have induced me to believe that indi- viduals suft'ering from the gouty diathesis are more susceptible to the influence of lead than the majority of other people. It is a well-known fact, that when the drinking water in any house is slightly impregnated with this metal from the cis- tern or pipes with which it has come in contact, some of the residents in that house may experience the symptoms of saturnine poisoning, while the rest may be unaffected, although drinking an equally large quantity of such water ; thus proving that some people are pecu- liarly susceptible to its influence : some remarkable examples of this fact have come under my notice. In the medicinal administration of lead preparations, as in cases of hemorrhage, or excessive mucous discharges, it will be observed, if patients be closely watched, that the blue line ap- pears on the gums in some cases with ex- treme rapidity, and that even colic pains are soon experienced ; but that in others the use of the lead salts can be continued for a lengthened period, without the pro- duction of any such phenomena. In sev- eral instances where patients have proved to be very easily affected, it has been found that they were of a gouty habit, and many of them had repeatedly suflered from severe attacks of the disease. 3. In some instances, severe attacks of Gout have been induced in gouty patients by the medicinal administration of lead salts, on account of the occurrence of epistaxis or other forms of hemorrhage ; and the frequent recurrence of the seiz- ures, whenever the medicine has been re- peated, has satisfactorily shown that the phenomena were to each other in the relation of cause and effect. 4. On investigating the physiological action of the administration of lead salts, it is discovered that a very decided effect is produced by that metal upon the se- creting power of the kidney, as far as uric acid is concerned ; the function is notably diminished. 5. The blood of individuals suffering from lead paralysis always contains an abnormal amount of uric acid ; and the same, probably, holds good in all cases of lead colic. 6. There are many facts which seem to show that the influence of lead, when un- combined with that of fermented liquor, is scarcely able to produce gout ; for al- PATHOLOGY OF GOUT. 531 though in England G-out is so common among those who work witli lead prepara- tions, yet neither in Trance nor Scotland has the connection been noticed. In Edinburgh, however, even lead poisoning appears to be much less frequent among painters than in England. Before concluding this subject, it should be observed that it has long been a mat- ter of medical observation, that lead poi- soning often gives rise to pains in the limbs which have generally been regarded as rheumatic or neuralgic in character. These pains, however, which appear to be likewise produced by some other met- als, must not be confounded with Gout, with which they probably have no rela- tion. Pathology of Gout. — Our space is insufficient to allow of even a brief sum- mary of the different views wliich have been held from time to time, and by dif- ferent writers, of the real nature of Gout. As the disease has been known from re- mote antiquity, and as it is one which has always appeared to interest mankind, it is not to be wondered at that very nu- merous and diverse views have been ad- vocated. The existence of an altered condition of the blood has been always a popular belief among the ancient as well as modern pathologists; but various opin- ions as to the nature of the alterations have been held. The ancients, as was their wont, ascribed Gout to the super- abundance of phlegm, bile, and other natural secretions in the system, and they attributed chalk-stones to the con- cretions of such matters in the aifected parts ; and such ideas were held by some physicians even up to a comparatively late date. There have not, however, been wanting supporters of a totally different doctrine — men who, discarding all ideas of a morbid state of the fluids of the body, have looked upon the disease as dependent upon an alteration in the structure or functions of the nervous, vascular, and other systems. Cullen was the great supporter of the anti-humoral doctrine, and brought for- ward many cogent reasons for not regard- ing gout as due to an altered condition of the blood or the secretions therefrom. Cullen was a physician whose views are always worthy of consideration, and al- though many of his statements can now be shown to be erroneous, still a short summary of his objections may not be disadvantageously given, if only for the purpose 6i being combated. Cullen thought that there was no evidence of the presence of any morbid matter in gouty persons ; that neither the blood nor secretions from it had been proved to he altered in this disease, and that pre- vious to an attack there was no symptom indicating such a change; but that the balance of evidence was against this idea, seeing that many individuals before a seizure were apparently in unusually good health. From what has been al- ready stated in the present article, it will not be difficult to show the error of the above opinion; for it has been demon- strated beyond doubt, by clinical evi- dence, that the blood is invariably altered in Gout, from the presence of uric acid in the form of urate of soda ; that the secre- tions from the blood are likewise influ- enced ; that symptoms are usually pres- ent before the development of the articular inflammation; and, lastly, that the in- flamed parts are always altered by the secretion into their structures of the same urate of soda — a phenomenon which has never been shown to occur except in this disease, and which may therefore be re- garded as pathognomonic. Cullen, who was necessarily aware of the occasional presence of chalk-stones in gouty subjects, overcame the difficulty by stating that such deposits only occurred now and then, and after the disease had been present a long time ; and, in fact, regarded chalk-stones as accidental phe- nomena, and in no way essentially con- nected with the disease. Cullen consid- ered Gout to depend upon a peculiar conformation of some portion of the ani- mal economy, more especially the nervous system ; he regarded the chief exciting causes, such as intemperance, indigestion, cold, and other depressing influences, as acting upon the nervous centres, and looked upon most of the symptoms of retrocedent Gout as affections of the same kind. Cullen's theory of Gout is best expressed in his own words : " In some persons there is a certain vigorous and plethoric state of the system, which, at a certain point of life, is liable to a loss of tone in the extremities. This is, in some mea- sure, communicated to the whole system, but appears more especially in the func- tions of the stomach. When this loss of tone occurs, while the energy of the brain still retains its vigor, the vis medicatrix naturce is excited to restore the tone_ of the parts, and accomplishes it by exciting an inflammatory affection in some parts of the extremities. When this has sub- sisted for some days, the tone of the ex- tremities and of the whole system is restored, and the patient returns to his ordinary state of health. This is the course of things in the ordinary form of the disease, which we name regular Gout ; but there are circumstances of the body, in which this course is interrupted or varied. Thus, when the atony has taken place, if the reaction do not succeed, the atony continues in the stomach, or per- haps in other internal parts, and pro- 532 GOUT. duces that state which we have, for rea- sons now obvious, named atonic Gout. "A second case of variation in tlie course of the Gout is when, to the atony, the reaction and inflammation liave, to a certain degree, succeeded ; but, from causes either internal or external, the tone of the extremities, and perhaps of the whole system, is weakened ; so that the inflammatory state, before it had either proceeded to the degree, or con- tinued for the time, requisite for restor- ing the tone of the system, suddenly and entirely ceases. Hence the stomach and other internal parts relapse into the state of atony, and perhaps have thus increased by the atony communicated from the ex- tremities ; all which appears in what we have termed retrocedent Gout. "A third case of variation from the ordinary course of Gout is when, to the atony usually preceding, an inflammatory reaction fully succeeds, but its usual de- termination to the joints is by some cir- cumstances prevented ; and is, therefore, directed to an internal part, where it pro- duces an inflammatory affection, and that state of things which we have named the misplaced Gout." It is as easy to show the fallacies in this theory of Cullen concerning the na- ture of Gout, as td refute the many dog- mas which he pvits forward ; and, there- fore, the mere enumeration of it must be considered sufficient. Since Cullen 's time there have been writers on this disease, who, even with the knowledge of some at least of the facts recently discovered, still cannot bring themselves to admit the truth of the humoral doctrine of Gout. The late Sir C. Seudamore, although con- fessing many difficulties, was, up to a few years before his death, of opinion that there existed a species of plethora. The subject of chalk-stones \\as already a difficulty with him, and the discovery of the constant presence of uric acid in the blood of gouty patients shook his confi- dence in his old ideas upon the subject. A recent writer. Dr. Gairdner, believes in the existence of a state of plethora of the chylopoietic organs as a constant ac- companiment of Gout, and thinks like- wise that the veins of the part are in a varicose state, that the heart is oppressed with a flood of returning venous blood, made impure from the non-elimination of urea, uric acid, and biliary matters ; and he thus views the phenomena of a paroxysm of Gout : "Venous congestion I consider the first condition essential to the formation of the gouty diathesis. It is no new observation ; it is found inter- spersed through the writings of all former authors. Even those who adopt expla- nations inconsistent with such a state of things, notwithstanding admit it. This Btate of the blood was first clearly an- nounced as the great cause of Gout by Galen, whose opinions have continued to influence the minds of succeeding phy- sicians in a greater or less degree to the present day. The truth of the fact lieing, I imagine, unquestionable, it will alwaj's continue to embarrass the doctrines of those who advocate opinions ■\\ifh wnich it is incompatible. But the great venous canals of the body, as well as the larger arterial vessels, are endowed with a re- siliency which enables them to struggle well against the flood of returning blood. This fluid, then, is compressed between two opposing forces — that, namely, which is derived from the heart and arterial sys- tem, urging it forward on its course, and, on the other hand, the antagonistic re- sistance of the great veins leading to the right auricle. Under this compression, I believe that the vessels give way, and a true hemorrhage is occasioned in the part aftected. If the rupture takes place in a minute capillary, carrying the serous por- tion of the blood only, adema is the con- sequence ; but if the burst bloodvessel be one carrj-ing red blood, a true ecchymosis is formed." And again : "It will surely he admitted that the capillary and nutrient vessels, distributed on the extreme and sentient fibrillse of the nerves, are affected in the same manner as the larger venous trunks. I believe these distended capillary vussels are the real seat and cause of the painful phenomena of Gout. Is it not credible that such vessels, dilated so as to admit fluids for which they were not intended, and bound down by the firm fascife, in which Gout has its usual seat, may give rise to much suftering ?" The great objection to Dr. Gairdner's views is, that there is no proof of the oc- currence of hemorrhage during the gouty seizure ; no one has seen the ecchymosis spoken of by him as a constant attendant on it, whereas other and frequent changes are invariably observed in the inflamed part. It is, indeed, true that abdominal plethora is often present in gouty habits, especially when the disease has been in- duced by high living ; but on the other hand, in many cases, even when the dis- ease is of an inveterate character, no symptoms indicating such a condition are discoverable. Furthermore, congestion of chylopoietic organs, accompanied with obstructed cardiac circulation, is very frequent and of long duration, and yet no Gout is developed. J\Iany other authors have, within the last half century, published views as to the nature of Gout ; amongst whom, in this country, may be mentioned jMurray, Forbes, Parkinson, "Wallaston, Parry, Sutton. Sir E. Home, and Sir Henry Hol- land. The reflections of the last-named physician on the subject are well worthy PATHOLOGY OF GOUT. 533 of attention. In France the principal authors have been Cruvoilhier, U. Petit, Barthez, Guibert, and Trousseau. Some of these have been inclined to favor the views of the solidists, but perhaps the opinions of the majority have had a de- cided tendency to humoralism. After these short expositions of some of the principal opinions, which have been held of the nature of Gout in recent times, and which have proved to be wlioUy or in part fallacious, it is necessary to lay be- fore our readers the view which we think accords more completely with facts than any other which has been proposed, and one which will explain nearly all the phe- nomena presented by the disease. In the first place, "it is essential to the produc- tion of this form of articular inflammation that the blood should contain an abnormal amount of uric acid, or rather of urate of soda ; and even the phenomena which constitute irregular Gout, or are regarded as gouty manifestations, demand for their occurrence the presence of the same salt in the circulating fluid." The truth of this proposition has been proved by some hundred clinical observa- tions upon cases of articular inflamma- tion ; and although it has not been fre- quently demonstrated in cases of irregular Gout, yet this has been done sufficiently often to make it matter of certainty. It will, therefore, be unnecessary to bring forward any further evidence of the cor- rectness of the proposition. In must not, however, be supposed that an excess of urate of soda in the blood constitutes Gout; this would be erroneous, for the salt is occasionally present in large quantities, and yet no gouty phenomena are manifested; but the individual so cir- cumstanced may be looked upon as espe- cially prone to its development, if othi'r circumstances arise which favor its pro- duction. In the next place, " gouty inflamma- tion is invariably accompanied with the presence of urate of soda in the inflamed tissue." We have already given much evidence of this fact, and in no case in which real gouty inflammation has been shown to have occurred have the morbid appear- ances failed to present themselves when sought for. Furthermore, " it can be shown that the amount of deposited urate of soda is not in proportion to the intensity of the inflammation, and that in some structures the infiltration may ensue and scarcely give rise to any inflammatory action; facts tending to the supposition that the de- posited matter may be looked upon as the cause rather than the effect of such inflam- mation." _ It is most important, as bearing con- siderably upon the true pathology of Gout, that the above proposition should be fully substantiated, and it is not dilhcult to bring forward much evidence in its fiivor. If an opportunity occurs of examining a joint, as the knee, which has been but once attacked, no great amount of alteration may be exhibited, although the inflam- mation has been intensely acute ; on the other hand, after a joint has become, as it were, callous, considerable deposition can be shown to occur without the pro- duction of much local inflammation. The same fact is better illustrated in the case oi' the ear, in which, as before stated, urate of soda is frequently deposited in the flbro-cartilaginous tissue. This phe- nomenon, although at times recognized from the sensation of heat, pricking, and tenderness (jf tlie part, yet more commonly takes place without the production of any symptom— the patient being, in fact, quite unconscious of its occurrence. In many chronic forms of Gout it is not unusual to find large collections of the white matter formed near the surface, with compara- tively little constitutional disturbance, and any one watching the progress of such a case must soon become convinced that the elimination of tlie salt is not an effect of the inflammation. To show that it is probably the cause is equally easy : let us compare, for example, the articulating surfaces of the knee-joint with the fibro- cartilage of the external ear, in respect to their liability of becoming inflamed from the presence of foreign bodies or the in- fliction of injuries; irritation of the former is known to be most serious in its results, from the acute action which is set up, whereas considerable damage may be done to the latter without any but the slightest inflammation ensuing. Would not a like difterence exist in the same tissues if a substance foreign to tlieir constitution be- came infiltrated by the action of disease ? " The inflammation of the gouty parox- ysm tends to the destruction of the urate of soda in the blood of tlie inflamed part, and probably also of the salt which has been thrown out." When describing the blood and secre- tions of gouty subjects, allusion was made to the fact that, although the fluid efTused from the action of a blister usually con- tains uric acid, yet an exception occurs in the case of its being applied over an acutely inflamed surface. Under these circumstances, it would appear that the uric acid is destroyed by the presence of the inflammatory action ; and, if this be true, the gouty paroxysm is, at least to some extent, a salutary process, tending to rid the svstem of accumulated uric acid; but, as the fit is always accompanied by local mischief, the good eftected is by no means unalloved. "Gontv deposits do not take pla,ce in- discriminately in any situation or in any 534 GOUT. tissue ; but a selection is made, in close relation to the vascularity of the part." If the remarks ou the morbid anatomy of Gout be referred to, it will be observed that the structures most liable to become aft'ected are those possessing little vascu- larity ; as, for example, cartilage, fibro- cartilage, ligament, tendon, and synovial membrane. It will be seen, also, that the deposit, as it were, avoids the contiguity of bloodvessels, as exemplified in the knee- joints, in which the surfaces in contact with the synovial fringes are free. Again, in the cartilage itself, the deposition, al- though intestinal, commences near the free surface, and gradually penetrates deeper into the tissues, but, even in ex- treme cases, scarcely extends beyond a third of its thickness, and is always at a considerable distance from the blood- vessels of the bone. It is probably owing to this freedom from deposition which vascular tissues enjoy, or to the rapid destruction of the urate of soda when placed under circum- stances which bring it into contact with bloodvessels, that acute gouty intlanima- tion does not affect the covering or lining membranes of the heart, as is the case with rheumatic inflannnation. The mor- bid changes which are often found in the valves of the heart, or the lining mem- brane of the aorta, form no exception to this statement, for they are not due to the presence of urate of soda, but to an alter- ation of an entirely different character. " The kidneys are often, if not always, implicated in Gout, and the afifection, possibly only functional at first, soon be- comes structural. The urinary secretion is likewise altered." Under the "Morbid Anatomy" of the disease it has been affirmed that, in all cases where Gout has existed for any length of time, some alteration is found in the kidneys ; deposition within or ex- ternal to the tubuli uriniferi is discovered, and the normal structure of the secreting apparatus is injured. In chronic cases the peculiar shrivelled or gouty kidney is frequently met with. As yet I have never seen this latter form of kidney disease vrithout finding the white deposition, and I cannot help thinking it probable that the presence of the urate may be the ex- citing cause of the subsequent changes which ensue in the structure ot the kidney. The kidney affection, whether func- tional or organic, readily explains the altered state of the urinary secretion : The functional disturbance may cause the defect and irregularity of the secretion of uric acid ; the organic alteration accounts for the further diminution in the excre- tory power of the organ, and the frequent presence of a small amount of albumen in the urine. " The impure state of the blood, due to the presence of urate of soda, is probably the cause of the disturbance which often precedes the gouty paroxysm ; that is of the so-called premonitory symptoms, as well as most of the anomalous affections (irregular Gout) to which such patients are liable." That suppression of the whole urinary secretion such as occurs in intense renal congestion and advanced forms of albu- minuria gives rise to many and alarming symptoms, is a well-known and acknowl- edged fact ; and hence it is reasonable to suppose that a suppressed excretion of one of its constituents should manifest itself by symptoms of a less intense and fatal character. Possibly some of the symp- toms may be due to the reaction conse- quent upon an attempt at deposition of urate of soda in certain unusual situa- tions. Dyspepsia, for example, is very common in albuminuria ; it is also fre- quent in persons of a gouty diathesis. " The causes which predispose to Gout, independent of those connected with in- dividual peculiarity, are eitlier such as produce an increased formation of uric acid or which lead to its retention in the blood." Although our knowledge of the causes which lead to the undue formation of uric acid is most imperfect, yet there can be little doubt that over-feeding, especially in regard of animal food, portal congestion, and deficient exercise, aid very much in the production of its excess ; and it is known from clinical experience that these are predisposing causes of Gout, as ap- pears to be also lead impregnation, the use of malt liquors, wines, and so on, which probably lead to a defective elimi- nation of the same acid. Deficient ner- vous energy, arising from mental or other causes, seems to act in the same manner. " The causes exciting a gouty fit are those which induce a less alkaline condi- tion of the blood, or which greatly aug- ment for the time the formation of uric acid, or such as temporarily check the eliminating power of the kidneys." The deposition of urate of soda is caused by its insolubility, and this may arise either from the large amount which is formed, or from the serum of the blood becoming less capable of holding it in solution. The blood serum is alkaline in reaction, and this condition may become lessened from various causes, especially from deficient action of the skin, the taking of a large amount of acid into the stomach, and, perhaps, an increased for- mation of some acid, arising from dyspep- sia : all the above-named circumstances will, it is known, often excite a gouty attack. It seems probable that there may be at times a great temporary in- PATHOLOGY OF GOUT. 535 crease of uric acid found in the system, by causes giving rise to an attack of dys- pepsia. "Deposits of urate of soda in the tex- tures of the body never occur but in true Gout." It has already been shown that urate of soda invariably accompanies gouty in- flammation, and it can be equally proved tliat it is not thrown out under other cir- ' cumstances. There are, indeed, many statements which appear at first to throw doubt upon the correctness of the above proposition, but which upon closer ex- amination can be shown to be erroneous. I have seen white nodules on the ears of young people who have apparently had no gouty tendency : these have been found to contain fat and amorphous granular matter, but no crystals of urate of soda. I once was shown a large tumor, taken from the scalp of a young woman, and was assured that it had been analyzed and found to consist of urate of soda, and that there certainly was no gouty ten- dency in the patient. On examining a portion of the tumor, no trace of uric acid could be discovered in it. Diseased joints from rheumatoid arthri- tis, and other chronic diseases, have been also asserted to be covered with a urate deposit : in all such cases I have shown that bone-earth concretion has been mis- taken for urate of soda. In examining the large toe-joints of a large number of bodies, a little white spot was seen in two instances ; yet no Gout had been known to have occurred during life. One of the individuals had been a cabman, and had granular kidneys — he had died from an injury ; the other had died of delirium tremens. In each case one foot only was atfected, and the space covered with the deposit did not exceed a sixteenth of a square inch. These spots were doubtless indicative of very slight gouty inflammation, and in the investiga- tion of cases of confirmed Gout it is ex- tremely common to find that patients have complained of twinges and slight tenderness of the great toe for several years before the occurrence of a distinct and unmistakable paroxysm. Explanation of other Phenomena which occur in Gout. — There are certain pecu- liarities in the history of Gout which still require explanation, one of which is the fact that gouty inflammation in its first visitation generally attacks the ball of the great toe. Boerhaave and Van Swieten tried to explain this by supposing that Gout chiefly attacked those tissues in which the fluids have most difficulty in passing through, as the periosteum, ten- dons, nerves, membranes, and ligaments, and such as are most remote from the heart, most pressed upon and injured, and most subject to cold and moisture. I be- lieve that there is much truth in these remarks, although expressed in terms which are not conformable to the patholo- gy of the present day. Let us endeavor now to explain the phenomenon. The great toe contains a considerable amount of tissues peculiarly liable to be- come the seat of the deposition of urate of soda ; as, for example, the cartilages and ligaments, tissues having either little vascularity or nourished independently of bloodvessels : the great toe being very re- mote from the heart, the circulation is weaker there than in many other parts, weaker than in the hips or knees. These remarks, however, both with regard to the tissues and the distance from the heart, apply even with greater force to the phalangeal joint of the great toe than to the metatarso-phalangeal joint, and apply also to the joints of the smaller toes ; but, on the other hand, this latter joint is more subject to injury by pressure; it often has to bear the whole weight of the body, and sudden shocks — as, Ibr in- stance, from false steps — are first felt in this articulation. In cases where the great toe has not been attacked, some pe- culiarity has been present in the conform- ation of the foot, which has had the eftect of throwing the pressure on some other part. That the metatarso-phalangeal joint is liable to injury, I have been able to ascer- tain from the examination of several great-toe joints in subjects who had never had Gout ; and it was found that in six instances only out of twenty were these joints absolutely healthy, there being in the rest more or less evidence of ulceration of the cartilages. The reasons for the great toe of one side of the body bein^ affected apply equally to the other ; and hence the disease not uncommonly attacks first one and then the other, within the space of a few hours or days. It is not difficult even" to explain the sudden shifting of the inflammation from one joint to another : it must be remem- bered, that the deposition precedes the inflammation, and it is well known that the establishment of inflammation in one part is often followed by its subsidence in another. The nervous connection through the spine may also explain the alternation of inflammation so often observed in sym- metrical joints. In explanation of the reason why nu- merous joints are attacked as Gout gains ground, or becomes more engrafted into the svstem, it may be advanced that the cartilages and ligamentous structures of the earlier implicated articulations being infiltrated with the urate, and the blood still remaining impure from the presence of the salt, other surfaces are required to be selected. The defective circulation m the external ear, from the nature of its 586 GOUT. structure and its exposed situation, is probably tlie iva^on wiiy tlie small urate nodules are so frequently found upon it. I may remark that, up to the present time, I have never seen the concretions on the ears of females ; this immunity may arise from their being usually cov- ered : individuals with cold ears seem to be most frequently affected with them. The cartilaginous, fibrous, and ligamen- tous tissues are peculiarly susceptible of becoming the seat of the deposit, partly from their little vascularity, and probably also from the fluids in these structures being less alkaline in reaction than the blood itself, and liable to become neutral or even acid. After death, in chronic gouty cases, the synovial fluid has been found in a few instances dis- tinctly acid. The explanation of the comparative im- munity from Gout enjoyed by females is to be sought for in their freedom from the influences of many extraneous causes, and their possession of a function which has a tendency to rid the system periodically of superfluous blood. As a rule, women take much less wine and beer than men, and altogether lead lives of greater pru- dence. After the cessation of the cata- menia, women become more liable to gouty paroxysms. "Women who inherit Gout strongly, even if tliey live very care- fully, are apt to suffer from the irregular manifestations of the disease ; the same remark applies to men who, inheriting the disease, and having the fear of it before their eyes, have from early life studi- ously avoided the causes which engen- der it. The reason of the almost certain recurrence of Gout, unless the greatest care be taken to overcome the tendency, must be sought for in the fact that the causes of the increased formation of uric acid in the system, and of its defective elimination, are generally irremovable ; the periodicity of the disease may be due to the gradually increasing impurity of the blood from the time of the purification which occurs during the fit, and also to periodicity of the exciting causes — as the recurrence of the vernal and autumnal changes. Diagnosis of Gout. — To make a cor- rect diagnosis in cases of joint disease is a matter of importance, not only as regards the treatment, but as respects the prog- nosis : it is likewise often one of great difficulty, and always requires great care, even with those who have had most expe- rience in the subject. To determine if a case be of a true gouty character or not : — The history of the case should be fully inquired into ; it must be remembered that Gout is strongly hereditary, and therefore, if either parent or grandparent of the patient suffered from it, the proba- bility of his joint affection having the na- tureof Gout is much strengthened. The age should be taken into account ; Gout is very rare before puberty, not com- mon till after thirtj'-eight or forty years of age ; it may occur at a very advanced age. The sex of the patient influences the diagnosis ; Gout is much more frequent in males than females ; in the latter it is seldom seen till after the catamenia have ceased. The mode of life of the patient for the several past years should be taken into consideration. Wine, malt liquors, and much animal food, tend to produce Gout ; spirits have little effect. The history of the disease in its early stages should be inquired into. If we discover that the ball of the great toe was first and specially affected, and that the intervals between the attacks were of considerable duration, the conclusion that it is true Gout is al- most certain to be correct ; but if the his- tory has not been of this characteristic nature, it must not be concluded that the affection is not gouty. An error may sometimes arise from laying too much stress upon the toe affection, to the exclu- sion of other symptoms ; I have seen a great toe swollen, tense, red, and hot, and having every appearance of being attacked with intense gouty inflammation, which has afterwards been proved to depend on pyaemia. In this instance, a day or two from the commencement of the seizure, other parts were implicated and the pres- ence of pus was manifest ; from the very first the amount of constitutional disturb- ance was far beyond that which occurs in Gout affecting one small articulation. The character of the symptoms should not be neglected. It must be remembered that in Gout the pain is generally severe ; during the early stage of the inflamma- tion tlie joint is very tense ; that it subse- quently pits, or is cedematous, and, lastly, desquamates ; that the febrile di^turbance is usually moderate, and in proportion to the extent of the local inflammation. The presence or absence of periodicity in the attacks must not be overlooked ; Gout, especially for the first few years, is almost invariably periodic, complete and long in- tervals occurring between the paroxysms. In true Gout, acute inflammation of the heart does not occur ; in rheumatism car- diac complication is frequent. If a deposit of urate of soda can be dis- covered either in the external ear of the patient, in the tips of the fingers, the bursfe over the olecranon, or in any other situation, it is a matter of certainty that the patient has the gouty diathesis. Great care, however, must be taken not to con- found enlargements of other kinds, as of the ends of the phalanges, or simple bur- PROONOSrS OP GOUT. 537 sal swellings, with those produced by the deposition of urate of soda. An examination of the blood of the pa- tient almost decides the point : this can be effected if only a single ounce is drawn from a vein, as not more than one or two drachms of the serum are required for the thread experiment. The lluid from a blister may be used instead of blood se- rum, although a negative result obtained from it is not so satisfactory. Lastly, the presence or absence of a trace of albumen in the urine, if the case be of a chronic character, may aftbrd some assistance, as this symptom is very frequent in Gout, and dependent on the slight kidney affection which so commonly ensues after the disease has lingered in the system for a few years. A case, showing the importance of at- tending to the above differential points, has within the last few weeks come under observation. A woman aged 35, married, with one child, has for many years worked in a laundry, and has been necessarily exposed to damp, and great alternations of tem- perature ; says she has always been tem- perate, but has drunk beer, and now and then a little spirits. The patient is very deaf, which renders it difficult to ascertain every point either in her previous history, or that of the dis- ease, and which at first obscured the diag- nosis. About two years since she had swelling of the left knee, and thinks this joint was alone affected ; she was unable to move about for five or six months. About a year from the commencement of the knee affection the knee and ankles were attacked and the great toe was im- plicated ; does not remember whether it was the metatarso-phalangeal or the pha- langeal joint ; the attack lasted a month or so. From this time to the present has been frequently obliged to keep her bed from joint disease, both the upper and lower extremities being involved. When first seen, both knees were tender and swollen, as likewise the ankles ; some tenderness also of two or three of the pha- langeal joints of the hands, and the first phalanx of the left index, and the same joint of the right middle finger ; these are considerably thickened and swollen, and their mobility much impaired ; no visible deposits either in ears or elsewhere. ISTo amount of febrile disturbance present. Catamenia regular. Urine free from al- bumen. None of her relations had suf- fered from joint disease. There was considerable difficulty in arriving at a safe conclusion in this case. Against the disease being Gout, and in favor of its being rheumatoid arthritis, there was the following evidence : the sex of the patient, her somefldiat early age, and the catamenia being still ju'esent; the supposed moderate abstinence from malt liquors (though she always took three pints of beer a day, with some spirits); the absence of any atiection of the great too in the first attack and the question as to which joint of the toe was implicated in subsequent seizures ; the duration of the disease and its almost progressive charac- ter from the first ; the non-discovery of chalk-like deposits in the body; and, lastly, the probability of the joint aftection being brought on by cold. On the contrary, in favor of its being Gout were the following circumstanc(;s : the appearances of general good health ; the distinct interval of six months between the first and second seizures ; and the probability of the patient taking more malt liquors than she herself allowed. To remove any doubt upon the subject a very small venesection was performed, and upon analysis the serum was found to yield a large quantity of uric acid by the thread experiment. This was almost de- cisive of its being Gout ; but on very close inquiry, finding that the elbows had been allected several times, the state of the bursas over the olecranon process was ex- amined, and in the right bursa some thick- ening was detected, as likewise the pres- ence of two or three flattened little masses, doubtless of urate of soda. The presence of these little masses in the bursa, con- joined with the fact of the blood being rich in uric acid, fully established the na- ture of the case ; and this discovery was of no small importance, not only in the treatment of the attack, but as to the means to be taken in future to keep the disease from making further inroads in the system. Prognosis of Gotjt. — An attack of acute articular Gout is probably never fatal, and individuals are often seen who have suffered from severe paroxysms for many years, and yet appear to have ex- perienced little or no injury beyond their sufternigs at the time. If the intervals between the seizures continue to be of fair duration, as one year or half a yenr, when the patient is beyond middle age, the prognosis is favoralsle, and there is no reason why any appreciable shortening of his life should ensue, provided he is will- ing to live according to rule, and is not exposed to accidents or other powerful causes of the disease. In confirmation of this statement is the fact that robust- looking persons of very advanced age are not infrequently seen, who have been the subject of periodic visitations of Gout for a great number of years. When, how- ever, in comparatively early life, the at- tacks are frequent and prolonged, the prognosis becomes much less favorable, and especially if the urine exhibits any trace of albumen, either during the pa- 538 GOUT. n-\vsms or in the intervals of freedom from them. The appearance of the patient's urine helps us in making a prognosis. If it was formerly turbid from urates, or if it gave rise to a deposit of crystallized uric acid, and has become of late clear and of a paler color, the change probably indicates that the kidneys have to a considerable extent lost their power of eliminating uric acid, and that which seems to the patient a favorable change is in reality a sign of a serious structural alteration in an important secreting organ. It is a grave sign in Gout to find the urine ]2ale, the specific gravity exceed- ingly low, and the fluid devoid of uric acid ; and if, in addition to this condition, albumen is likewise present, the indica- tion becomes still more unfavorable. Chronic Gout has a decided tendency to shorten life, and this fact is recognized by insurance companies, who, however, do not appear to make much distinction be- tween the acute and chronic forms of the disease : at different offices varying rates are adopted. In the early attacks a patient is likely to inquire of his physician, if it is possi- ble to prevent a return of his ailment — a question tantamount to asking if there is any known method of absolutely eradi- cating the tendency to Gout from the system. There are records of individuals who have experienced but one attack, though they have lived to a great age. I have known thirty-live years elapse between a regular attack of Gout in the great toe and the patient's death, which took place after he had attained his seventieth year. Sev- eral cases have come under my observa- tion in which the disease, after having recurred periodically for many years, grad- ually declined in intensity and duration, and at last altogether disappeared. The appearance of Gout can never be looked upon as a good omen ; a statement contrary to a once popular opinion. The greater the age at which Gout first seizes the individual, the more satisfactory the prognosis. If it attacks very young subjects, the future prospects are bad. Hereditary is generally much less tract- able than acquired Gout. The appearance of chalk-stones on the surface is always inauspicious, even if confined to the helix of the ears. Gouty patients are more liable to suffer severely from accidents and exposure than the majority of people ; the more the kid- neys are implicated, the less able are they to withstand the effect of shock upon the system. In concluding the subject of the prog- nosis of Gout, I will remark, that I con- sider that a single fit of Gout, however slight, should be looked upon as an inti- mation that the patient cannot go on with impunity in his then habits of life ; it is a warning that either he must change them or expect returns of the disease, which, as time advances, are certain to increase both in frequency and duration, and both embitter and shorten existence. On the other hand, I am equally per- suaded that if proper regiminal and medi- cinal precautions be taken, the gouty patient may be saved from such an alter- native and the disease, instead of increas- ing in intensity, may be gradually miti- gated, and probably interfere but little with the comforts of life. Treatment. — The subject of the treat- ment of Gout naturally divides itself into, first, the treatment of the articular inflam- mation ; secondly, the management of the gouty subject during the intervals of the attacks ; and, thirdly, the treatment of the complications and irregular manifesta- tions of the disease. Under the head ol Treatment we shall discuss not only the medicines which it may be necessary to administer, but likewise the dietetic and regiminal management. Treatment of Acute Omit. — Let us first examine if there is any necessity for giv- ing medicine at all, and whether or not it is prudent to leave the joint disease to pursue its own course uninfluenced by any drug. Cases are now and then met with in which the affection has been left to itself, and several such have come before me. From the opportunities thus afforded, I have ascertained that many of the early and slighter attacks of Gout will subside in a few days, provided the patient is moderately careful in diet ; but that, if the usual mode of living is indulged in, the attack may be prolonged, even to many weeks or months ; or, if slight re- missions take place from time to time, they are soon succeeded by exacerbations, until at last the patient's general health gives way, the appetite fails, and thus under a necessarily altered diet the dis- ease exalts itself; even then the attack may last a long time, as is likewise the case under homoeopathic treatment, which, if honestly practised, and with the use of infinitesimal doses, is, I should imagine, exactly equivalent to the non-exhibition of medicines. When the articular inflammation is al- lowed to run its own course, and has been endured for a long time, it leaves a con- siderable amount of injury in the affected parts, the bloodvessels become weakened, the distension of veins and the local oede- ma remain, and the joints are left in a condition liable to take on unhealthy ac- tion from trifling constitutional disturb- ances. TREATMENT. 539 Assuming then, that medicinal treat- ment can be of real benefit, it is for us to determine the remedial agents best adapt- ed to diminish or cure the intlammatiou. There is one drug which has an undoubted influence in controlling gouty inflamma- tion, and its action in articular Gout ap- pears as marked as that of cinchona bark in the cure of ague ; this remedy is eol- chicum. It signifies not what part of the colchicum plant is taken, whether the corm, the seeds, or the flowers, for the same principle pervades the whole plant ; neither does it signify what preparations are made use of, whether the wine, the tincture, or the extract, provided equiva- lent doses be administered, for the eft'ects of all are the same. Colchicum, as before stated, has a direct controlling power over the joint disease, and I cannot call to mind a single instance in which its influence was not well marked, although in many cases a question may arise as to the propriety of its exhibition. Colchicum in full doses produces a marked sedative effect upon the nervous and vas- cular systems ; it has likewise a distinct influence upon the intestinal canal ; and if continued too long and in too large doses, causes tormina, and a very trouble- some form of diarrhoea. It also produces a peculiar change in the fecal excretions, so that those accustomed to its use can detect it by this circumstance alone, even when otherwise unaware of the exhibition of the drug ; this alteration in the alvine excretions is probably due to the influence of colchicum upon the secreting apparatus of the bowels or their appendages, more especially the liver and pancreas. Col- chicum has generally been supposed to cause a more copious flow of urine, and to favor the elimination of its solid con- stituents ; but of this there will be occa- sion to speak further on. Although colchicum causes purging, still its peculiar influence is quite apart from this effect. Occasionally an almost magical change is produced by a single large dose, without the appearance of the least increase in the secretion from any organ, the effect being manifested in the rapid subsidence of the pain and other symptoms of the joint inflammation ; and simple purging, even though copious, will often fail to produce any notable effect under the same circumstances. I am of opinion that, in articular Gout, colchicum may be advantageously administered dur- ing the time that the inflammatory symp- toms are present ; and the dose of the wine of colchicum may be from ten to twenty or even twenty-flve minims re- peated every six hours. Colchicum given in the above manner will of itself be suffi- cient in most cases to cut short the gouty attack, and I have often depended on it alone ; but, at the same time, in the ma- jority of cases, it is advantageous to com- bine it with other remedies, which muht necessarily vary in different cases. From what has been stated of the condition of the blood and of the urine, it will at once appear that some moderate alkaline plan of treatment is likely to prove advan- tageous, both for the purpose of increas- ing the alkaline state of these fluids, and also to keep in solution the salt of uric acid, which is liable to be deposited in the cartilaginous and ligamentous tissues. There can be no doubt of the value of al- kaline remedies in the gouty paroxysm, and, in many cases, such salts, given in a freely diluted form, are sufficient of them- selves for its removal, and are peculiarly applicable when there are circumstances rendering the administration of colchicum undesirable. Alkalies may be given either in the free state, or combined with car- bonic acid, in the form of the carbonates or bicarbonates, or united with some vegetable acid, as the citric, tartaric, or acetic acids. If the stomach is irritated, and an over-secretion of acid be present, then the free alkalies or their carbonates may be administered ; but if, on the other hand, there be no such condition, then the salts with the vegetable acids may be used, which produce an alkaline state of the blood and urine, although they do not act as antacids in the stomach. These alkaline remedies not only tend to keep up and restore the normal reaction of the blood, but likewise augment the excretion of urine, and with it the elimination of those solid matters which are unduly re- tained in that fluid in gouty states of the system. It is important, likewise, to make a selection of the alkali, and unless there are circumstances which render the use of soda desirable, such as an imper- fect action of the liver, or a deficient se- cretion of bile, this alkali is the least fitted for exhibition, as it has much less power than other fixed alkalies of dissolving or holding in solution uric acid. The salts of potash are, in the majority of cases, more suitable than the salts of soda, as they not only exert a much greater sol- vent action upon urate of soda, but like- wise augment in a greater degree the excretion of the urine. A third fixed alkali or its salts can be employed in lieu of soda or potash, namely, lithia, an alkali now able to be procured in quantities suf- ficient for medicinal use. Besides the administration of alkaline remedies and the cautious use of colchi- cum, it is important in attacks of acute Gout to attend to the state of the intesti- nal canal and the skin. If the bowels be confined, some aperient must be given, and the selection of the drug should de- pend upon the peculiarities of the patient. If mere constipation exists, a simple pur- gative, as the compound colocynth ex- 6^0 GOUT. tract, may be administered at niglit, fol- lowed by a saline aperient, as a seidlitz powder, "or the eft'ervescing eitro-tartrate of soda and magnesia ; or, if a more active dose be required, the common black draught can be substituted for these latter. If, however, the portal system shows e\-idence of congestion, and the function of the liver is disordered, some more powerful cholagogue will be useful, especially if the patient has been in the habit of taking purgatives. A small amount of blue pill or of calomel can be combined with the colocynth, or podo- phj-Uine, in cjuarter or half-grain doses, may be substituted for the mercurial. It should be borne in mind that, in gouty habits, mercurials must be used with great caution, as in many cases there is a considerable susceptibility to their action, and very unpleasant consequences may follow their administration in repeated doses. Saline purgatives are verj"- desirable ; many of them act remotel}' as antacids, and all tend to relieve portal congestion. A verv useful combination, and one often emplov'ed in acute attacks of Gout, is a draught containing sulphate and carbonate of magnesia, to which colchicum alone or bicarbonate of potash and colchicum, may be added. The function of the skin, if very defec- tive, may be promoted by the use of a hot-air or vapor bath, and at the same time the acetate of ammonia may be given, combined with other I'emedies. The action of the kidneys is usually suf- ficiently promoted by the saline treatment, especially if accompanied Ijy the free use of diluents. Blood-letting, in the form of venesection from the arm, was frequently had recourse to in former times ; but this practice is now almost abandoned. The use of small bleedings has still perhaps a few advo- cates, and of such treatment I had much experience some 3-ears since. There can be no doubt that in some cases of very acute Gout, especially when many joints are implicated and fever runs high, speed}' and marked relief is procured by taking a small amount of blood from the arm ; but it is questionable whether even in such instances it would not ultimately have been better for the patient to have obtain- ed the relief a little more slowly, and without the loss of so valuable a fluid as the blood. The doubtful advantage of the practice will be more apparent when it is stated that everything that produces lowering of the vital powers tends to en- graft the disease more permanently upon the system. A question now arises, — Although gen- eral blood-letting is undesirable, should not local depletion be resorted to ? The ax)pearance of a joint when acutely in- flamed, the state of the tension and red- ness, the high temperature, and the ex- quisite pain, all seem to point to the necessity of, or at least the advantage likely to accrue from, the abstraction of blood from the part ; and the indication has often been acted upon. My own ex- perience quite accords with that of former observers as to the danger of the practice, and several instances have come under my notice of considerable and irremediable injury which has resulted from the use of leeches in these cases. I have frequently seen great-toe joints stiffened after a few attacks, when local depletion has been resorted to, and within the last eighteen months two remarkable cases, in which the patients have completely lost the use of both knee-joints from two or three at- tacks only : in both instances leeches had been applied very freely ; in one more than thirt}' to each joint. I can with confidence warn those engaged in the treatment of an acuteh'-inflamed gout}- joint never to have resort to this mode of combating the disease. It would seem that the abstrac- tion of blood from the joint allows or favors the free deposition of the urate of soda in the tissues, and thus the ligaments become rigid, and ankylosis ensues. Al- though more or less stiffiaess is not infre- quently seen as the result of long-continued gouty action in a joint where no local de- pletion has been emplo}-ed, still, as a rule, the free movement of a joint is but little impaired by even numerous attacks of acute Gout. As it has been shown that leeches should not be made use of in the joint affection, the next point is to consider ■\\ hether any or what local remedies may be advantageously employed. If the pain and redness are slight, all that is neces- sar}- is to cover the part with flannel or some other light and warm clothing : this precaution is simply for the purpose of avoiding the chance of a chill. Should, however, the inflammation be very in- tense and the suffering great, carded cot- ton should be wrapped round the joints principally affected, and oil silk or gutta- percha sheeting so applied, that the mois- ture is retained, and b}- this means a kind of vapor bath is formed. Some care is necessary to insure the complete closure of the oil silk, so as to prevent the escape of vapor ; for unless this is effected, the warm covering of cotton, instead of giving relief, heats and augments the pain. As some patients are verv' intolerant of pain, it is at times desirable to apply ano- dyne remedies, and the most efficacious are belladonna and opium. I prefer a solution of atropia and morphia, dissolved in spirit and water, in the proportion of one grain of atropia and eight grains of hy- drochlorate of morphia to the fluidounce ; a small piece of lint may be dipped in TREATMENT. 541 the solution and placed on the part, the oil silk being employed as above de- scribed. The tincture of belladonna and of opium may be used, but the solution of the alkaloids is much more cleanly and elegant. Aconite and its alkaloid ha\'e been proposed for lulling pain in Gout ; but when strong, they may cause irritation of the skin. Blisters have been used with advantage, when there exists great want of power in the system ; possibly their value in chi'onic and asthenic Gout may be in part due to the fact of the serum withdrawing some of the morbid matter from the aflected joint. We have alluded above to the adminis- tration of colchicum, and mentioned some of the symptoms which may arise from its administration in full medicinal doses, and also its marked influence in controlling gouty inflammation. Some practitioners have attributed the good effects of the reniedj' to its action on the bowels. That it often purges when given in full doses, and that it may give rise to a peculiar excretion from the bowels, is true ; but it is equallj^ a fact that marked and rapid relief frequently occurs from its exhibition when no appre- ciable influence on the intestinal canal can be detected ; and, on the other hand, free purging can be induced in a gouty patient by other means, without the pro- duction of relief to the local inflammation. It may hence be safely inferred, that the peculiar influence of colchicum does not result from its purgative action. Others have been disposed to attribute the bene- ficial influence of colchicum to its action on the kidneys, and have regarded it as a diuretic, which not only causes an in- creased elimination of the watery portion of the urinary excretion, but likewise of the solid constituents, and more especially the uric acid. If these properties were possessed by colchicum, there would be little difficulty in accounting for its valua- ble influence in controlling Gout ; but, unfortunately, clinical experience does not favor these views. It is true that some observers, as Dr. Christison and Dr. J. McGregor Maclagan and Professor Chelius, have made observations which at first sight would render it probable that colchicum increased tlie solid excretion, but as only single specimens of urine were taken, and no reference made to the total elimination in the twenty-four hours, a serious source of fallacy existed; the urine after the administration of colchicum might, it is true, have been higher in spc- I cific gravity and richer in urates, but this ! circumstance may have been due to a diminished secretion. Chelius 's observa- tions were made on patients recovering from gouty attacks, in whom it is not un- common to find, for many days, a grad- ually increasing amount of uric acid with- out the administration of any medicine. From numerous observations' made some years since on the influence of colchicum upon the secretion of urine in gouty and other cases, I arrived at the conclusion tliat, in health, colchicum diminishes rather than increases the excretion of uric acid and urea by the kidneys, and that the elimination of the watery portion of the urine is often lessened, more especially when purging is caused by the remedy. It is probable that the statements as to the increase of uric acid have arisen from the fixct that the analj^ses have been made on urine passed at some one period of the day onl}'. IIa-\'ing failed to discover any visible alteration in the principal secretions pro- duced by the administration of colchicum, it is necessary to seek some other mode of explaining its action. That it is a seda- tive to the vascular system is a well-known fact, which has been fully proved by clini- cal experience ; in subjects with weak hearts it causes temporary intermission of the pulse. Dr. Maclagan found on two occasions twenty minims of the tincture lowered the number of beats from eighty- seven to sixty-flve and from eighty-four to sixty-two per minute respectively. This controlling power exerted upon the circulation, although it may explain to some extent the relief experienced from the drug, still is quite unable to elucidate the whole ; for if the sedative action were the only eftect, colchicum should be equally efficacious in acute rheumatism as in Gout ; but that it is not so has been proved beyond doubt. Another explana- tion of the eflfects of colchicum has been proposed ; namely, that its action is chiefly exerted upon certain tissues of the body, especially the ligamentous and car- tilaginous, in the same manner as other remedies are known to affect particular organs, as belladonna the pupil of the eye, digitalis the heart, and so on ; but the same objections hold good here as in the former case, for the action of the drug should be equally potent in controUing in- flammation of the same tissues when not gouty in its character. Treatment of Chronic Govt. — The treat- ment of the acute paroxysm having been sufficiently described, it remains for us to speak of the manner in which the chronic conditions of the disease require to be managed ; if in acute Gout it is necessary to niake the treatment depen- dent upon the state of the system and the idiosyncrasy of the patient, it is even still more so when the chronic forms are pre- scribed for. We have seen that a gouty fit, whether it occurs in the strong and ' Medioo-Chh-urgical Transactions, vol. xli. 1858. 642 GOUT. robust or in the weak and spare habit, is dependent on the same proximate cause ; yet that it may be excited by various cir- cumstances in diflferent individuals, for in one patient the state of the digestive or- gans, in a second tlie function of the slcin, and in a third the secretion of the kidneys, may be principally at fault : and all these considerations must be taken into account when called upon to treat any one labor- ing under chronic Gout. Value of Golchicwn. — Colchicum is found equally efficacious in subduing the exacer- bations in chronic Gout as in combating the early fits in the acute disease, due re- gard being paid to the strength of the patient, and the dose regulated accord- ingly- It has been asserted, and the opinion is a very prevalent one, that the use of col- chicum in the acute disease tends to cause the attacks to recur more frequently, and to induce a chronic state of the malady ; but there are no good grounds for such an idea, unless the remedy has been much abused. It must be remembered that Gout, even when left to run its own course, and quite independent of medicinal treat- ment, has a powerful tendency to return, and the natural course of the disease should not be confounded with the effects of any treatment which may have been pursued. It is important to disabuse the minds of both the profession and public of the pre- judice against the guarded use of colchi- cum, as the permanent danger caused by allowing the inflammation to linger for a lonw period is far greater than any injury which the proper use of colchicum can entail. It is not improbable, if an attack of acute Gout is allowed to run a long course, that, at the termination of the fit, the patient is for a time more free from the disease ; i. e. , the blood is purer than if the inflammation had been simply ar- rested without any care having been taken to rid the system of the morbid matter. Although colchicum given alone has a powerful influence in diminishing the sub- acute inflammations in chronic gouty cases, yet it may often be very advan- tageously combined with other medicines, and, amongst these, that which claims the first notice is guaiacum. Value of (r((fi?V(C!(m.— This resin may be given either in the form of the mixture of guaiacum of the Pharmacopoeia, in which the powdered resin is kept in a state of suspension by means of the acacia muci- lage, or as a powder combined with aro- matics, or in many instances, still more advantageously, ns the ammoniated tinc- ture of guaiacum made up into a draught. Guaiacum sometimes acts on the mu- cous membrane of the alimentarvcnnal as a purgative, but this occurs less frequently with the ammoniated tincture than with the powdered resin. This aperient action is often rather useful than not ; but if it is not desirable, it may usually be pre- vented by the addition of a minim or two of laudanum to each dose. The resin evidently becomes absorbed, at least in part, and after it has entered the circula- tion acts as a stimulant to the smaller arteries and capillary system of vessels. It often promotes the function of the skin, and clinical experience appears to show that it has a specific effect upon the fibrous and ligamentous tissues, as well as on the mucous surfaces ; it also increases the warmth of the extremities, and reUeves pain connected with a languid circulation. Guaiacum may be administered for a long period of time without injury; I have had patients under my care who have taken it for a whole year. Within the last few years I have given this drug extensively, and with great advantage ; it is especially useful in the asthenic Gout of old subjects, but to young patients it may also be given with benefit. Value of Iodide of Potasshim. — Another remedy of service in chronic Gout is the iodide of potassium. This salt undoubt- edly possesses great power in controlling inflammation of fibrous tissues ; its action on the periosteum is very marked in the case of nodes, also in painful neuralgic affections dependent upon an inflamma- tory state of the nerve coverings ; it is more especially useful when the pains are increased at night and by the heat of bed. It is also useful in removing the recent thickening of the tissues around joints, but proofls still wanting of its possessing auj' power of causing the absorption of urate of soda. In gouty inflammation, when fluid has been thrown into the cavities of the joints, and has been slow of absorption, the ad- ministration of the iodide of potassium has often appeared to be attended with great advantage. Cinchona Barle and Quinine. — The pre- parations of bark and quinine possess an undoubted power of controlling inflamma- tion, and within the last three or four years I have largely employed them for this purpose. With regard to the action of quinine, there are certain observations in relation to its physiological action which are of interest, and may also prove of therapeutic value. Dr. Ranke has stated that quinine has the power of diminishing the amount of uric acid in the urine. To prove this. Dr. Ranke gave in one dose twenty grains of sulphate of quinia to a patient, and found that the excretion of the acid was only one-half the average : the influence of the dose continued for about two days. In my own observations the average of the excreted uric acid during these days was but slightly under that which it had TREATMENT. 543 been before the quinine was given. In one instance, for example, the average of uriu acid in the urine for two days was 5"89 grains when no quinine was exliibited, and 5'37 grains for three days when tlie patient was taking eigliteen grains of tlie sulpliate each day, in divided doses. As- suming tliat Dr. Kanlfe's statement is cor- rect, and that tlie elimination of uric acid is much lessened for two days after the dose, it is a matter of much interest to in- quire if the effect is due to a diminished formation, or defective excretion from the kidneys. From my observations, I was inclined to ascribe the effect to the sudden and powerful impression of the drug upon the nervous system influencing the excre- tion of uric acid, and not to any decrease in its formation in the system. I shall, however, be unwilling to offer a strong opinion upon the subject at present, as I consider that further experiments are re- quired. Quinine may be beneficial in controlling gouty inflammation, whether it produces one or other effect : of the in- fluence of colchicum there cannot exist a doubt ; still it has not been proved either to augment or diminish in any marked degree the elimination or formation of uric acid. Yellow cinchona bark has been used in lieu of quinine, and where there is great vascular debility, the astringent principle of the bark appears to be of service. It is advantageous to unite small doses of colchicum to the quinine ; and when using the former drug in largo doses, the addition of the latter is of service in pre- venting depression of the nervous system. Constitutional Treatment of Chronic Gout. — Although due attention to the inflam- mation of the joints is of great importance in the management of chronic Gout, there is another object to be steadily kept in view, namely, the removal of the morbid condition of the blood, and the solubility of any uric acid which may fail to be eliminated. It has already been shown that uric acid is thrown out entirely, or almost entirely, by the kidneys, and it has also been demonstrated that in Gout there is always some diminution of the uric-acid eliminating power, and often an almost entire suppression of this function. It follows from this, that one great object must be to increase this excreting power, and several remedies may be made use of to effect this, amongst which alkalies and salines stand out prominently. Value of Alkalies and Salines. — These agents have long enjoyed favor in the treatment of chronic Gout, and not with- out reason ; sometimes they are given in the form of ordinary medicine, sometimes in the form of natural or artificial mineral waters. It may be observed here that as chronic Gout is a disease which has usu- ally been many years in becoming fully established in the system, so it is one in which benefit cannot be expected, except from a long-continued perseverance in some judicious plan of treatment ; and when a mere exacerbation of inflammation has subsided, the cure must not bethought to be effected. Under these circumstances it is most desirable that the plan adopted should be simple, and neither disagree- able nor troublesome ; and it will be found in practice that a patient will often per- severe for an almost indefinite time with the use of mineral waters, when he would refuse treatment by the ordinary mode of administering drugs. The alkalies and alkaline earths most commonly ordered are the salts of potash, soda, lithia, magnesia, and lime ; and these are usually combined with carbonic or some vegetable acid, and occasionally with phosijhoric acid. If these bases are given in the caustic state, they act as direct antacids, and many of them influence the mucous mem- branes as sedatives, or, in strong doses, as irritants : hence potash, soda, a nil lithia are seldom given in the free stale, unless there are special indications for their employment. When carbonates or bicarbonates of the bases are adminis- tered, the antacid effect is equally pro- duced ; but if combined vfith the vege- table acids, as the citric or tartaric, the alkalies lose their power of neutralizing acidity in the stomach. After absorption into the blood, and elimination by the kidneys, the alkaline reaction is equally produced by the vegetable salts as by the carbonates or free alkalies, for the acid is broken up m transitu, and the base elimi- nated in the form of a carbonate. It is, therefore, desirable to select either a car- bonate or neutral salt, according as it is thought advisable or not to produce an alkaline effect upon the stomach. In making a selection of the base, sev- eral circumstances must be taken into consideration, and especially the organs and functions peculiarly influenced by the dift'erent alkalies and earths. Potash and its salts act especially on the kidnejrs, causing not only an alkaline state of the urine, but usually a marked increase in the secretion itself. Observation has repeatedly shown that potash has a marked effect in augmenting the quantity of urine ; its effect on the excretion of the different organic solids has not been clearly made out ; no uni- form results have been obtained sufficient to show its influence upon the uric acid ; some experiments appear to indicate an increased, some a decreased excretion of tills acid, and others, again, that it was unaffected. There are many difficulties in the investigation ; in alkaline urine, uric acid is soon decomposed, and if the 544 GOUT. quantity of urine is much increased, a portion of it may be lost in the analysis. Potash and other allcalies may act in more than one way ; not only maj' they increase the elimination of uric acid, but they probably facihtate its destruction in the system, and certainly aid in imparting solubility to it in the blood. Soda salts have less intiuence upon the kidneys ; they act less powerfully as sol- vents of uric acid ; but, on the other hand, they appear to aid the secretion of bile, or act as hepatic alteratives. They are indicated in gouty cases accompanied with marked derangement of the liver. Lithia salts have only been used as in- ternal remedies during the last six years. They are active diuretics, more active than salts of potash ; they are also power- ful solvents of uric acid, and on account of the very small equivalent of the metal, caustic lithia or its carbonate possesses great neutralizing power for acids. The urate or lithate of lithia is by far the most soluble of all the salts of uric acid. When first introduced by the author as a remedy for Gout, lithia was supposed to exist only in a few minerals, but more recently its presence has been discovered in a variety of substances. It has been found to be a constituent of the human body, of many plants, and can be shown by means of the spectrum analysis in the ashes of the blood, and even of a cigar ; it is found, also, in the waters of several mineral springs, especially those of Baden- Baden ; also in the springs of Carlsbad, Aix-la-Chapelle, Marienbad, Vichy, &c. Salts of lithia, especially the carbonate and citrate, have now been employed ex- tensively, and apparently with consider- able success. It is, of course, a matter of extreme difficulty to form a very strong opinion upon the value of any drug, es- pet'ially when the effects are not at once evident to the senses, and are long in being produced ; but lithia appears to have many desirable qualities ; if the opinion of patients can be relied upon, lithia salts taken for a long period in a very dilute form have the power of pre- venting gouty paroxysms in chronic cases, and some evidence has been afforded of their power of rendering joints more movable, and of causing some solution and absorption of chalky matter which has been already deposited. Lithia salts certainly act rapidly and powerfully in preventing deposition of urates and uric acid in the urine, and in the calculous tendencies of many gouty subjects must necessarily prove of much value. The dose of carbonate of lithia may he from five to ten grains dissolved in aerated water, or the citrate may be given in doses of from eight to twelve grains or more. Before leaving the subject of the alka- lies and their salts, it may be useful to allude to the value of administering these preparations in a very diluted fornii. Many soluble salts, if given in the form of concentrated solutions, will act as pur- gatives, whereas if very freely diluted they produce diuresis ; and it must be at once evident to any one who considers the subject, that the introduction of a large amount of fluid into the system has the effect of rendering the blood more capable of holding sparingly soluble mat- ters in solution, and of augmenting the various secretions from the body, es- pecially the urine, and hence of facilitat- ing the expulsion of any such matters from the system. It is necessary also to select proper times for the exhibition of these remedies ; as the object is to have them rapidly absorbed, they should be given on an empty stomach, at least an hour before food ; if taken at or soon after a meal, they are apt to cause distension and discomfort, and at the same time they are very slowly absorbed : any amount of free alkali, when taken at the time that digestion is going on, impedes the process very seriously by neutralizing the free acid of the gastric fluid. This is a fact too frequently overlooked in prac- tice. Small doses of salines, if their use is long persevered in, are preferable to large ones, as they produce no disturbance of the digestive process, act more freely on the kidneys and skin, and are not likely to cause debility. Magnesia and its carbonates have been long used in the treatment of chronic Gout, and there can be no doubt that these salts are of value in many cases. Magnesia forms a moderately soluble salt with uric acid ; it is also an alkali, and acts both as a direct and remote antacid ; it is useful as an adjunct, and especially in instances in which "there is great acidity in the intestinal canal, and at the same time a sluggish state of the bowels. The salt formed in the stomach by its union with the acid produces a purgative effect, which tends to relieve the portal circula- tion, and often aids indirectly the func- tion of the kidneys. Carbonate of mag- nesia dissolved in excess of carbonic acid is an elegant form of administering the remedy. The lime salts offer no special advan- tage. Lime water may be employed as an antacid if there is much tendency to diar- rhoea, as the salts of lime have a consti- pating effect. There are some other salts, not yet alluded to, whose virtue depends partly on the acid contained in them ; for exain- ple. the phosphates of soda and ammonia. Both these salts increase the solubility of the urate of soda, and may be uped with advantage in certain instances. The TREATMENT. 545 phosphate of ammonia has been employed in many cases of chronic Gout, and clin- ical observation appears to show that it is useful in preventing paroxysms, probably by keeping the blood in a purer state. The result of my own experience of the use of the phosphate of ammonia is favor- able ; it is especially indicated in cases in which the circulation is feeble, and the function of the skin impaired : this re- mark applies equally to other ammoniacal salts. Treatment of Errors of the Digestive Function. — As the stomach and other parts of the digestive apparatus are gen- erally affected in chronic forms of Gout, it is of importance that their condition should be carefully attended to ; purga- tives, stomachics, and alteratives are the remedies resorted to for correcting any morbid state of these organs. Value of Purgatives. — It has been already stated that free purgation alone will not rapidly cure gouty intlammation, and that it is impossible to explain the effects of colchicum upon this idea ; that, for ex- ample, sulphate of magnesia, although it causes a free watery action, will not re- lieve in the same manner as colchicum, even when the latter drug produces no appreciable action upon the bowels. Pur- gatives, however, are often of much value, especially when there is a portal conges- tion present, and the occasional use of the compound colocynth extract, or some such preparation, is usually of great ad- vantage. Mercurials should, as a rule, be avoided, as they are peculiarly prone to cause ptyalism in gouty subjects, and as their frequent use lowers the powers of the system. Value of Stomachics and Tonics. — If there exists an irritative form of dyspep- sia, accompanied witii flatulence, acidity, and heartburn, this is generally relieved by the administration of free or carbonated alkalies ; if pain or palpitation is present, a few drops of hydrocyanic acid may be added to each dose, taking care to relieve any sluggish condition of the liver and bowels. These alkalies are often advan- tageously combined with some bitter stomachic, as the juice or extract of ta- raxacum ; or, if there appears to be great want of tone, the more powerful bitters, as chamomile, gentian, chiretta, quassia, &c. &c. If much flatulence be present, then ginger or capsicum may be likewise added. Ash-leaves in the form of an infusion nave been also reconnnended, and clinical proof afforded of their etiiciency in chronic j Gout. I have frequentl}' made use of ! them, and with advantage ; but the amount of infusion taken each day has always been considerable, and the action nf the diluent must not be forgotten. Vllw of Ferruginous Preparations — In VOL. I.— 35 the majority of instances iron salts are not indicated, but at times cases are met with in which their administratimiis attended with striking beuettt. They prove most useful when the blood is impoverished from the diminution of the red corpuscles, and the circulation enfeebled from weak- ness of the walls of the heart, and where the whole nervous system has become ex- hausted. It is often a good plan to com- bine these with small doses of the extract of colchicum. The selection of the ferruginous prepa- ration should be made according to the peculiar requirements of the patient : if only the hamiatinic property is wanted, reduced iron (ferrum reductum) may be prescribed ; if the astringent influence is required, the sulphate may be made use of Value of Diaphoretics o-r Sudmifics. — Friction of the skin must not be over- looked in the treatment of chronic gouty cases ; we must remember, that although there is no elimination of uric acid irom the healthy surface, still the skin gives off' a large amount of some other acid, which, when retained, renders the blood serum less alkaline. The salts of ammonia are useful when the skin is particularly in fault, especially those in which the alkali is combined ■with a vegetable acid, such as acetic acid ; but it is better in most cases to promote the due performance of the cutaneous func- tion by insisting upon a sufliciency of ex- i^rcise, and the free use of water to the skin, combined with friction, and wearing flannel next to the skin. Hot-air and vapor baths are also valua- ble, and, when it can be borne, the Turk- ish bath occasionally; hot salt-water baths may also be made use of Treatment ff the Local Affection. — One of the slighter forms of inconvenience, arising from long-continued gouty inflam- mation in any part, is the production of ffidema, a symptom evidently depending on local debility or weakness of the vessels of the affected parts, usually the lower extremities : this is often much increased by disease of the kidneys, or sometimes of the heart. When the swelling is depend- ent simply on local weakness, it is best treated by the use of some mechanical support, as the elastic stocking and slight friction, with or without some stimulating and lubricating appUcation ; the limb should be elevated, so as to facilitate the free return of blood to the heart, ffidema depending on a kidney or cardiac disease must be specially treated. A far more distressing complication, and one far more difficult to deal with, is that arising from chalk-stones, and the distortion and rigidity of the joints pro- duced by deposition within the structure of the articulations. If chalk-stones appear on superficial 546 GOUT. parts, they may be of little inconvenience, and are often spontaneously removed; for example, if the nodules on the ears of gouty patients are observed for some few years, a considerable change is generally noticed ; they may escape from rupture of the cutis, or if they increase in size, so as to cause any inconvenience, they may be punctured, and by this means dis- persed, the contents escaping either in the semi-liquid or solid state. There is no danger attending an opera- tion upon the ears, nor in many other situations, when the chalky concretions are small, and especially when in a liquid state and very superficial, provided the patient is at the time in a tolerable condi- tion of health; but the case is far other- wise if the chalk-stones are large and solidified, and specially if their ramifica- tions are deep-seated. In such cases the removal is apt to be attended with serious and even fatal consequences, arising from the extreme difficulty in the healing of the sore, or the supervention of a low form of erysipelas. Tlie greater the amount of kidney affection, the greater the danger of operating. Not infrequent- ly, when the deposits approach the sur- face, they burst spontaneously and ab- scesses are then formed ; these are often very difficult to heal on account of the matter being deep-seated. I have known cases in which such abscesses acted as a kind of safety-valve, and their closure has been immediatel}'' followed by a paroxysm of gouty inflammation. The best mode of treating these abscesses is to keep upon them a water dressing, as long as there is a free flow of the matter ; then to have them dressed with some stimulating oint- ment, and occasionally either to apply a lotion of sulphate of zinc, or touch the surface with a stick of lunar caustic. Now and then, if the opening becomes nearly closed, at the time that there is a large accumulation of the urate of soda behind, it is advisable to enlarge the opening by a slight incision. It has been thought by some physicians, both in ancient and modern times, that the deposits of urate of soda which occur in Gout are capable of being dissipated by external applications, and alkaline preparations have usually been employed for this purpose, such as solution of pot- ash, or soda, or lime. I have in some cases had compresses, steeped in a sohi- tion of carbonate of lithia, kept on the parts for a long time, and patients have assured me that they have found decided benefit from them ; but although such a solution exerts a very powerful solvent action upon the deposits when removed from the body, it is difficult to imagine how they can act through the skin ; but as such treatment can do no harm, it is worthy of a further trial. When joints are much stiffened fiom gouty inflammation, considerable relief is obtained from the use of a Ijlistering liquid. This appears more useful, and, upon the whole, less annoying to the pa- tient than iodine paint ; and it usually removes any infused liquid, and chronic inflammatory action, which may be lin- gering about the part. After all tender- ness has disappeared, movement may be attempted, very gently at first, but gra- dually increased ; the joints may also be rubbed with some slightly stimulating liniment, or with strong salt and water. In the treatment of these cases it must always be borne in mind, that the rigidity is often due to interstitial deposit in the ligaments, and that a restoration of these structures to a healthy state can hardly be hoped for ; still, as this condition may often be complicated with a chronic in- flammatory action, it is always advisable to attempt the removal of such complica- tions. Treatment qf the Irregular Forms of Ooitt. — The treatment of irregular Gout must necessarily be very different in different cases, and it is a matter of extreme diffi- culty to lay down any precise regulations for the guidance of the practitioner; how- ever, a few general rules may be advan- tageously given. Should metastasis take place to any im- portant organ, it seriously implicates its functions, and therefore our main object must be to take such steps as will restore this function ; and, as the metastasis usually follows the sudden suppression of gouty inflammation of some joint, the one Very essential part of the treatment con- sists in the endeavor to bring back articu- lar inflammation. This object is best effected by the application of heat or counter-irritation to the extremities, as by hot bottles, sinapisms, &c. At times we may treat the part itself, especially if there is evidence of inflammatory action existing in it ; this may be effected by leeches, blisters, and mustard poultices ; local depletion, however, is rarely neces- sary. The peculiar condition of the sys- tem, or the existence of the gouty diathe- sis, must not be overlooked. A question of no little importance at once arises when the diathetic condition is considered; it is that which relates to the value of colchi- cum in irregular Gout. Sir Henry Hol- land is of opinion that it can be employed with advantage, and as far as my own experience goes I quite coincide with him, although unable to explain its action. This want of knowledge applies with equal force to the action of colchicum in the genuine articular form of the disease. In metastic Gout of the heart and lungs, cardiac stimulants, as ammonia, ether, and other anti-spasmodics, are espe- cially indicated. If the bladder is affected. TREATMENT. 547 ■belladonna and henbane may be advan- tageously used to diminish spasm ; in short, remedies directly influencing the implicated organ may in all cases be re- sorted to, at the same time that the means tending to reinduce the articular inflam- mation should not be neglected. Value of Mineral Waters in Gout. — Min- eral springs are frequently resorted to by gouty subjects, and it is important that the medical man should know when to advise and when to oppose such a step, and likewise the waters most suitable for different cases. Although it cannot be denied that many patients receive great benefit from the proper administration and use of these waters, still it must be allowed that their action is not always beneficial, and that in some cases it is very injurious. All mineral waters have one action in common ; it is that of water itself; and there is little doubt that the value of this agent when properly employed is consid- erable. The waters of some of the min- eral springs of great reputation contain little foreign matter, and must owe most of their efficacy to the water alone. The other waters employed in gouty cases contain either alkaline carbonates, chlo- rides, or sulphates. Some of the waters are impregnated with sulphuretted hydro- gen, and another class owe the chief of their powers to the iron which enters into their composition. Many of the springs are of an elevated temperature ; some of mean heat ; others cold. All mineral waters rich in saline mat- ters, if taken too freely, usually set up a febrile disturbance or crisis ; the system becomes oppressed, there is a feeling of heaviness, languor, or agitation, and this is followed by loss of appetite, thirst, a furred tongue, and heat of skin, some- times by vomiting and diarrhoea. Such symptoms are probably due to the blood becoming saturated with the saline mat- ter, from the excreting organs being un- equal to the task of eliminating the whole quantity introduced during the treat- ment. The different springs of Vichy are all rich in carbonate or bicarbonate of soda, containing about forty grains to the pint : some have the temperature of lOlo Fahr. ; others are cold. When taken internally m even moderate doses, they cause the urine to be neutral or alkaline, without affecting the transparency of the fluid ; when employed in the form of the bath, wie effects appear to be very similar. From the soda contained in them they probably act upon the liver ; and fi-om the amount of liquid absorbed, and the tem- perature at which the water from many of the springs is drunk, they also in- fluence the function of the skin. Vicliy waters appear to be adapted for the treatment of Gout when it occurs in strong subjects in whom the function of the liver and digestive organs is at fault, and are contra-indicated in very chronic cases, especially if there is a tendency to the rapid formation of chalk-stones, or if the powers of the system have become much enfeebled : my own experience is that, in this latter class of cases, they rather tend to favor the formation of these concretions. The internal exhibition of the waters is usually accompanied with the use of the bath ; if they disturb the stomach, the bath alone should be employed. TFws6acZen waters contain a large amount of chloride of sodium, and are of a high temperature, 100° Fahr. They are less debilitating than Vichy waters, and more stimulating to the various functions : they consequently are more adapted for cases in which the circulation is sluggish and the secretions deficient ; also in cases of rigidity from thickening of the textures. They are powerless in removing any solid deposition of urate of soda. Aix-la-Ghu'pelle is frequently resorted to ; the waters are slightly saline com- pared with those of "\\'iesbaden, high in temperature, Vi~P Fahr., and in addition to chloride of sodium, contain some car- bonate and sulphide of sodium, with free sulphuretted hydrogen. They act as stim- ulants to the secreting organs, and more especially to the skin ; they are indicated in cases in which the skin is in fault, and they have also been found useful in re- moving rigidity of the joints. The waters of Ai:c-a-)iavoy resemble closely, as far as the sulphur is concerned, those of Aix-la-Chapelle. Carlsbad waters are in great vogue in the treatment of Gout. They are rich in sulphate of soda, and contain likewise carbonate of soda and chloride of sodium ; of a high temperature, 167° Fahr. They often cause purgative action, and likewise give activity to the kidneys and skin, and are useful in cases accompanied by de- ficient action of the bowels, with a con- gestive state of the liver ; but should be avoided by weakly patients. The waters of Baden-Baden are saline, and from recent analysis are said to be rich in lithia. Dr. Kuef has affirmed that they have proved very useful in Gout, and possess the power even of removing visi- ble deposits of urate of soda. The waters of several other springs, as of Kissingen, Marienhad, Hamburg, Ems, and several other localities, contain sahne matters, and have occasionally been used in the treatment of gouty conditions of the habit. The waters which possess but little solid matter, and which have acquired a repu- tation in gouty cases, are those of Wild- bud, Teplitz, Gastein, Buxton, and Bath. 548 GOUT. They are all of somewhat elevated tem- perature, are chietiy used in the form of the bath, and appear to be peculiarly adapted for the treatment of the disease in the old and infirm. According to nu- merous observers, great benefit has been often experienced from their employment. The following rules may serve as a guide in prescribing the use of mineral waters in gouty cases : — 1. They should not be employed when there exists any appreciable amount of organic disease either of the heart or kid- neys. 2. Tliey should be. avoided when an acute attack is either present or threaten- ing. 3. The particular water should be selected according to the nature of the case. When the patient is robust, and of full habit, the alkaline springs ; when torpidity of the bowels predominates, the purgative waters ; when there is a want of vascular action, the saline waters ; when the skin is inactive, the sulphur ■skaters ; lastly, when debiUty prevails, then the more simple thermal waters should be chosen. 4. In all cases the use of the water should be cautiously commenced, and care should be taken not to oppress the stomach by giving too much liquid, nor to' induce debility or other injurious effects l)}" allow- ing too long a sojourn in the bath. 5. In every instance, when practicable, it is advisable to avoid producing the so- called "crisis," for when febrile" disturb- ance is set up in the system, the secre- tions are checked, and an acute paroxj'sm of Gout is almost always induced ; it is far better to take a prolonged than a too severe course of a mineral water. Diet and Kegimcn in Gout. — The diet in the treatment of the different forms of Gout is of groat importance, far more so than in the majority of diseases. When the affection is acute in character, and the patient robust, he should be confined for a few days to a diet consisting of little more than farinaceous food and diluents ; and this kind of food may be persevered in until the inflammation shows a decided tendency to abate, the thirst diminishes, and the appetite begins to return. Under the term farinaceous food are included bread, arrowroot, sago, tapioca, and such- hke substance ; to these may be added milk ; while water, and toast-and-water, may be indulged in without restraint ; provided the liquids are taken upon an empty stomach. Stimulants are scarcely required under these circumstances ; but if the patient has been accustomed to Hve freely, a little brandy may be taken with the solid food ; even a moderate indul- gence in wine or malt liquor will keep up the gouty inflammation for an almost in definite period. When febrile disturbance has abated, a more generous diet may be allowed— at first fish, then fowl or game, and at last ordinary meat. In strong persons it is desirable to keep a moderate curb upon the appetite, for fear of inducing a recur- rence of the inflammation. As soon as possible exercise may be re- sumed, and it is most desirable that this should be persevered with daily ; but if the lower extremities are much affected, there is a fear lest too great an amount at any one time may excite local irritation in parts which have recently been in- flamed. As yet it has been assumed that the goutj' attack has occurred in a strong individual, and is of an acute and sthenic kind ; but this ma}' not always be the case, for even a first fit may find a patient broken down in constitution, and quite unable to bear the least withdrawal of nourishment or stimulus. Under these circumstances, care must be taken to give such nourishment as the digestive organs can easily assimilate, as beef-tea, strong but plain soups, eggs, milk, &c. ; and, when practicable, to confine the stimulus to some distilled spirit, as brandy or whisky, giving these only to the extent of keeping up the action of the heart and the efficiency of the circulation. A few general rules may be advantage- ously given, which will serve as a guide for the treatment of gouty patients in general, and apply more especially to such as suffer from the chronic forms of the disease. It is desirable to regulate the amount of food, so that the s3-stem shall be fully nourished, and the strength kept up as much as possible, but anything taken be- yond this is decidedly injurious, as it tends to oppress the digestive organs, and in- duce debility rather than vigor of frame. As to the character of the solid diet, it may be stated, that every article which causes unpleasant symptoms, recogniza- ble by the patient himself, should be stu- diously avoided ; and hence the less what are termed "made dishes" are partaken of the better : the same remark applies to all rich and highly-spiced food, and to anything that tempts the person to take more than he otherwise would. Articles of animal food of which the texture has been hardened, as salted meats, hams, and so on, are less easy of digestion, and should be discarded, as also veal and pork, which are much less easy of digestion, than mutton and good beef; white fish is generally digestible, as also fowl and game. There should be a due admixture of animal and vegetable food ; it is an error to suppose that an animal diet necessarily tends more to the formation of uric acid than a vegetable one. The tortoise, feed- TREATMENT. 549 ing on a simple lettuce, cxci-etes a large quantity of urate of aiuiuouia, far more in proportion to the weight of the aniuial, thau is excreted by the dog exclusively nourished with meat. Vegetables, as potatoes, greens, and the like, may be partaken of with advantage ; the soluble salts whicli they contain are of value in keeping np the activity of the secreting organs. The same remarks hold good with re- gard to soft fruits when partaken of in moderation, as strawberries, grapes, and oranges ; also other fruits when stewed or baked, as apples and pears ; but these latter, as likewise plums and stone fruit in general, should be avoided in a raw state. Extreme moderation should be e.Keroised when saccharine fruits are eaten, as sugar is liable in many subjects to lead to the production of acidity, and hence favor the development of Gout. The same precaution is necessary in re- ference to the addition of sugar to other articles of diet. As to beverages, both tea and coffee may be taken it they do not disturb the nervous system. At one time it was sup- posed that the latter was prophylactic against Gout, seeing that the Turks en- joyed an immunity ; but, if strict Maho- metans, they do not take alcohol in any shape, and hence avoid its most powerful cause. It is an important question to decide whether alcohol is to be ever allowed, and, if so, to determine the form which is best adapted for the patient. All malt liquors should be eschewed, as they almost always cause an increase of dyspepsia, and, if at all strong, have un- doubtedly a very powerful influence in in- ducing the disease and in keeping up a paroxysm. Strong wines will also prolong an attack to an almost indefinite length of time, and if they are moderately indulged in will often lay the foundation of the gouty dia- thesis. The wines to be carefully avoided are port, sherry, madeira, and any in which tlie fermentation has been checked by the addition of alcohol. If wine is taken at all, that which is best adapted for the majority of patients is a sound claret — one free from sugar and without acidity. When red wine does not agree with the stomach, then hock or moselle may be substituted, or even a light and dry sau- terne or chablis. The beverage best suited for those of a strongly-marked gouty diathesis is un- doubtly French brandy, taken in very limited quantities, and freely diluted with water. Wliisky, hollands, or gin, may in many cases be substituted for brandy ; but the two latter should be avoided if there is any appreciable amount of kidney disease, or at least should not be taken without advice. The distilled spirits should only be used at the meal, and from one to three ounces may be daily allowed, the amount depending upon the former habits of the individual. If Gout has become developed at a very early age, and the youth strongly inherits it, a question arises whether it would not be desirable to advise an entire abstinence from alcoholic drinks. Such a step would be the most Ukely to check the further progress of the malady.' Exercise must be enjoined, for it is of the highest importance, and without it all our endeavors may prove futile. The kind of exercise must be adapted to the peculiarities of the patient ; walking and horse exercise are equally useful, and may be conjoined with advantage. Fresh air is of great importance, and in many instances a complete change during the winter and spring to some warm and dry climate will enable the patient to es- cape an attack. All violent exercise likely to cause ex- haustion, all severe mental application and late hours, should be studiously es- chewed. In concluding the subject of the man- agement of Gout, the author's opinions may be thus summed up ; — 1. Gout in its acute form is quite as controllable, and as much under the influ- ence of remedies, as any otlier inflamma- tory affection. The duration of the parox- ysm and the amount of injury to the joints depend much upon the treatment. 2. The more chronic forms of Gout, which are met with in every degree of severity, are likewise under the control of the physician, if not for their radical cure, yet for so much relief as will enable the patient to enjoy life, and prevent further increase of the mischief, so liable to ensue if the disorder is allowed to run its own course, and more especially if recklessly tampered with. 3. As gout is a disease which is not only apt to return with increased severity, but to acquire a firmer hold on the consti- tution at each visitation, it is a matter of serious moment to consider whether it may not be prudent in the intervals of the attacks, not only to regulate the diet and regimen, but even to have recourse to means, scarcely to be called medicinal, by which the blood may be kept free from the impurities which lead to the produc- tion of the paroxysms. 4. The treatment of Gout founded on CuUen's aphorism, of trusting to patience and flannel, is to be highly deprecated. [> This recommendation may be very ad- vantageously extended to all gouty subjects, unless greatly debilitated. — H.] 550 RHEUMATOID ARTHRITIS. It may indeed be argued that it is the natural treatment, and that nature is a sure guide ; but it must be remembered that man living in a civilized state is not in a normal condition, or in all probability he would never have acquired the disease, and that when suffering from a disorder so acquired, he must be content to have recourse to artificial remedies. If he could entirely lay aside his usual habits, and follow in aU respects the dictates of nature, there would probably be little need to seek relief from medicine. 5. Although a plan can be sketched out which is apjjlicable to the majority of cases of Gout, still each individual case not only exhibits its own peculiarities, and becomes a separate study, but like- wise demands, in certain respects, a sepa- rate treatment. The neglect of this con- sideration is apt to lead to a mere routine practice, closely bordering on empiricism. EHEUMATOID AETHEITIS. By Alfred Baring Garrod, M.D., F.R.S. Definition. — A form of inflammation of the joints, accompanied with but little febrile disturbance, and distinguished from gout and rheumatism by its pro- gressive character, by the peculiar morbid changes which it induces, and by the ab- sence of any known morbid state of the blood. Synonyms. — Kheumatic Gout is the name commonly given to this disease, but equally applied to other joint affections. Dr. Adams uses the term Chronic Rheum- atic Arthritis. Dr. Todd included it under Chronic Rheumatism of the Joints. It has been called Nodosity of the Joints by Haygarth and Heberden ; Usure des Cartilages articulaires by Cruveilhiar ; Rheumatism Noueux, by Trousseau and other French writers. The term Rheum- atoid Arthritis was applied to this disease by the author in 1858. History of Rheumatoid Arthei- Tis. — It will be essential to the clear un- derstanding of this subject that some explanation be first given of the name proposed to be employed to designate this disease, and the reason of its adoption ; and to give reasons for the rejection of the many terms which have been used at different times. The term "rheumatic gout" is one which is very commonly em- ployed, both by the profession and the public ; but it is difficult to arrive at its true significance, seeing that but few have described it as a separate disease : the term has also been used to signify very different diseases. It is not uncommon to hear gouty patients say they are suffering from rheumatic gout, simply because the disease, which for many years was mani- fested in the feet only, now implicates other joints, as the elbows and hands ; in fact, they regard their malady as gout when it is confined to the feet, but as rheumatic gout when it affects the upper extremities. Sometimes the subacute forms of true rheumatism are designated as rheumatic gout, and more especially if the smaller joints are the seats of the attack. There exists, however, a third disease, distinct both from gout and rheumatism, to which the name is more frequently applied : it is this malady which we have called Rheumatoid Arthritis ; and it is this which will engage our attention in the present article. The name "chronic rheumatic arthri- tis" has not been employed, partly from the fact that the disease sometimes as- sumes an acute character, — if this were the only objection, it might be argued that ^\■c could designate this form by the name of "acute rheumatic arthritis," — and partly because the name rheumatic arthri- tis implies that the disease partakes of the nature of true rheumatism, which we be- lieve is not correct. The same objections, of course, apply to the words "chronic rheumatism of the joints." "Usure des cartilages articulaires" (wasting of the articular cartilages) is an expression limited in its meaning ; it only expresses one of the morbid changes which result from the disease. "Nodosity of the joints," and " rheum- atism noueux," express the presence of a frequent alteration in appearance, caused by the affection — one not constantly found. "Morbus coxee senilis" could not be used except when one particular joint is implicated, and it is a matter of some doubt whether this form of the disease has the same pathology. DESCRIPTION OF RHEUMATOID ARTHRITIS. 551 The term "Eheumatoid Arthritis" has been employed for the following reasons : — The disease is one chiefly affecting the Joints, and is of an inflammatory charac- ter ; hence the name arthritis. It is also one which, at least in its early stages, produces external changes closely resem- bling those caused by subacute forms of rheumatism ; but as it can be shown that the nature of the affection is not the same as that of rheumatism, the prefix ' ' rheum- atoid" instead of ''rheumatic" is suffi- ciently expressive. As the word typhoid is allowed for the purpose of designating a form of fever somewhat resembling, but not identical with, typhus, so no objection can be raised to the use of the prefix rheuma- toid, when it is intended to signify that the articular inflammation, although not of the same nature as rheumatism, yet resembles it in some of its characters, and more especially in those which are readily appreciated by the senses. With regard to the history of our know- ledge of Eheumatoid Arthritis little can be said. It is only since the time of Hay- garth that it has been looked upon by any pathologist as an independent disease, and even at the present time it is often de- scribed under the name of chronic rheum- atism, rheumatic gout, &c., and classed as a variety of some other affection. Desceiption" of Eheumatoid Ar- thritis. — Eheumatoid Arthritis is met with either as an acute or as a chronic disease : the former is much less frequent than the latter ; in fact, it has only been described within the last few years ; it will, therefore, under the circumstances, be desirable to reverse the ordinary mode of treating such subjects, and to describe first the more comnion form, namely, chronic Eheumatoid Arthritis. Chrcmic Sheumatoid Arthritis. — The affection may occur in both sexes, and at almost every age, and its invasion often assumes a form very similar to that about to be described. A 3'oung woman has become, from some cause, decidedly out of health ; perhaps from menorrhagia or leucorrhoea, or from hemorrhage during parturition, or from prolonged anxiety or physical fatigue ; she is exposed to cold, and, after a few days, feels some pain in the knee ; there is slight swelling and tenderness ; perhaps the temperature is a little elevated ; simple rest to the joint may be followed by relief, or even a cure, for the time, the swelling abating, and the tenderness and pain vanishing ; or perhaps this result may have been expe- dited by the application of a blister, or some other form of counter-irritation. After a few weeks or months, as the case may be, perhaps from a second chill, another joint, or even that which was previously implicated, becomes affected, and a similar train of symptoms arises, but with this important exception, that, m all probability, the inflammation does not again subside, but continues fixed to the joint, and gradually extends to others. During this time there may be no appre- ciable constitutional disturbance beyond the general ill-health above noticed, but in some cases dyspepsia or nervous symp- toms are exhibited. The disease, if unchecked, travels over the whole body, affecting almost every articulation of the limbs, and causing much deformity and distortion, from the enlargements and contractions which it produces ; nor are its ravages confined to the limbs alone, but other joints may be attacked, especially the temporo-maxil- lary articulation, causing the closing of the jaw; the upper cervical vertebras may likewise be involved, and the neck become fixed ; and thus at last the patient is ren- dered crippled and altogether helpless throughout the remainder of life. The above example is, indeed, one in wdiich the disease has effected all the mischief it is capable of; fortunately, it does not always proceed to this length, but is arrested at some stage or other of its progress, and then only a limited amount of distortion is induced. The deformities produced by Eheuma- toid Arthritis are not altogether charac- teristic of this disease, for they are pro- duced likewise by chronic gout ; but in their advanced conditions the separation of the one disease from the other is usually a matter of no difficulty. The changes in the arms and hands, when severely affected, are of the follow- ing kind : The elbow is flexed, perhaps at an angle of 35° from full extension ; the forearm in a semi-pronated position ; the joint is also much enlarged and mis- shaped, more or less rounded from the alteration and hypertrophy of the heads of the bones, as well as of the soft tissues. The wrists are rigid, almost straight, and scarcely admit of motion in any direction. The hands are usually thin, from the absorption of fat, and from the wasting of the other soft tissues ; the extremities of the phalanges are nodular, as also the heads of the metacarpal bones. The fingers are usually turned outwards and their joints rigid, often completely fixed. As a rule, the metacarpo-phalangeal ar- ticulations of the fingers are flexed, and the first phalangeal extended, causing the second phalanx to be thrown backwards ; the second phalangeal joint is also flexed. One, or even every finger in a hand, may be thus altered. The phalangeal joint of the thumb is usually extended, or bent backwards. Sometimes the nodose condi- tion is well marked, but not infrequently it is but slightly developed ; complete dis- RHEUMATOID ARTHRITIS. location of some joints is occasionally met with. The knee is generally much en- larged and rounded in the same manner and from the same causes as the elhow ; it is commonly half flexed. Sometimes there is evidence of liquid effusion, but in the later stages this may be wanting. When the hip is affected, the thigh be- comes flexed, sometimes abducted, with the foot everted; at other times adducted, with the foot turned inwards ; not infre- quently there is felt over the large joints a sensation as though the bones were loose. As a rule, the hands become crippled and distorted at an earlier period than the feet. Though frequently attacked, the jaw and neck seldom become fixed. An affection which, if not identical with Rheumatoid Arthritis, at least closely re- sembles it, was first made known to the profession by Heberden, under the title of "digitorum nodi," and described by him as consisting of little hard knobs, about the size of a pea, situated upon the ends of the fingers, where they remain through life, being usually attended with little or no pain, and, though they cause but slight inconvenience, are decidedly unsightly. Heberden thought that they had no connection with gout, seeing that they occur in persons never afflicted by that disease ; but Dr. Begbie considers them of a goutj' character, as they are frequently met with in that diathesis. The disease is sometimes confined to the extreme ends of the fingers, but now and then extends to the other small joints. When examined, the nodular feeling and the peculiar appearances are found to be owing to hypertrophy and other alterations in the epiphyses of the phalanges, and, except in position, and the small size of the affected joints, do not appear to difter from the enlargements and distortions above described as occur- ring in other situations. Ladies are often much concerned at finding these nodules on their fingers, and are willing to take any amount of trouble to arrest the progress of their formation and to attempt their removal. Acute Kheumotoicl AHhritis. — Kow and then cases are met with which, in most of their symptoms, closely resemble acute rheumatism ; several joints are attacked, the swelhng is considerable, there is dis- tinct increase of temperature of the af- fected parts, with pain, tenderness, and redness. In these instances, constitu- tional symptoms, as thirst, loss of appe- tite, heat of surface, a rapid pulse, and other evidences of febrile excitement, are often observed. There are, however, wanting some of the characteristics of rheumatic fever — namely, the profuse sweating and the proneness to acute in- flammation of the internal and external membranes of the heart, so common in acute rheumatism, and likewise the erratic disposition or tendency of the inflamma- tion to fly from j(iint to joint. Between cases of genuine acute Rheumatoid Arth- ritis and those of the very chronic varie- ties there is every intermediate shade of difierence. The only real difficulty in these cases is to determine whether the acute disease is true Rheumatoid Arthritis, or whether it is genuine rheumatism which has acted as the exciting cause of the former affection. As the acute disease is so little known and recognized by the profession, it may bewell to give an illustration, and the following case maj' be taken as a typical example. A lady, forty-two years of age, when living in Australia, in the bush, was con- fined, and being unable to procure a good supply of cow's milk was induced to nurse her child for a period of twenty months : at the same time she herself had but a very deficient amount of meat. By these means she was reduced to an extremely weak state. After a short time she no- ticed that some of her joints became af- fected ; at first the knees, then the ankles, afterwards the elbows and wrists, and, lastly, many of the small articulations of the hands. These parts were painful, somewhat swollen, hot, and tender, but the local symptoms were never intense, nor was the constitutional disturbance very great ; that is, there was no high degree of febrile excitement. After a few weeks some of the joints were much in- jured ; the knees, although reduced in size from the absorption of the fluid, could neither be fully extended nor flexed, and the patient was soon unable to stand by reason of their rigid condition ; the move- ment of several "of the other joints was also limited, although in a less degree. The causes of the debility being removed, the patient soon gained strength and flesh, and the tendency to the joint affection passed off, but not without having inflicted irremovable injury. Diseases caused by the Bheumatoid Dia- thesis. — In both gout and rheumatism, symptoms which may be termed irregular manifestations are occasionally met with, and the same holds good in Rheumatoid Arthritis ; in other words, structures other than those of the joints, but of a similar nature, may take on the same kind of dis- eased action. Sometimes these symptoms occur simultaneously with the joint affec- tion ; sometimes they alternate with it, or appear to be altogether independent of it. In well-marked cases of this irregular form of the disease, the inflammation has attacked the eyes, ears, or structures of the larynx ; producing in the first organ sclerotitis, in the second inflammation of the internal car, and in the last hoarse- ni.'ss, and a pecuhar dry cough, not at- tributable to pulmonary disease. MORBID ANATOMY OF RHEUMATOID ARTHRITIS. 553 Analysis of^ the A^iimal Fluids in BJieu- matoicl Arthritis. — Very little information has been obtained from an examination of the blood, m-ine, or sweat of patients, suf- fering from Eheumatoid Arthritis, which is calculated to throw light upon the na- ture of the disease. The only analyses of the blood that the writer is cognizant of have been made by himself, and with simply a negative re- sult. If any amount of active mtlamma- tion is present, the fibrin is increased, and the clot becomes firm, cupped, and buffed. The serum has the ordinary properties of the serum of healthy blood, and yields no uric acid. The analysis of the urine has likewise given negative ri^sults. The perspiration has not been exam- ined, but there is no reason to suppose that any peculiar alteration would be found in it. Morbid Anatojiy of Eheumatoid Arthritis. — The morbid anatomy of this disease has been very elaborately worked [Fig. 33. out by Dr. Adams, to whose volume the reader is referred for full details of the various changes which take place. In the present article a summary only of the results found in different eases, and ditter- ent stages of the malady, will be given. If a joint is examined in an early stage of the disease, when swelling is promi- nent, a considerable increase of synovial fluid is found, and the joint exhibits tlie same appearances as in cases of ordinary inflammation ; tlie lining membrane is often red, from over-injection of the blood- vessels. It is not an easy matter to ol)tain an opportunity of examining joints in this condition, as Rheumatoid Arthritis is sel- dom fatal, except in its very advanced stages ; but the supervention of other maladies sometimes enables us to do so. No deposits of urate of soda are found in any stage of this disease, and I am per- suaded that the statements to the con- trary are erroneous, and, as yet, there has been certainly no proof given in support of such assertions. Of course it is not im- possible that a patient may have had gout Fig. 34. Arthritis of Knee-joint. Changes in the Head and Keck of the Femur and in the Acetabnlum in Arthritis ] in a joint, and that afterwards the same articulation may become the seat of Rheu- matoid Arthritis ; but this, if indeed it ever occurs, is most rare, and would not in any way favor the idea that deposition of urate of soda is a phenomenon of this form of inflammation. When the effusion in a joint has been absorbed, the capsular membrane is usu- ally found thickened. In tlie hip, or shoulder, the round ligament or tendon of the biceps is probably destroyed ; inter- articular cartilages are sometimes ab- sorbed, and a case has recently come under my observation in which the articu- lation of the jaw exhibited this alteration in a very complete degree. If the fluid becomes absorbed before much serious change has taken place in the internal structures of the joint, the ligaments have generally undergone so much lengthening as to allow of unnatural mobility, thus rendering dislocation easy. From almost the very commencement of the inflammatory action, the articular cartilage begins to suffer, a slow process of absorption takes place, the cartilage appears to split up into fibres, vertical to the surface of the bone ; little depressions are observed, and these at length coalesce, and the bone is left in part uncovered ; as the disease proceeds, the whole surface may be thus denuded, and as the osseous surfaces are brought into contact with each other in the movements of the ar- ticulations, they become polished m a re- markable degree by the friction, and an ivory-like condition, termed eburnation, is produced. Sometimes this eburnation occurs in streaks or patches in the direc 554 RHEUMATOID ARTHRITIS. tioii of the motion of the joint; sometimes the whole surface may become thus al- tered. More rarely the cancellated struc- ture of the heads of the bones is exposed by the absorption of the denser matter at their extremities, and the ends of the bones become enlarged and misshapen by the deposition of osseous matter. If the bone is sawn through, it is often found unusually spongy, and contains a large amount of oily matter, from the occur- rence of a species of fatty degeneration. Within the joints vegetations and bands are frequently seen, also foreign bodies of various sizes, some cartilaginous in structure, others having the consist- ence and texture of bone ; and these are usually adherent to the internal surface by ligamentous bands. Causes of KnEUMATOiD Arthritis. — The predisposing causes of Rheumatoid Arthritis may be thus classified : First, those which are inherent in the patient ; secondl}', those which arise independently of the individual. 1. InJIuences dependent on the Individual. ^Hereditary Disposition does not appear to exert any very special influence, except that children of weakly parents probably inherit their debility. In looking over the histories of a large number of cases, the writer cannot find much evidence of the direct influence of liereditary predis- position ; if it exists, it is very much less powerful than in the case of gout. It is not uncommon to find one member of a large family suffering severely from the disease, and the rest entirely free from it. Sex. — It is commonly thought that women are more liable to Rheumatoid Arthritis than men. M. Trousseau speaks of the affection as very rare among men, very frequent amongst women. Women are doubtless very prone to be attacked, as they are most likely to be subjected to the predisposing causes, especially irregu- larities of the uterine function ; and it would appear that deranged menstrua- tion, independent of hemorrhage, predis- poses to the disease. Men, however, are by no means free, and some of the most severe cases are found among them. Age. — Rheumatoid Arthritis may occur at almost any age. I have seen ft in its worst form in children of ten and twelve years of age, and I have also seen it com- mence in very old people above seventy years. Individuals of weak frame, whose cir- culation is languid, and whose extremities are habitually cold, are more liable to the disease than others ; and it should be mentioned that patients having a tuber- cular diathesis are often the subjects of Rheumatoid Arthritis. •2. Influences independent of the Indi- vidual. — Everything which causes debility and loss of tone in the extreme circula- tion, as hemorrhages from the uterus or elsewhere, deep and prolonged grief, severe and protracted mental anxiety, acts as a predisposing cause of the dis- ease. It not infrequently results from rapid child-bearing, or too lengthened lactation ; also from night-watching. Cold is very frequentlj' an exciting cause of the disease, especially if it has been pro- longed, and has caused severe depression of the functions of the nervous system. In one instance I have seen the affection in its most severe form apparently the re- sult of diabetes mellitus. In some cases injuries or shocks appear to have acted as exciting causes. Now and then acute rheumatism acts as an exciting cause of Rheumatoid Arthritis. Malt liquors and wines do not appear to exercise any influence in either causing or protracting Rheumatoid Arthritis. Pathology of Rhetjmatoid Arth- ritis. — The examination of the blood in Rheumatoid Arthritis has failed to dis- cover any constant or pathognomonic changes in that fluid ; but as j^et the number of analyses has been very limited. One fact of importance they have elicited, namel}', the absence of uric acid ; and thus we are able to distinguish the blood in this disease from that in true gout. Pathological anatomy has likewise en- abled us to distinguish Rheumatoid Arth- ritis from gout, on the one hand, and from rheumatism on the other, by de- monstrating the absence, in the affected joints, of deposits of urate of soda, which are constant in gout, and by showing the presence of ulceration of the cartilages, and of other structural alterations, which are not found in simple rheumatism, even after repeated attacks. The consideration of the history and progress of the disease has shown that it differs completely, in its essential nature, from both gout and rheumatism, and fully justifies the rejection of the name " rheu- matic gout, " which must of necessity con- vey to every mind the idea of a hybrid disease, a compound of both gout and rheumatism. If a disease should be so designated, because it differs completely in its intimate pathology from both affec- tions included in its compound name, then no fault can be found with the no- menclature. It seems difficult to persuade those who have been brought up in the old idea of this hybrid affection that such disease has no real existence. Dr. Aitken, in his excellent work on the Science and Practice of Medicine, al- though be admits that Hunter warmly opposed this compound appellation, "rheumatic gout," deems it is neverthe- DIAGNOSIS OF RHEUMATOIB ARTHRITIS. 555 less pathologically correct, and thinks that a hybrid disease, depending on the combined cachexia of gout and rheu- matism, has a real existence, as recog- nized by Craigie, "Wood, Spencer Wells, and Fuller. On turning, however, to the last-named author, the following passage is met with : " The disease should not be regarded as of a hybrid character, or, in other words, made up in part of rheuma- tism, in part of gout. " And again : "It has no connection with either of these diseases, beyond that which attaches to it in virtue of its being a constitutional dis- order, producing local manifestations in the joints. " Mi^ht not the very same be said of pyaemia ? Is this not a constitu- tional disease, producing local symptoms in the joints ? It is a much easier task to prove what Rheumatoid Arthritis is not, than to give the slightest clue to what it is : at present I should hesitate to offer a strong opinion as to its nature. It appears to result from a peculiar form of nial-nutrition of the joint textures, an inflammatory action with defective power ; but of its depend- ence upon the presence of any morbid principle, or upon a weakened condition of the vessels or structures of the affected parts, no evidence exists upon which any reliance can be placed. Thus much only appears to be made out : it usually occurs in weakened suljjects, and exposure to cold is in many oases the exciting cause of its development. A full and searching investigation into the nature of R.heumatoid Arthritis is still a desideratum. Diagnosis of Kheumatoid Arthei- TIS. — Perhaps there is scarcely a subject of greater importance in the whole range of joint affections, than the diagnosis of Rheumatoid Arthritis ; for upon a correct understanding of it depends the future comfort and physical well-being of a large class of persons. Rheumatoid Arthritis, as has been al- ready shown, assumes various forms, and individual cases of the disease are often with difficulty distinguished. The affec- tions with which it is apt 'to be confound- ed are gout and rheumatism. It is there- fore important to be able at once to dis- tinguish Rheumatoid Arthritis from the above-named diseases. Haygarth thus describes the difference between what he termed nodosity of the joints (Rheuma- toid Arthritis) and gout, &c. : — "The nodes appear most nearly to re- semble gout : both of them are attended with pain and swelling of the joints, but they differ essentially in many distinguish- able circumstances. In gout the skin and other integuments are generally inflamed, With pain, which is very acute, soreness to the touch, redness and swelling of the soft parts, but in no respects like the hard- ness of bone. Thegout attacks the patient in paroxysms of a few days, or weeks, or months, and has complete intermissions, at first for years, but afterwards for shorter periods. The gout attacks men much more frequently than women. There is one distressful circumstance which dis- tinguishes this disorder : it has no inter- mission, and but slight remissions, for during the remainder of the patient's life the nodes gradually enlarge, impeding more and more the motion of the limb ; the malady spreads to other joints, with- out leaving or producing any alleviation in those which had been previously at- tacked." The following considerations will enable us to effect the diagnosis in at least the majority of cases : — It is questionable whether Rheumatoid Arthritis is in any marked degree capable of being inherited ; whereas gout is dis- tinctly hereditary. The sex of the patient does not aid us much. Both sexes are liable to the dis- ease, and the difference in their liability is too slight to enable us to give it much weight in diagnosis. Nor does the age of the patient argue nmch, as it has been shown that Rheumatoid Arthritis attacks both children and very aged persons. In many instances Rheumatoid Ar- thritis is preceded by a condition of ill- health ; there are evidences of bad nutri- tion and exhaustion of the nervous system. Rheumatoid Arthritis usually begins as a sub-acute disease, and the joint affec- tion gradually increases ; but occasionally it commences in an acute form. These latter cases may be mistaken for acute gout or rheumatic fever. There are, however, peculiarities in its course by which it can generally be distinguished from either of these diseases ; the most marked being its progressive character, which has been fully described above. From acute gout it may be distinguished by the length of the paroxysm, the absence of periodicity, by the large and small joints being equally attacked at the outset, and the great toe not being specially involved. From rheumatic fever or acute rheu- matism, by the comparative freedom from constitutional disturbance, the longer du- ration of the paroxysm, and the absence of acute cardiac inflammation. From chronic rhumatism it can he dis- tinguished by the comparative absence of structural alteration in the former disease. The most frequent diflaculty which oc- curs is to separate chronic Rheumatoid Arthritis from chronic gout, and, on re- ferring to the article "Gout" in the pre- sent volume, a case illustrative of this difiiculty will be seen. There should always be a careful search made for evidences of urate deposits on the ear and 556 RHETIMATOTD ARTHRITIS. at the tips of the fingers, and in the bursa; over the olecranon process of the elbows ; iDut from mere inspection it is difficult to make a diagnosis, especially if the affec- tion has become chronic. When the diagnosis is very obscure, notwithstanding that the above rules have been followed, it may be at once cleared up by an examination of the blood ; in Eheumatoid Arthritis there is no uric acid present : there is also, in most cases, the absence of any material alteration in the urine. One disease is with difficulty separated from the acute forms of Eheumatoid Ar- thritis — namely, the joint affection arising from urethral suppuration : the history of the case will of course enable us to clear up the diagnosis. Prognosis of Rheumatoid Arthri- tis. — Rheumatoid Arthritis is unques- tionably a very intractable disease ; and this is not to be wondered at, if we con- sider its ordinary antecedents. Its most common predisposing cause is a thorough- ly impaired condition of the system, and this in many instances has arisen from influences which have been for years in operation : it cannot, therefore, be even reasonably hoped that an affection occur- ring under such circumstances can be rapidly cured : it is often a great achieve- ment to arrest its further progress. If the disease is far advanced, and the joints severely injured, it is impossible to restore the articulations to their former state, even if the constitutional tendency to the disease is thoroughly arrested. Still, under such circumstances, it some- times happens that patients, who for years have been unable to move, will regain their power of locomotion, a result caused by the formation of a kind of false joint in some of the more important articulations. When the disease is less advanced, when the affected joints are few in number, and their mobility but partially interfered with; when at the same time there is freedom from any disease which must of necessity keep up the impaired state of health ; lastly, when the progress of the affection has not been rapid — then a more favorable view may be taken of the case, and a recovery more or less complete may be hoped for. When the disease is at its commence- ment, or at least when but little damage has ensued, and at the same time the af- fection shows little tendency to assume an acute character, then a coniplete recovery may be anticipated, if proper measures be adopted : if, however, the patient is in any way weakened, or treated as if he were suffering from a sthenic malady, then the probability of the disease becom- ing deeply engrafted into the system, and causing serious mischief, is greatly in- creased. The accurate diagnosis and proper treat- ment of cases of Rheumatoid Arthritis exercise a very important influence upon its prognosis. Treatment of Rheumatoid Arte- ritis. — The treatment of Rheumatoid Arthritis is a subject of the highest im- portance, more es-pecially in the earlier stages of the disease, when as 3-et the joints are not seriously or irremediably injured. From what has been stated under the "Causes" and "Pathology" of Eheuma- toid Arthritis, it will be naturally inferred that a prolonged sustaining plan of treat- ment is imperatively called for, and that all depleting measures must tend most materially to increase the rapidity and severity of the disease. I have witnessed a great number of cases in which deple- tion has been persevered in for a time, and with the eflect of producing lamenta- ble results, as the joints became perfectly disorganized ; and in many of these it is probable an opposite treatment would have been attended with different results. We must remember that, during the more acute inflammatory stages; the dis- ease nuist not be treated in the manner recommended to be adopted in gout. Col- chicum is always worse than useless, and the patient should be well sustained throughout the whole of the treatment ; neither are the alkalies, so serviceable in rheumatism, of any permanent value in Rheumatoid Arthritis. With the exception of stating that a supporting plan must be adopted from the first, no rules applicable to all cases can be laid down, a fact which must be evident, if we consider the different causes which lead to a condition of habit favor- able to the development of the disease. If the disease has been caused by hemor- rhage of any kind, and anaemia exists, then the first object must be to restore the blood to its normal state, and prepa- rations of iron are imperatively called for. If the mere ha?matinic influence is re- quired, the reduced iron (ferrum reduc- tum) may be administered, or the ammo- nio-citrate or seme other very mild salt of this metal ; if, however, the aneemia is combined with a relaxed state of habit, the more astringent preparations should be employed, as the sulphate or perchlo- ride of iron. If anaemia exists from other causes than hemorrhage, similar remedies may be had recourse to. Ferruginous salts are also of much value in keeping up the power of the heart, but in all cases they should be given in small doses, and persevered in for a long time. In certain conditions where the nutri- tion is imperfect from causes often unable to be defined, cod-liver oil may be given TREATMENT OF RHEUMATOID ARTHRITIS. 557 with great advantage : if the habit is ma- terially improved by it, the progress of the joint affection is usually checked. Cod-iiver oil is particularly indicated in patients of spare habit, and when the dis- ease has been attended ^vith wasting of the body. If the nervous system has been seriously implicated by depressing causes, as anxiety, grief, prolonged at- tendance on sickness, then remedies more directly affecting this system must be em- ployed, either by themselves, or in con- junction with those already mentioned. Quinine, as a nervine tonic, is often of much service, as likewise, when astrin- gents are indicated, the preparations of cinchona bark ; assafoetida, valerian, and ammonia are of value when there is much mental depression. If the circulation is very languid, guai- acum may be administered with benefit, or guaiaoum united with yellow bark; as, for example, the ammoniated tincture of the former medicine, and the simple tinc- ture of tlie latter. Guaiacum appears to exert a marked effect upon the capillary circulation, in- creasing the warmth of the extremities, and rendering the functions of the skin more active. Arsenical preparations are in some cases of considerable value : how they act is a subject of considerable difficulty to explain. We have clinical evidence de- monstrating their peculiar action upon the skin, and it may be that their indu- ence is exerted also upon the fibrous and cartilaginous structures, or they may more especially affect the nervous system as tonics, and thus prove of service. Arsenic may be given either in the form of the arsenite of potash (liquor arsenica- lis), or the arseniate of soda (liquor sodas arseniatis). From repeated trials, I have come to the conclusion that arsenic, in the state of arsenic acid, is less irritating than when in the lower condition of oxi- dation, and can be given in larger doses. Iodides' are of service in some eases, especially during the more acute stages, or when warmth has a marked effect in causing an augmentation of the pain. Iodide of potassium may be administered alone, or in combination with guaiacum or guaiacum and bark ; or the iodide of iron may be given, especially if ferrugi- nous preparations are indicated. The Syrup of iodide of iron, in doses of from twenty to thirty drops twice a day, and continued for some months, has in seve- ral cases proved of much benefit, even to the extent of completely arresting the progress of the disease. In special cases special remedies must be employed. If, for example, menor- rhagia has been in anj^ way the cause of the debility, and still continues, bromide of potassium may be advantageously had recourse to ; and should the muscular system have been wasted, especially the nmscles of the affected limbs, nux vomica or strychnine can be given to restore their function. ilineral waters are often resorted to from a mistaken view of the nature of the malady. I have seen much injury resulting from their employment fi-om the debility they have induced. The springs most adapted for the subjects of Rheumatoid Arthritis are those of Schwal- bach, Pyrmont, and Spa, or any other ferruginous waters, which sit easily upon the stomach. The stronger saline and alkaline waters, as those of Carlsbad, Wiesbaden, and Vichy, unless used with great care, are apt to aggravate the dis- ease. In some very chronic cases, the springs of Wildbad and Gastein have proved of much service. Change of air, occupation, and scenery, by aiding the general health, exerts a beneficial influence upon the progress of the malady. Loccd Treatment of Rheumatoid Arthritis. —Iw the early stages, when there is ten- derness and swelling of any joint, relief is often experienced from the application of blisters, and a most convenient form is the cantharides liniment of the British Pharmacopoeia : it produces, in almost all cases, full vesication, and with little annoyance ; it can be frequently applied, so as to produce a series of flying blisters. Under this treatment the effusion will often quickly subside, and the tenderness become much lessened or even removed, and the liability to serious or permanent injury of the joint is thereby greatlj^ les- sened. Other forms of counter-irritation, as iodine paint, croton oil, may be used, but I believe the blister treatment above mentioned is productive of more benefit. AVhen the aftection of any joint has be- come more chronic, and blisters have ef- fected all they are able to accomplish, fur- ther benefit may be obtained from the use of plasters, Vi-hich act not only by the slight counter-irritation they produce, but Uke- wise, if properly applied, from the support they afford to the joint. The kind of plas- ter selected should depend on the require- ments of the case. If little more than simple support be needed, soap plaster may be used, and the joint may be bandaged with narrow strips of this, spread by ma- chine on linen. If more irritating appli- cations are desired, then the galbanum or ammoniacal plaster can be used, or the ammoniacal and mercurial, or the iodine plaster : when using the two latter, severe irritation of the skin should be avoided. The application of lotions containing spirit of such a strength as to cause but slight irritation of the skin sometimes 558 EHEUMyiTISM. gives great relief. If there is much pain, the belladonna liniment may be used in lieu of the simple spirit. Baths are in some cases useful, espe- cially when the function of the skin is de- fective ; but care must always be taken that debility be not induced, otherwise any good result is more than counteracted. Bathing is certainly not curative in this disease, it can only be looked upon as pal- liative, and should be employed with this understanding. In chronic cases, when friction can be used without increasing the tenderness of the parts, it may be employed either alone, or combined with some stimulating lini- ment ; or the joint may be well sponged with strong brine, and then rubbed dry, so as to cause the salt to enter the skin. It is often asked whether it is desirable to allow movement of the affected joints ? I believe the best answer to be this : never allow such an amount of movement as wiU cause the joint to be more painful on the following day ; but any motion short of this may be employed with advantage. If this rule were followed, it would pre- vent the use of joints recently or acutely attacked, and rest in such cases aids the subsidence of the inflammation ; on the other hand, it would allow those articula- tions in which the disease has become chronic to be moved to such an extent as to stay the wasting of the muscles of the limb, and to prevent the stiffening of the joints. [Many practitioners have confidence in the utility of mercurial ointment, applied once or twice a week to the inflamed joints. More benefit is likely to accrue from the employment of an ointment of carbonate of lead; two drachms to an ounce of simple cerate.' — H.] Diet and Reghvien in Eheumatoid Arthkitis. — As far as the fluid portion of the diet is concerned, it is a matter of indifference whether malt liquors, wines, or dihtilled spirits are taken, provided that they agree with the stomach : it is far diflerent in true gout. Whichever kind of alcoholic beverage causes the patient to eat with most relish, and digest with most comfort, should be selected. There is no necessity to give enough to stimulate, but only a sufficient amount to sustain the vigor of the assimi- lating functions. I am convinced that wines and malt liquors have no influence in favoring the development of Rheuma- toid Arthritis, although they powerfully predispose to the production of gout. The solid portion of the diet should be of the most nutritious character and of easy di- gestion, for our main object is to keep up the strength of the system : nor have we any proof that an excess of animal food tends to increase the disease, as is the case in gout. Meat should form a good proportion of the diet, if the stomach is capable of digesting it ; and whatever articles of diet are found to improve the general health may be given with advant- age. A frequent change of air and scenery should be advocated, all prolonged men- tal exertion avoided, and, as far as possi- ble, all causes of anxiety should be re- moved. A residence in a moderately warm country during the winter months is de- sirable, but the air of the place should be dry and bracing. Such a climate will en- able the patient to take exercise and have fresh air when otherwise he would be con- fined to the house. If the joints allow of it, moderate exer- cise should be enjoined, but not sufficient to cause subsequent fatigue. The clothirfg should be warm, but much perspiration avoided. RHEUMATISM. By Alfred BARiNa Garrod, M.D., F.R.S. The subject of Rheumatism will be dis- cussed in the present article under the heads of Articular and Muscular liheuma- [' This vehicle is preferable to lard on ac- count of tlie softening effect of the carbonate. Vaseline is iiable to the same objection, in this particular mode of application. — H.] tism ; the first, or Articular Rheumatism, in its more acute form, being commonly known as Rheumatic Fever. Such a di- vision has been adopted, as it is a question at the present day whether the articular and muscular affections are in reality manifestations of the same disease. DEFINITION HISTORY. 559 A. Abticular Rheumatism. DEFiisriTiON. — (1) Acute Articular Kheumatism. A specific inflammation of the structures in and around the joints, attended with great febrile disturbance ; erratic ; not accompanied with deposits of urate of soda, and (?) not leading to sup- puration. (2) Sub-acute Articular Rheu- matism. The same attection as the above, but manifested in a much less intense de- gree, and with little febrile disturbance ; generally following upon the acute disease. Synonyms. — Rheumatic Fever ; Ar- thritis. History. — Although there is every probability that mankind was afflicted with Rheumatism from the very earliest periods, still we gather from the writings of ancient physicians that they did not separate this malady from other forms of joint disease, but comprehended all of them under the general term "arthritis," the only distinction being made dependent on the particular articulations implicated. Monsieur Baillon, a French physician, first made use of the word Rlieumatism (from jjiifm, a stream, a fluxion) : in a Latin treatise published in 1G42, entitled " De Rheumatismo et Pleuritide Dorsali, ' ' he separates this disease from gout in the following sentence : " G-out is a disease of a certain part, and periodical ; Rheuma- tism of the whole body, and more uncer- tain in its attack." Sydenham afterwards makes a distinc- tion between the two alfections : "This disease, when unattended with fever, is frequently mistaken for gout, although it differs essentially therefrom, as will easily appear to those who are thoroughly ac- quainted with both diseases ; and hence it is, perhaps, that physical authors have not mentioned it, unless indeed we esteem it a new disease." Cullen thus defines Rheumatism : "A disease from an exter- nal and often an evident cause ; pyrexia ; pain about the joints, following the course of the muscles, fixing upon the knees and larger joints in preference to those of the feet and hands — increased by external heat." Even since Cullen's time there have been authors, both in this country and abroad, who have included Rheumatism and gout under the same category, amongst whom stands prominently the name of M. Chomel. The late Sir Benjamin Brodie, in his work on diseases of the joints, clearly sep- arates Rheumatism from rheumatoid ar- thritis, although he designates the latter affection ulceration of the cartilages. At the present time it may be confi- dently asserted that, omitting purulent affections of the joints and these con- nected with urethral suppui-,uIon, there exist at least three well-marked ai-ticular diseases dependent on morbid states of the system ; these are Rheumatism, gout, and rheumatoid arthritis : and probably to them we may add a fourth, namely, muscular rheumatism. Description of Acute and Subacitte Rheu- matism.—'To illustrate this subject we will give a sketch of an acute attack of rheu- matism, such as is daily met with in prac- tice. A young woman, possibly some- what out of health, is exposed to severe cold, or to cold and damp conjoined ; she feels a distinct chill or rigor, and this is followed, probably during the second or third day from the exposure, by the de- velopment of the joint affection ; the ankles become painful and unable to bear the weight of the body, and on examina- tiou they are found tender to pressure, swollen, unduly hot, with a distinct flush upon the surface ; at the same time the system exhibits a state of febrile excite- ment, the pulse is rapid and commonly hard, the whole surface hot and bathed in perspiration, having a peculiar acid, at least acrid, odor. The tongue is coated with a thick creamy fur ; there is loss of appetite, but increased thirst and a con- stipated state of the bowels ; the urine is usually scanty and high-colored, and gives rise on cooling to a copious red deposit. The inflammation is seldom confined to one joint, but gradually extends over the whole body. The larger joints are more frequently affected than the smaller in the earlier periods of the attack. The erratic nature of the affection is usually well exhibited ; at one time the knees and ankles, at another the elbows and wrists suffer ; and not infrequently the development of inflammation in one set of joints is accompanied by its rapid subsidence in another. A symmetry is often shown in the order of attack : the right ankle, then the left ; the right knee, then the left ; and so on for the other articulations. It is a matter of astonishment to observe how quickly and completely the inflammation will sub- side in any part. A knee, for example, will one day be intensely hot and swollen, and so exquisitely tender as not to bear the weight of the bed-clothes ; but on the following day will scarcely show any evi- dence of its previous suffering. This con- dition of the patient may continue for many days or perhaps weeks, the dura- tion depending partly on the intensity ot the disease, partly on the habit of the patient, and partly on the treatment ad- opted. Its usual duration, when under no special treatment, is from ten days to three or four weeks ; but perhaps no dis- ease exhibits greater differences m this respect, and hence the difficulty, except when a number of cases are compared, ot 560 RHEUMATISM. accni-ately estimating tlie value of tlie various jilaus of treatment which have been employed for its cure. Cases are now aucl then met with which spontane- ously terminate in five or six days, otliers which run a course of six or even eight weeks. With few exceptions, the pain of tlie joints and the febrile disturbance are greater at night than in the day ; but the nocturnal exacerbations are less marked in rheumatic fever than in acute gout. After a varying time the joints become free from redness, swelling, and tender- ness, the pulse lowered to its healthy standard, the temperature and sweating of the surface diminished ; at the same time the tongue cleans, the thirst abates, the appetite returns, the urine clears, and in short the system is restored to its healthy state, with the exception of a cer- tain amount of wasting and debility, necessarily induced by the increased wear' of tissue and the defective nourishment which have taken place during the period of febrile disturbance. From these, how- ever, the patient soon recovers, when able to take a generous diet and enjoy fresh air and exercise. It is not unusual to find that patients after recovering from attacks of rheumatic fever, as far as regards the constitutional symptoms, are liable to suffer from pains in those joints which have been the seat of inflammation : these pains are not con- stant, Ijut assume a neuralgic character, and will generally be found to be in pro- portion to the length of time the joints were affected during the febrile attack. Thus far our description has been con- fined to a case of acute rheumatism, in which the inflammation has been limited to the joint structures : unfortunately, however, it is not always so, for in a large percentage of cases the covering or lining membrane of the heart, or even the sub- stance of the organ, becomes implicated, and peri- and endo-carditis ensue. Some- times the heart disease follows a some- what sudden subsidence of the joint in- flammation, but more commonly the articular and cardiac affections run a simultaneous course. When inflammation of the pericardium takes place, the patient usually expe- riences a sensation of tightness or pain in the chest, but not always, as the acvite discomfort caused by the condition of the joints draws the attention altogether from the slight uneasiness due to the cardiac complication. On applying the stetho- scope a distinct friction or rubbing sound is heard, often limited at first to a small extent of surface, generally at the base of the heart, but it commonly spreads over nearly the whole of the surface of the organ ; when the amount of effused fluid is large, there is increased dulness of the percussion note over the cardiac region, and the heart's sounds are diminished in intensity, and heard as if from a distance. When, on the other hand, the endocar- dium is implicated, abnormal heart sounds are produced usually at the aortic or mitral valves, giving rise to basic or apex systolic murmurs ; or, if the closure of the aortic valve becomes imperfect, a basic diastolic murmur is also developed. These various phenomena are due to the pour- ing out of lymph and serum upon the surfaces of the pericardium, or the secre- tion of plastic lymph or fibrinous coagula upon the valves of the heart. When the cardiac substance is involved, great ir- regularity and extreme feebleness of the action of the heart ensue, often leading to sudden and fatal collapse. For further details concerning the physical signs and sj'mptoms which occur in pericarditis and endocarditis the reader is referred to the articles devoted to those diseases, as these affections, when they arise from rheumatic inflammation, follow the same course and exhibit the same phenomena as when due to other causes. Pleurisy of a true rheumatic nature sometimes occurs during the progress of rheumatic fever, and the phenomena are the same as in the ordinary forms of acute pleuritis. More rarely the peritoneum becomes affected by rheumatic inflammation. When the heart is implicated, delirium is usually present, especially at night ; but in some few cases the rheumatic condition appears to attack the membranes of the brain, and then the symptoms of cerebral meningitis are produced. Sometimes the membranes of the spine are involved, and symptoms of spinal meningitis are set up. Chorea is apt to supervene in young subjects after the cessation of the febrile disturbance in rheumatic fever, where the heart has been implicated. Description of Hiihacnie Articular Bheu- matism. — At times, from various causes — as the nature of the patient's constitution or the presence of cardiac complication — articular rheumatism assumes a form to which the name subacute may be pro- perly applied ; the joint symptoms remain, but in a much less severe degree, and there is an almost complete absence of febrile disturbance. Such a condition may continue for weeks or even months, at one time relieved, at another aggra- vated, and the disease may then be coni- ^ pared to a similar subacute form not in- frequently seen in gout, and to which the ,. term chronic is applied. _ j In subacute rheumatism there is often ; some tenderness of the joints, slight swell- ^ ing, and heat, but the disease differs from , ij both chronic gout and rheumatoid arth- ,; ritis, inasmuch as it may continue for a ?' HISTORY. 561 long time without leading to any great deformity' or permanent "injury to the articulations. It will be seen that the statements made above are at variance with those conunonly met with in works on this disease, in which the results ascribed to the subacute attection are so formidable. The difter- ence is easily explained : most authors attribute to chronic rheumatism the changes that in the present work are de- scribed under the head of rheumatoid arthritis. The occurrence of one attack of rheu- matic fever imparts a great susceptibility to the system for its return, which a sec- ond augments, and thus after a time the patient is liable to become the victim of frequent seizures, though these will pro- bably assume a less sthenic form, and are often of such a character as to entitle them to be called subacute rather than acute. When a patient has been brought to this condition, the most trifling exposure to cold, or even the slightest depressing cause, may prove sufficient to light up the disorder. Even in individuals who have suffered long and severely from repeated attacks, it is unusual to find any very serious al- terations produced in the affected joints ; they may for a time remain more or less swollen from effusion of fluid, the liga- ments may become stretched and relaxed, hut there is no permanent thickening left either from tlie deposits of the chalk-like matter (urate of soda) so constantly found in gout, or from the formation of false cartilages and other changes, the effect of rheumatoid arthritis. Consideration of the different Phenomena in Acute Bheumatism. — The various symp- toms which are observed in cases of acute rheumatism demand further investigation than could be given them in the above sketch, and the first which claim atten- tion refer more especially to the joints themselves. The pain is generally very severe, but less intense than in gout; the swelling also is usually less marked than in the latter disease; there is rarely found extreme tension of the skin, and seldom oedema or desquamation of the cuticle ; the redness is likewise less in Bheumatism than in gout, although this symptom may sometimes be present in a marked degree; and, lastly, the enlargement of the veins leading from the inflamed joint is certainly much less prominent in this disease than in true gout. Rheumatic inflammation has a decidedly erratic disposition, and, as it were, flies from joint to joint, or at least one articula- tion suddenly ceases to exhibit inflamma- tory symptoms, and another, probably the corresponding articulation, becomes as suddenly implicated; and this alternation ffiay occur many times during a single at- VOL. I.— 36 tack. A certain amount of symmetrical action is likewise observed, as in almost all diseases the symptoms of which dej)end on an altered condition of the blood. On reflection it will be found that our sur- prise should rather be excited by a want of sj-mmetry than by its occurrence ; for supposing that any morbid element has a peculiar attraction to any one joint— a knee, for example— it is necessarily drawn to the second knee more powerfully than to any other joint ; or supposing again that the circumstances in one particular joint more especially favor the develop- ment of any specific form of inflannnation in it, the conditions of the corresponding joint on the other side of the body must do so likewise. It has been stated that the swelling of the inflamed joints is less in Bheumatism than in gout, and the same holds good with the pitting on pressure, and the sub- sequent desquamation of the cuticle. This last symptom, so constant in gout, is not observed afti^r rheumatic inflammation : but it must not be concluded that because pitting is present the inflammation is not rlieuraatic ; this would be erroneous, for cases of genuine rheumatic fever are now and then met with in which pitting of the skin is well marked : when (his pheno- menon occurs, it is generally in weak sub- jects. In several such instances I have proved, not only by carefully examining all the symptoms, but also by analyzing the blood, that the cases were of a true rheumatic character, and had no relation to gout. The constitutional symptoms which are most prominent in acute articular rheumatism next require consideration. The first of these, one of great importance, is the temperature of the bodJ^ That there is a well-marked heat of surface is evident to the touch, but the indications of the thermometer are far more trust- worthy ; for they show correctly the amount of tissue-waste going on in the system, and cannot be masked by the in- fluence of the mind or other circumstances which render some of the subjective symp- toms of comparatively little value. Dr. Sidney Binger, ^vhose researches on temperature in disease are of much value and interest, has made observations on three cases of acute rheumatism wliich were communicated to Dr. Aitken, and published in his work on the Science and Practice of Medicine. In some fatal cases, complicated with severe pericar- ditis, the temperature rose as hish as 106° Fahr., 109° Fahr., and 110° Fahr. before death. In some instances of acute articular rheumatism I noticed the temperature, and found it to vary from 100° Fahr. to 104° Fahr. ; but these observations have been made in cases in which recovery has 562 RHEUMATISM. taken place. The pulse, as already no- ticed, is usually quiet iu acute rheumatisiu ; it is also hard and full ; but exceptional cases are now and then met with in wliich the frequency is never great, although the febrile disturbance and temperature run high. More reliance can be placed upon ilie heat of the body than upon the rapid- ity of the heart's action in all cases of a^-Lite inflammation, and this especially Koltls good in Kheutiiatism, as the cardiac c.jniplications so frequently present in tliis disease alter the character of the pulse, independently of the amount of tissue- change which is going on in the system. The perspiration is generally considered to be intenseh' acid in acute rheumatism ; iu several cases I have found it less acid tnan in health}' subjects ; but it nmst be remembered that the amount of perspira- tion is excessive. The peculiarity of the skin secretion in this disease depends on its acridity perhaps more than on exces- sive acidity. Condition of the Blood in Acute Articular Rheumatism. — In acute rheumatism, if blood is drawn from a vein, the clot is found to exhibit a buffy coat, and is fre- quently cupped — appearances which indi- cate that the ftbrin is increased in quan- tity, and that this principle is also probably somewhat altered in quality. Many discrepant statements have been made upon this subject ; according to Haller, the blood yields a thick and firm clot in this disease, but others assert that under the buffy coat the clot is found to be loose and friable ;— probably both are correct in different instances. Andral and Gavarret analyzed the blood in fourteen cases of rheumatic fever, and found the maximum amount of fibrin to be 10 '2 parts in the 1000 ; the minimum 2'8 parts ; the mean was 6'7 : healthy blood yields, according to these observers, three parts per thousand. The serum of the blood does not appear to be very sensiblj' altered in composition ; Andral and Gavarret found an increase in the solid residue left by evaporating this fluid, the mean amount being 86 "0 per thousand against SO'O per thousand in healthy blood. The same chemists found a diminution in the total solids : thus the mean in the above-mentioned fourteen cases was 194-6 jiarts of solid matter to 805-4 parts of \vater in the 1000 parts of blood ; whereas in healthy blood the ratio between the solid residue and water is 200-0 to 790-0. In several analyses which I have made of the blood in acute rheumatism, I have found the amount of fibrin notably in- creased — namely, from four to six parts in the 1000 — and the clot has usually been buffed and cupped. The serum in thirty- five cases was found distinctly alkaline m reaction, it presented a healthy appear- ance, its specific gravity was somewhat I less than in health, and in no case vvas any uric acid detected either by the thread experiment described in the article on Gout, or by the ordinary method of sepa- rating this acid from blood. The absence of uric acid or urate of soda is important, as it at once shows essential difference between gout and Rheumatism. Urea does not exist in the blood in acute rheumatism iu quantities larger than in health, except in cases in which the kid- neys have been either previously affected, or have become congested during the pro- gress of the disease. As above stated, the serum was always distinctly alkaline in reaction : this fact was particularly ob- served and noted, as it has been affirmed that the serum is sometimes acid iu rheumatic fever. There are, as yet, no recorded observations indicating the amount of the alkalinity. Ko abnornial principle has been found in the blood ; lactic acid has been assumed to exist in it, but no proof has been given of its presence. In the subacute and chronic varieties of Rheumatism no marked alterations are found ; the fibrin is increased but slightly, and only in proportion to the amount or the febrile disturbance. In ten cases the maximum of the fibrin was .5'1, the mini- mum 2-6, and the mean 3-8 parts in the 1000 parts of blood. Urine in Acute Articular Sheumatlsm. — Examinations of the urine in acute rheumatism have been frequently made with the following results : To the eye its appearance varies much in difterent cases ; as a rule it is high-colored and scanty, clear when first passed, but speedily be- comes turbid from the deposition of urates ; when copious it sometimes remains bright even after it is cold. These characters are by no means peculiar to rheumatic fever, but are seen in many febrile affec- tions. The deposited urates are often of a deep tint from the coloring matters of the urine being in excess and attracted to the uric acid salts, and if the fever runs very high, and especially if portal conges- tion is present, the color becomes bright red or deep pink. On a more minute ex- amination, it is found that the secretion of water by the kidneys is usually dimin- ished ; the solids of the urine are increased. The increase in the solid matter is due chiefly to the augmentation of the urea, partly also to an increase of the coloring matter. The uric acid is augmented : Dr. Parkes has found as much as seventeen grains in one case ; the largest amount I have obtained has been fifteen grains. It should be remembered that this increase of uric acid in the urine is not peculiar to rheumatic fever; it occurs likewise in other febrile diseases, unless the excreting power of the kidneys is injured. The MORBID ANATOMY OF ARTICULAR RHEUMATISM. 563 chlorides are diminished during the febrile disturbance, but less so than in pneumo- nia. Dr. Parkes found the sulphates much increased in several cases in which the inflammation of the joints and the febrile disturbance were severe. When alkaline remedies are not administered, the acidity of the urine is usually great. Albumen is now and then met with during the course of this disease, sometimes only for a day or two, but its occurrence is much less frequent in rheumatic fever than in pneumonia. No proof has yet been given that lactic acid exists in the urine in rheumatic fever in greater amount than in healthy urine. Cardiac and other Inflammatory affections in Acute RheumaUsni. — It has been stated that in a large percentage of cases of rheu- matic fever the structure of the heart be- comes involved, and as such complications are of vital importance to the patient, they deserve in this place further con- sideration. It has long been suspected that some relation existed between acute articular rheumatism and inflammatory diseases of the heart. In the first volume of the Medico-Chirurgical Transactions there is a paper by Sir I). Dundas on this subject, ill which he states: "In all cases which I have seen, this disease has succeeded one or more attacks of rheumatic fever. In one case, the aftection of the heart ap- peared at the commencement of the rheu- matic fever, and its action was so rapid that the pulse could not be counted for many days ; much difficulty of breathing and oppi-essiou, attended with a sense of debility, took place ; and the inflamma- tion, pain, and swelling of the extremities, after having shifted from one joint to an- other for many weeks, subsided ; but the affection of the heart continued, generally attended with great pain, producing in the progress of the disease, and towards its close, a considerable disposition to dropsy, under which the patient lingered for many months." As far back as 1788, it would seem that Dr. Pitcairnhad noticed that persons sub- ject to Rheumatism were attacked more frequently than others with symptoms of heart disease, and he considered that the two diseases often depended on a common cause. Tlie connection between Rheunia- tism and cardiac disease was also known to Dr. Wells, Dr. Baillie, and others. The heart affection, however, was re- garded by these authors rather as the effect of a metastasis of the rheumatic inflammation from the joints to this organ, than as an essential part of the disease itself. Some French authors claim the merit of the discovery of the close relation- ship for M. Bouillaud, who in his work, published in 1840, called special attention to the coincidence of pericarditis, endo- carditis, and pleurisy with acute articular rheumatism. Since the above period, the relationship has Ijecu fully determined, and these diseases arc now looked upon as portions of the rheumatic aflection, and not as mere accidental complications. There is considerable discrepancy of opinion among different authors as to the kind of cases of rheumatic fever in which cardiac inflammation is most likely to ocfur. Some are of opinion that even in the slightest forms of the disease, when febrile disturbance is moderate, the struc- tures of the heart may become seriously aftected. Others think that the liability to the lieart disease is far greater in the severe forms of articular rheumatism, and that even when the joints are not much implicated, still the systemic disturbance is always great, and the peculiar phe- nomena of the disease strongly marked. As far as my own experience goes, it amounts to tiiis, namely, that although the severer forms of the articular disease are very apt to be complicated with cardiac inflammation, yet even in the very slight forms, measured by the febrile and joint symptoms, serious mischief may arise in the heart ; and several such cases have come under my own observation. Wlien the heart is much influenced, this will of itself be a source of great constitutional disturbance. It is supposed by some pathologists that the vegetations which take place on the valves of the heart are not always due to endocardial inflamma- tion, but may arise entirely independently of such, and are owing rather to an altered state of the blood itself. It is a matter of extreme difficulty to determine the relative frequency of the cardiac affection in rheumatic fever ; in young subjects the heart is much more prone to be attacked than in adults ; the kind of treatment adopted in the early stages appears likewise, from the statistics of Dr. Dickinson, to have a considerable influence upon the result. Bouillaud thought the heart became affected in one- half of the cases, but Dr. Macleod in about one-fifth only. Morbid Ait atomy of Articular Kheitmatism. — The opportunities of ex- amining joints affected with rheumatic in- flammation are not numerous, as the ar- ticular affection never kills, and a fatal determination, even when the heart or other important organ is attacked, is for- tunately rare. In a few instances, where death has occurred when inflammation of the joints was actually presented, I have found considerable redness of the synovial membrane, and increased vascularity of the synovial fringes ; an augmentation of the synovial fluid, and sometimes little gelatinous coagula of fibrin ; under the microscope nucleated cells were seen but 56i EHECMATISM. none of the ordinary appearances of pus. In one case of mono-articular disease, the fluid was indeed turbid witli pus cells, but in this instance, some doubt existed as to the true nature of the affection. In Dr. Fuller's work a detailed account is given of the post-mortem appearances in sixteen cases of acute rheumatism ia St. George's Hospital. In eight of these cases the joints were examined : in some of them the only morbid appearances were increased vascularity, a thick tena- cious fluid, with granular globules or a few pus cells ; in some the fluid was tur- bid, and soft fibrinous coagula were found ; in other cases pus is described as being present both in the joints and likewise along the tendons. In two cases nothing abnormal was ob- served : but in one the inflammation had subsided some weeks before death ; and in the second, as far as the history is given, the local mischief was not great. Chomel, who examined a knee-joint two days after the cessation of acute rheumatic inflammation, found an excess of synovial fluid, but no other morbid change. In examining joints which had been frequently and severely affected in rheu- matic fever, but in which the inflamma- tion had completely subsided, the only appearance I have observed, indicating any deviation from the normal condition, has been a lax state of the ligaments of the articulations, and an opacity of the articular cartilages, or a loss of the natural bluish-white opalescence of this tissue. No mention has been made of ulceration of the articular cartilages, and I have had proof that at least a dozen attacks of rheu- matic inflammation may occur in a joint without any such change taking place. In no case has the slightest trace of urate of soda been found, although very carefully looked for, and on one occasion I had the opportunity of examining and comparing two knee-joints — one that of a young man who had died from heart dis- ease at the time that the joint was suffer- ing from recent rheumatic inflammation ; the other, that of a man who had been killed by an accident, which had pre- viously caused the development of gouty inflammation of the part. The difference in the two cases was very striking : the vascularity in each was about the "same ; in the latter there was the characteristic white thickening of the cartilages from the crystalline deposition, and in the former the complete absence of such an appearance. For the changes which ensue when rheumatic inflammation attacks the peri- cardium, endocardium, or sul^stance of the heart, as likewise when the pleura or membranes of the brain are affected, we must refer the reader to the articles on the various diseases of those structures. Causes of Rhetjmatism.— The causes of acute rheumatism may be divided iuto (1) those which belong to the individual, and (2) those which are external to and independent of the patient. (1) Influences dependent on the Individual. — Hereditnry Preelispositiein. — Although the influence derived from this cause is not so well marked as in the case of gout, still it is very p(jwerful. Chomel and Requin stated that, in 72 cases, ,36 had rheumatic parents, 24 had healthy pa- rents, and 12 were unable to give any in- formation upon the point. This statement, however, is of little value, from the fact that these physicians did not distinguish cases of Rheumatism from those of gout. Dr. Fuller traced an hereditary in- fluence among the rheumatic patients admitted into St. George's Hospital, in nearly 29 per cent. : the writer has found that in about one-fourth of his patients hereditary p)redisposition could be traced ; many other authors have come to a simi- lar conclusion ; and it may be looked upon as an established fact, that a disposition to Rheumatism can be inherited. Age. — Young people are much more liable to be attacked with rheumatic fever than those more advanced in years, and in this respect Rheumatism differs essen- tially from gout. Heberden gives an in- stance in which Rheumatism occurred in a child only four years old. Others have made similar statements. Hay garth states that rheumatic fever affects persons of all ages from flve to seventy-two inclusive ; more frequently from six to thirty, but most frequently from sixteen to twenty years of age. Sex. — In a table given by the writer of .51 consecutive cases of rheumatic fever which came under his care, 31 were females, and 20 were males. There are, however, many discrepant statements with regard to this point. From many statistics it would appear that men are more subject to Rheumatism than women : thus it was fovmd that out of 289 cases of acute rheumatism admitted into St. George's Hospital, 151 were males, and 138 were females : and again, out of 136 cases of the same disease recorded by Dr. Latham, 75 were males, and 61 females. In Dr. Haygarth's cases, 99 were males, and 71 were females. It has been thought that women, after the catamenial period, are as liable to be attacked with Rheumatism as men. I have no hesitation in saying, that if this remark applies to true articular rheuma- tism, it has little or no value ; for after the age of forty-eight it is very rare to find either men or women affected for the first time with this disease. Women, however, are prone to have both gout and rheumatoid arthritis upon the cessation of the menstrual function. PATHOLOGY OF KlIEUMATISM. 665 State of Health.— Thore can be little doubt that articular rheumatism is more apt to become developed iu individuals who have from some cause or other be- come weakened, either from insufficient nourishment or from disease : hence one cause of its more frequent occurrence amongst the poor and ill-fed than amongst the rich. It is very common to meet with it in women who are suckling, the de- bility arising from over-lactation giving them greater liability to be attacked. (2) Influences external to the IndU-uluaJ. — Cold is certainly a very common exciting cause of articular rheumatism, and on re- ferring to tables which have been con- structed by different observers it will be found that this cause is far more potent than any other. The majority of patients are able to trace their malady to some one direct exposure to cold, and especially to cold combined with moisture. The more liable the person is from causes within himself, the less is the exposure which is necessary to develop the dis- ease ; a cold draught when over-heated, a damp bed, getting thoroughly wet through and becoming chilled, are the circumstances most prone to excite articu- lar rheumatism. It would appear prob- able that cold acts by causing a sudden check to the function of the skin. Scarlatina is often followed by an ar- ticular afifection which has all the charac- teristics of acute or subacute rheumatism, but which must be separated from the fearful purulent disease of the joints occa- sionally met with under these circum- stances. If the Kheumatism which fol- lows scarlatina is of the same character as rheumatic fever, its occurrence may be explained by the fact, that the scarlatina poison acts especially upon the skin, and greatly influences the cutaneous function, which is proved by the subsequent severe desquamation of the cuticle. It has been supposed that other causes, as the suppression of the menstrual dis- charge, or of habitual fluxes of various kinds, can act as the exciting cause of ar- ticular rhematism ; but if the recorded instances are carefully inquired into, it will be found that they are either cases of gout, or of some kind of purulent joint affection. In a certain number of cases of rheu- matic fever, the patients are unable to state any exciting cause of the attack, ^.nd if the predisposition to the disease is very great, it may often occur without any ap- preciable cause. Effects of Climate, Seascms, and Weather. —Dr. Aitken gives, in his work on Medi- cine, the returns, by Colonel Sir A. Tul- loch, of Eheumatism in the regiments sta- tioned at home and in the different colo- nies belonging to this country. Out of 1000 soldiers admitted at the military hos- pitals, in Jamaica, 29 ; Nova Scotia and New Brunswick, 3U ; Bermuda, 33 ; J.Iul- ta, 34 ; Ionian Islands, 3ii ; Gibraltar, .38 ; Canada. 40 ; Mauritius", 40 ; Wind- ward and Leeward Command, 49 ; United Kingdom, M ; and Cape of Good Hope, 57, were sufferers from iilieumatism. The following passage from the abo\e work contains all that is known on this sub- ject ;— " It is not, therefore, in the coldest climate that Rheumatism is most pre\a- lent, but in those seasons and iu those cli- mates remarkable I'or damp and variable weather ; and thus, says Sir A. TuUoch, ' we find in the mild and equalffe climate of the Mediterranean or the Mauritius the proportion of the rheumatic affections even greater than in the inclement regions of Nova Scotia and Canada ; and though some of the provinces of the Cape of Good Hope have been without rain for several years, yet Rheumatism is more frequent in that command than in the West Indies, where the condition of the atmosphere is as remarkably the reverse.' Exposure to heat, however, would appear to have much influence in the production of Rheu- matism ; for we find that returns of the navy show a considerably larger propor- tionate number of attacks than those of the army — the number per thousand annual mean strength attacked in the Mediterra- nean fleet being 63 '9, in the West Indies and North American station 09, and in the South American station 72-3." Chomel remarks that Rheumatism is seldom met with near either the equator or the poles, but that it becomes more fre- quent as we proceed from these regions, and that it is more especially rife in the temperate zones. In England the occurrence of rheumatic fever appears to be much more common in the eastern than in the western counties : this is usually accounted for by the expo- sure of the former portion of the country to the northeast winds. As far as seasons are concerned, it may be stated that no part of the year is ex- empt. Haygarth's tables give the follow- ing results in 150 cases :— The disease be This statement is undoubtedly true, as a rule ; but it requires modification in regard to cages of Rheumatism in patients inheriting a gouty constitution. — H.] TREATMENT OF ARTICULAR RIIEUMATIPM. 569 Cinchona BarJcand Quhiine. — Although bark had been previously employed in the treatment of acute rheumatism, by Drs. Morton, Hulse, and Fothergill, Dr. Hay- garth was the first who used it extensively, and brought forward clinical evidence of its utility ; but the treatment did not ap- pear to gain much favor with the profes- sion ; doubtless the large amount of cin- chona bark necessary to produce a decided effect upon the system was a great draw- back upon its administration : the substi- tution of quinine for the bark itself re- moved this objection, and the sulphate of the alkaloid has been tried very largely in France, and in verj' considerable doses, varying from one to six grammes in the twenty-four hours. From the statements of Briquet, Monneret, and Yinet, this remedy has a very decided influence upon the course of the fever, acting as a power- ful sedative upon the circulation, and allaying the pain and swelling of the ar- ticulations ; it often appears to prevent the development of cardiac complication, and even when this is present, it exercises uo injurious influence. The effect of the quinine upon the disease is most decided when given in full doses, even to the ex- tent of producing uncomfortable symp- toms in the head and stomach. Alkaline and Saline Treatment. — The treatment of acute rheumatism by saline and alkaline remedies has long" found favor with the profession, and many modi- fications have been adopted ; but before speaking of their relative merits, it will be well to define clearly what is meant by the saline and alkaline treatment. There are certain saline remedies which, after absorption into the system, are elim- inated by the kidnej's in the same state as when they enter the stomach ; for exam- ple: (1) nitrate of potash, chlorate of potash, and other salts in which the base is conjoined with a mineral aoid ; (2) alka- line salts with carbonic acid, in the form of the neutral or bicarbonate of the base ; (3) salts with alkaline bases united with a vegetable acid, as citric or tartaric acid. Although these salts are neutral in reac- tion, when introduced into the stomach, they become speedily altered in the blood, the acid is decomposed, and a carbonate of the base appears in the urine ; and hence, although they produce no alkaline effect upon the mucous membrane of the alimentary canal, yet upon the blood and the secretions their alkaline effect is well marked. Whether this effect on the blood is exactly the same as that of the free alkalies, or their carbonates, has not yet been determined. Saline remedies have sometimes been employed in small doses, simply for the purpose of acting upon the secreting or- gans ; at other times they have been given in very large doses, in order to alter the character of the blood itself, or powerfully influence the vascular ,s3'steui. The first saline to be tliscussed is nitrate of potash. Tliis remedy -was used about a hundred years ago by Dr. Brocklesby, in conjunction with bleeding. He ordered a dilute solution of the salt in water-yruel (about 120 grains to the quart), arid as much as an ounce or more of nitre in the twenty -four hours. With this he states that he cured many cases m seven or eight days. 8ince the above date it has been em- ployed by M. Geudinn, M. Martin-Solon," and in this country by Dr. Basham.^ From M. Martin-Solon's communication we cannot deduce the real value of the treatment, as the details are not suffi- ciently recorded, and it has been shown that under any treatment many cases get well in a comparatively few days. Dr. Basham states that one, two, or even three ounces of the nitrate, freely diluted, may be taken in the twenty-four hours without inconvenience. He looked upon and employed the nitre as an ad- junct to other remedies, and hence it is difficult to determine from his table of seventy-nine cases of _ acute rheumatism the real influence of the salt in combating the disease. Dr. Basham considers the local application of nitre of great value in causing abatement of the pain and swell- ing of the joints. The nitre treatment, upon the whole, seems to have been followed by good re- sults, and in Dr. Dickinson's record of seven cases treated in St. George's Hos- pital a favorable result was obtained. Allcaline Treatment. — Although an ap- parently over-acid state of the body, and an increased amount of fibrin in the blood, in acute rheumatism, would naturally suggest the value of alkalies as remedies for this condition, it does not appear that they were systematically employed until the year 1847, when Dr. Wright published a communication on the subject. Since that period both Dr. Fuller and the ^^'riter have made a full trial of them, one ad- ministering the alkali combined with some vegetable acid, the other prescribing it in the form of the bicarbonate. Dr. Fuller's results will be found in his work on Eheu- matism ; the writer's earher trials in a communication to the Medical and Chi- rurgical Society in 1855, in which an ac- count is given of fifty-one consecutive cases, treated upon the "full alkaline plan. The average duration of the disease in twenty males was 11-3 days, the duration under treatment 6-2 days ; the average ' De I'Emploie du Nitrate de Pot.isse k haute Dose dans le Traitement du Eheunia- tlsme articulaire. (Bulletin p6n de Thorap. aofit, septembre et octnbrc, 1843.) ' Med.-Chirur. Trans, vol. xxxii. 670 RHEriMATISM. duration of the disease in tliirty-one fe- males was 15'7 days, the duration under treatment 7-3 days. In no case did any heart disease occur after the patient had talten the remedy forty-eight hours. The plan consists in administering a dilute solution of bicarbonate of potash in about thirty-grain doses, every four hours, until the joint symptoms and febrile dis- turbance have completely disappeared. These doses produce no inconvenience either to the stomach or bowels ; the uri- narj' secretion is not notably increased, but its character is completely altered, and the reaction becomes either neutral or alkaline ; it usually remains clear, but occasionally gives rise to a deposition of the triple phosphates. Upon the heart the alkaline bicarbonate acts as a sedative, reducing the frequency of the pulse some- times forty-eight beats in the minute, but not causing any faintness. When a patient is fully under the alka- line treatment, the blood is distinctly altered, and the coagulation of the fibrin takes place more slowly. Many other remedies have been pro- posed for the cure of acute rheumatism, some of which it will be only necessary to enumerate ; lemon juice has been jpre- scribed by Dr. Perkins and Dr. Ciraud on the Continent, and in this country by Dr. G. O. Eees. It is usually given in quan- tities of from three to eight fluid ounces each day, and it is supposed to act as a sedative to the vascular system. It is doubtless a fact that, under its use, many cases of the disease rapidly get well, but, as has been shown above, this must not be taken as a proof of its curative power, and before we can decide upon its value, it will be necessary to have the tabulated results of a large number of trials of lemon Juice, and to compare them with those obtained from other methods of treat- ment. Other remedies used, either for the cure of the disease or the alleviation of certain of its symptoms, are, iodide of potassium, guaiacum, aconite, emetics, purgatives, diaphoretics, and hot-air baths. Iodide of potassium is used to reheve the obstinate pains which linger when the acute symptoms have passed off, and more especially pains which are increased by heat, and most troublesome at night. Guaiacum is valuable in subacute cases, when the circulation is weak, and the jiains relieved by the application of warmth. Aconite has been proposed to alleviate the acute pain of the joints, but when given in efficient doses it is apt to cause depression of the heart's action, and may be dangerous. Hot-air baths exert a soothing influ- ence, but great care is rpquired If used during the time of febrile disturbance ; and their curative value is somewhat questionable. No proof has yet been given of the value of a free administration of emetics or purgatives ; but proper attention must be paid to the state of the bowels. [Since its introduction to the notice of the profession by Strieker, of Berlin, in 1870,' the treatment of acute Kheuraatism with salicylic acid has received much com- mendation from practitioners on both sides of the Atlantic. Amongst those early observing its efficacy have been Traube, Broadbent, Maclagan, See, He- rard, Beaumetz, Jaccoud, and Lepine. The doses reported by Strieker and See were large, The former gave twenty or thirty grains every hour for six doses ; the latter, a drachm and a half daily, in five doses ; or, an equivalent amount, two drachms and a half of salicylate of sodium. Other practitioners, however, have found that smaller quantities will answer the desired purpose ; while very large doses are not free from danger. Empis and Jaccoud have reported cases of sudden death, not improbably explained by exces- sive doses of the drug. Probably ten grains every hour for five or six hours will usually suffice to make the powerful impression required. After that, the same or a less amount may be gi\'en thrice daily, until convalescence is assured. Under its influence two or three days will often be the whole period of severity of the symptoms. Cardiac complications are, there is reason to believe, less fre- quent under this than under any other treatment. Salicylic acid may be given in glycerin, or dissolved in alcohol with the aid of citrate of ammonium.^ Salicylate of sodium is generally accepted as, on the whole, the most available form of combination of the acid. Prom a drachm to two drachms or more of the salt may be given during the first day of treatment ; with diminished doses after- wards. No other mode of treatment of acute Eheumatism has, as yet, received so much testimony in its favor. — H.l Treatment of Heart, Lung, ana Brain Complications in Acute Rheumatism. — Having given an account of several of the more important methods of treating rheu- matic fever, it is desirable that we should inquire if any deviations are necessary when inflammation attacks the structures of the heart, lungs, or other internal or- gans. It has been already stated, that [' Berliner Klin. Woohensclirift, Nos. 1 and 2, 1876.] [2 An ounce of alcohol, with a drachm of ci- trate of ammonium, will dissolve two drachms of salicylic acid. Cassan, of Paris, first pro- posed this solvent. Bull. General de Tl.e'ra- peutique, April 30, 1876.— H.] TREATMENT OF ARTICCLAR RHEUMATISM. 571 the articular inflammation leads to but little mischief, and that the joints rapidly recover their healthy state. It is, how- ever, very diflerent in the case of the heart ; for there is a great disposition, both in the endocardial and pericardial serous membranes, to throw out lymph, which may lead to the thickening of the valves and adhesion of the surfaces of tlie pericardium ; it is therefore a matter of no little moment to ascertain whether any plan can be adopted either to prevent such mischief supervening, or of rapidly and efficiently checking it if it has already taken place. There appears to be every probability that the inflammation of the serous mem- branes of the heart is of the same kind as that of the joints, but it must be remem- bered that the structures themselves are of a somewhat diflerent character, and remedies which produce little or no eftect upon the joints may cause a decided action upon the cardiac tissues. It must also not be forgotten that inflammation lingers much longer in the heart, and is modified by the incessant movement of the organ. It is a very common practice in cases of pericarditis, or even of endocarditis, to apply leeches over the cardiac region ; and it is a chnical fact, that the tightness of the chest and pain are decidedly relieved by their application. Although it is difli- cult to explain tlie value of tlie local ab- straction of blood in these cases, still I believe it is undoubted, and I cannot there- fore hesitate to recommend it. Tlie loss of blood need not be large, from three to twelve leeches are generally sufiicient, and the bleeding should never be allowed to produce any appreciable weakening of the patient. Cupping may be employed in lieu of leeches, but I am inclined to prefer the slow loss of blood by the use of leeches, to its more expeditious abstraction by the cupping-glass. BUsters applied to the heart's region are also of much value, either before or after the application of leeches : care should be taken by previously applying collodion to the leech bites, and covering the surface of the plaster with tissue paper, to avoid the absorption of cantha- ridine, and the production of renal irrita- tion. Now and then, if there be much effusion into the pericardium, the bhster may be kept open, either with savine oint- ment, epispastic papers, or by some other iiieans. When leeches have not been pre- viously employed, the above precautions are less necessary. The simple applica- tion of a blister over the cardiac region is productive of much relief to the patient, and is followed by a decided improvement in both the heart's movements and sounds. A very important question in the treat- ment of the cardiac complications relates to the value of mercurials. It has been shown that the mercurial treatment of the joint affection does not prevent the occurrence of inflammation of the heart, and it only remains to be ascertained whether this metal has any power of ar- resting inflammation after it has once ensued. A iwimi it appears scarcely prob- able that a remedy, which has no in- fluence in preventing inflammation, should have the power of arresting it when it has already commenced ; but as the mercurial treatment is strongly advocated in such cases even by some who do not consider it as a preventive, it will be necessary to in- quire a little further into the matter. A few years since, almost every prac- titioner would have given this drug, and many at the present day scarcely dare omit its administration ; for it is supposed to limit and control the inflammatory action, and to cause the absorption of the products which have been thrown out. During the time of great febrile excite- ment it is very difficult to get the system under the influence of mercuiy, and it may be that, when this is effected, it is rather due to the prior abatement of the inflammation than from the influence of the metal. For many years I was in the constant habit of administering calomel in cases in which inflammation of the heart was pres- ent, but for tlie last eight or ten years I have not done so as frequently, and have seen no reason to regret the change of pr.actice : the cardiac inflammation ap- pears to have yielded quite as readily, and the patient, on the subsidence of the fever, has not had to suffer from ptyalism in addition to debility. As the question cannot be considered in any way fully settled, it must be left to each practitioner to follow his own course, and form his own judgment on the value of the mercurial plan of treatment. When it is adopted, the common method is to give calomel in doses of from one-half grain to three or four grains, every four or six hours, usually combined with a small amount of opium, to prevent the purgative action of the mercurial. If much difficulty is experienced in pro- ducing the effect upon the gums, then in- unction is often had recourse to, and this may be practised by causing a drachm or so of the blue ointment (unguentum hydrargyri) to be rubbed thoroughly into the skin of the inner side of the thigh, or into the axilla ; sometimes a blistered sur- face over the heart's region is dressed with the mercurial, instead of the green ointment. I have frequently adopted this latter method, and should prefer it, if mercurials are employed at all : it may be that the peculiar eftect of the metal is produced upon the tissues in the neigh- borhood of the blister, before the general system becomes aftected by it. 672 RHEUMATISM. During the whole course of treatment of the airdiac iuliamniatiou, the plan thought to hu mo^t advantageous for the joint aft'ectiou sliould he steadily perse- vered with, as anything which favors the abatement of the systematic disease must also relieve the internal complications. It is always a matter of the highest mo- ment to insist upon the most complete quiet ; constant movement of the organ must necessarily take place, hut every- thing should be shunned which increases this movement, or adds to the work which the heart has to perform. All chance of mental agitation, as well as bodilj' exer- tion, should therefore be strictly avoided. After the intlammation has subsided, the heart is generally left in an irritable state ; to allay this, a belladonna plaster is useful, and the administration of small doses of digitalis, combined with some salt of iron. jNIore or less antemia is always produced during the febrile dis- turbance, and this tends to keep up the excitement of the heart ; and hence the value of the ferruginous preparations. If the pleura3 become inflamed during the progress of acute rheumatism, the affection may be treated upon the same principles as the pericarditis ; leeches and blisters may be prescribed, and calomel and opium given, if considered of value by the practitioner ; and the same re- marks apply to the management of the brain and spinal complications which now and then arise. Local Treatment in Acute Ttheumatism. — In the majority of cases little or no local treatment is needed ; the affected joints should be protected by some light cover- ing, as cotton-wool, tiannel, or even a light handkerchief — but nothing further is called for : but now and then the pain is so excessive, or the patient is so sensi- tive to it, as to render it desirable that some direct application should be made use of. Hot-water fomentations may be first tried, but if not found sufficient, bel- ladonna may be added ; a very convenient preparation for the purpose is the liniment of the British Pharmacopceia, which may be either sprinkled upon the hot flannel, or diluted with two or three times its bulk of hot water, and applied by means of a piece of lint, taking care to prevent evap- oration by oil-silk or some other imper- meable tissue. A solution of atropia, or atropia combined with morphia, forms a very clean and elegant substitute. The extracts of belladonna, henbane, conium, and aconite have been recommended, as also the tincture of opium and decoction of poppy-heads. Alkalies and salines have also been ex- tolled as topical remedies in acute rheu- matism ; Dr. Basham has employed a solution of nitrate of potash, and Dr. Ful- ler one of the carbonate of potash or soda. Leeches have sometimes been used to the inflamed joints: I have never seen occa- sion for "their employment in genuine rheumatic fever. Blisters applied so as to cover all the inflamed joints have been highly spoken of by Dr. Dechilly and others ; Dr. Mar- tin-Solon made a report on the subject to the Academy of Medicine in 1850, and in the discussion which ensued it was stated, that the treatment had no other effect than to quicken the subsidence of the in- flammation in the joints. Dr. Herbert Davies has recently revived the use of free blistering, and orders armlets, wrist- lets, and even flngerlets of blister plaster, at the time when the inflammation is most acute ; he recommends linseed-meal poultices to be subsequently applied, in order to promote the free flow of serum ; he places these blisters entirely around the affected limbs, and in the case of the knees, orders them of at least three inches in width, regarding any slight strangury which may arise as of little importance compared with the benefit afforded by the free vesication. According to Dr. Davies, the blister treatment causes a speedy diminution in the frequency of the pulse, rapid subsid- ence of the joint affection, and lessens the liability to cardiac inflammation ; within twenty-four hours after the removal of the blisters, the urine is stated to become alka- line in reaction. Dr. Davies's results in a large number of cases appear to be favorable. Qidno-allMUne Treatment.— Dnrmg the last ten years, since the publication of his paper on the treatment of Eheumatism with large doses of bicarbonate of potash, the writer has made a very extensive use of the following plan, from which he thinks he has obtained more valuable results than from any other ; it may be termed the quino-alkaline treatment, and is thus practised : Sulphate of quinine is ordered to be rubbed up with a solution of bicar- bonate of potash, to which a little muci- lage and some aromatic, as tincture of cardamoms or spirit of chloroform, is sub- sequently added ; each ounce-and-half dose contains five grains of the quinine and thirty grains of the potash salt, the quinine being reduced to the state of car- bonate. To the adult the above dose is given each four hours, and persevered with until the joint affection and febrile disturbance have completely abated. When the quino-alkaline treatment was first made use of, a few days were allowed for the exhibition of the alkali alone, and then the quinine was added, but of late the quinine has been given from the first ; it neither increases the thirst nor the furred state of the tongue, and its influ- ence upon the heart is to lower its pulsa- tions, but not to weaken them,— and MUSCULAR RHEUMATISM. 573 hence, when peri- and endo- carditis are present, its employment is not contra- indicated. If cardiac complications exist, local depletion and counter-irritation may be made use of. In the subacute forms of articular rheu- matism, the same plan may be employed, but in a milder form ; that is, the doses may be smaller, or fewer in number. If desired, the citrate of potash, or some other alkaline salt with a vegetable acid, may be substituted for the bicarbonate : when irritation of the intestinal canal is present, the bicarbonate appears to act as a valuable sedative, but when there is a tendency to constipation, the citrate or tartrate may be advantageously given, care being taken that absorption of the salt be not too much prevented by its action on the bowels. The potassio-tartrate of iron may be added to the quino-alkaline draught after a time, and often with much advantage if any amount of anaemia is present. Although the results obtained from a large number of trials have not yet been tabulated, the writer feels assured that the above treatment is much more effica- cious than the simple alkaline plan, that there is far less tendency to the occurrence of relapses, and that the patient is left in a more satisfactory condition after tlie cessation of the febrile disturbance. Diet and Begimen im Rheumatism. — In acute rheumatism, when the febrile dis- turbance runs high, food can only be advantageously given in the liquid form : it is, however, important to sustain the strength of the body as much as possible, and for this purpose milk, if it can be assimilated, is one of the best forms of nourishment, as it contains all the ele- ments necessary for repairing the waste of the system. If milk in an undiluted state is too heavy, it may be mixed with an equal measure of soda water. Besides milk, beef-tea, mutton and other meat broths, and jellies, may be given. It is desirable also to introduce a certain amount of amylaceous and saccharine matters into the system ; hence arrow- root, made with water, milk, or beef-tea, may be administered. Soda water, lemonade made with cream of tartar or citrate of potash, and flavored with lemon, toast and water, or plain water, may be employed to allay thirst. Alcoholic stimulants are seldom needed in the young subject, unless there is great de- pression from the presence of serious car- diac mischief : wine, in true Rheumatism, has no tendency to keep up the specific inflammatory action. Asthe fever abates, and the power of the digestive organs returns, the diet may be impaired ; at first bread, light pud- dings, then white fish, fowl, and after- wards ordinary meat : but care must be taken that the stomach be not distended nor the system disturbed by the presence of food incapable of being digested. Throughout the whole course of the treat- ment of Rheumatism, both in its acute and subacute varieties, the great object should be to sustain as much as possible the strength of the patient, for by this means the duration of the disease is diminished, and the subsequent recovery rendered less tedious. During the height of the malady, when the skin is freely perspiring, care should be taken not to allow the surface to be suddenly cooled ; for although the free action of the skin does not appear to give rehef to the pains, yet a sudden check to it cannot fail to be injurious, and may lead to metastatic action. Individuals who have once suffered from rheumatic fever should be extremely care- ful as to their clothing ; they should al- ways be completely clad in flannel, which may vary in thickness at different times of the year ; the feet should be kept warm, and every precaution taken to avoid a chill. B. Muscular Rheumatisji. Definition. — An affection of the vol- untary muscles, of an inflammatory nature (?), but unaccompanied with swelling, heat, redness, or febrile disturbance. Synonyms. — Designated according to the situation of the affected nuiscles. Lumbago, Torticollis, Pleurodynia, &c. ; termed also Myositis, Slyo-rheumatism, and Myodynia. [Myalgia, Inman.' — H.] History. — By British writers this dis- ease is often included, with other affec- tions, under chronic rheumatism, a name manifestly incorrect, as the malady often assumes an acute character. On the Con- tinent some authors have claimed for it a separate existence, and the disease can scarcely be looked upon as a chronic form of articular rheumatism, seeing that its pathology is different. Description of Muscular Rheuma- tism. —Muscular rheumatism usually com- mences as an acute disease, but has a, considerable tendency to assume a chronic form : it may affect any of the voluntary muscles, but is prone to attack certain sets rather than others. The seizures are frequently sudden ; sometimes, for exam- ple, a patient awakes in the morning and finds himself incapable of turning in bed [' Dr. Inman applied the term myalgia, however, to pain of any origin, located in the muscles, including, therefore, that resulting from over-fatigue, &c. — H.] 67-i RHEUMATISM. or of twisting the neck, and tlie attempt to do so gives exquisite pain. If ttie atlec- tion is very acute, he may suffer paiu even when quiet, for tlie muscles are often in- voluntarily thrown into a state of spasm ; in the less severe forms the patient may be comparatively comfortable when at rest, but on the least movement he ex- periences agony by the paroxysm thereby excited. On examining the seat of suffer- ing, no external phenomena are visible, but there may be slight tenderness on pressure ; there is also a freedom from febrile excitement, at least at the onset of an attack, but as it progresses, thirst, loss of appetite, and heat of skin may ensue, probably due simply to the continuance of the pain, and the loss of sleep thereby oc- casioned. In muscular rheumatism the pulse is but little affected, and the urinary secretion preserves its normal state. A very important feature in this disease is the absence of inflammation of the heart, so characteristic of the articular affection. In the acute stages the symptoms increase towards evening, and are augmented by heat ; but when the disease becomes chronic, the pain is not unfrequently re- lieved by its application. The duration of acute muscular rheu- matism is generally short, usually not more than a few days, seldom exceeding a week : but when its intensity has be- come mitigated, it often proves tedious, and may be prolonged for an indefinite period of time ; it is also apt to be again lighted up, if the patient be exposed to any of its exciting causes. The principal varieties of muscular rheumatism are as follows : — Lunthngo (lumbodynia), when the large masses of muscles on each side of the spine in the lumbar region are implicated. When acute it renders the patient utterly helpless ; the most intense agony is in- duced on the slightest attempt to rise in bed, or even to turn in any direction. TortKollis (cervicodynia, or crick in the neck) is a term applied when the muscles on one side of the neck are affected. The patient is compelled to hold his head awry, in order to relax the muscles. Sometimes the sterno-mastoid is principally impli- cated, sometimes the disease extends to the muscles at the back of the neck. When some of the intercostal muscles are the seat of the malady, the affection is called Intercostal Bheumatism (pleurody- nia) : the symptoms are pain in some part of the chest, rendered intense by the act of breathing, but relieved by such pres- sure as prevents the movement of the ribs. The above three names are in common use, but many others have been occasion- ally employed by authors desirous of designating diseases simply from their locality ; and thus have arisen the terms Scapulodynia, Dorsodynia, Cephalodynla, according as the muscles about the slioul- ders, or of the dorsal region of the spine, or those of the head, are particularly im- plicated. As any of the voluntary muscles are capable of taking on morbid action, these names might be multiplied indefinitely ; the walls of the abdomen, the niuscles"ot' the limbs, the tongue, pharynx, dia- phragm, are stated to be sometimes impli- cated ; and even some of the involuntary muscles, as of the oesophagus, stomach, intestines, and uterus, appear to be sus- ceptible of the disease. Causes of Musculak Rheumatism. — These may be divided into 1st, those dependent on the peculiarities of the indi- vidual, and, 2d, those which are altogether external. Causes dependent on the Induidual. — True muscular rheumatism is seldum seen in very young subjects ; it generally oc- curs after the age of puberty, and more commonly in full adult age. One attack of the disease engenders a liability to its return, as is the case with articular rheumatism. Individuals of a gouty habit are fre- quently attacked with a muscular afl'ec- tion, which cannot well be distinguished from ordinary muscular rheumatism. Causes external and independent of the Individual. — The only external causes of muscular rheumatism appear to be colJ and damp, more especially if combined with an over-use of the muscles : lumbago, for example, is often produced by strain- ing the lumbar region ; and cold draughts of air, as from a partially open window will frequently prove the exciting cause of an attack of torticollis. Pathology of Muscular RHsmiA- TiSM. — The nature of muscular rheu- matism is usually regarded as closely allied to articular rheumatism, the differ- ence in the symptoms being supposed to depend on the peculiarities of the struc- tures which are affected in the two dis- eases. Some reasonable doubt may, how- ever, be entertained of the correctness of this opinion, for the following reasons : If the proximate cause of the muscular affection is the same as that of the articu- lar, the heart would probably become in- flamed in a certain proportion of the cases ; but it is not so : and again, there is an absence of the peculiar secretion from the skin, so marked in articular rheumatism. The state of the blood has not yet been ascertained, but there is rea- son for believing that the fibrin is not much augmented. For the present we must be content to await the result of more numerous and searching inquiries, before attempting to MUSCULAR RHEUMATISM. 575 explain the true nature of muscular rheu- matism. Diagnosis of Muscular Rheuma- tism. — Acute intercostal rheumatism may be mistaken either for pleurisy, or for a neuralgic alfection so frequent in hysterical subjects : from the former it may be separated by the absence of the friction sound and other signs of intlam- mation of the pleura ; from the latter, by the absence of well-marked spinal tender- nes^s. It is sometimes difficult to dis- tinguish the chronic form of muscular rheumatism from the dull pains arising ft-om other causes, as from progressive muscular atrophy, the presence of metallic poisons in the system — especially lead and mercury — and likewise the poison of syphilis ; also from ordinary inflammation of the muscular tissue. Lumbago may be mistaken for a painful affection of the loins, arising from calculi or gravel in the kidneys. A careful examination of the history is usually sufficient, in each instance, to en- able us to arrive at a correct diagnosis. Prognosis of Muscular Rheu- matism. — Muscular rheumatism, al- though difficult to cure, is not attended with serious results ; there is not the fear of cardiac inflammation, the great source of danger iu articular rheumatism. The sdatica arising from lumbago is often both painful and obstinate. Treatment of Muscular Rheu- matism. — In the acute stages of muscular rheumatism, especially in lumbago, local depletion, generally by cupping, is re- sorted to. That this remedy gives tem- porary relief, there cannot l^e a doubt, but whether it be necessary or not is an- other question. My own opinion is, that it is seldom or never called for, and that the same relief may be obtained from other topical applications which are less open to objection. Hot fomentations are very valuable ; as, for example, spongio- piline, wrung out of hot water, and ap- plied either alone or sprinkled with tincture of opium, or the liniment of bel- ladonna, or a combination of the two. When the affection becomes more chronic, then a thinner piline lightly sprinkled with belladonna liniment, with or without the addition of the volatile oil of mustard, proves very useful, acting as a counter- irritant, and at the same time relieving pain by the anodyne properties of the beU ladonna. Turpentine fomentations, or stupes, may be substituted in some instances for the above applications. Occasionally bhsters are applied, and if the aftection prove obstinate, they may be kept open, with the addition of mor- phia or some other anodyne. The internal remedies which have been employed in cases of muscular rheuma- tism are numerous. When the affection is acute and recent, benefit often arises from the use of salines, which act on the skin and kidneys, and alter the state of the blood. From my own experience I should recommend the acetate of ammonia in large doses, combined with some alka- line salt, as the bicarbonate of potash, and with the addition of iodide of potas- sium. The time, however, soon arrives for the use of some medicinal agent, as quinine, which exerts a marked action upon the nervous system ; and this may be advantageously combined with the other remedies. Sometimes large doses of the hydrochlorate of ammonia are use- ful ; and in cases which occur in gouty habits, colchicum alone, or in combination with other medicines, may be prescribed with much benefit. When the disease becomes chronic, medicines which increase the capillary circulation are generally useful : guaiacum stands at the head of the list, and may be given either in substance or as the am- moniated tincture ; after guaiacum fol- lows sassafras, mezereon, turpentines, resins, and balsams. Sulphur in small doses is frequently of much advantage, and it can be adminis- tered in substance or in the form of the sulphur waters of Aix-la-Chapelle, of Aix in Savoy, or Bareges. Arsenic is likewise occasionally adopted as a remedy in long-standing, obstinate cases. When the pain has subsided, friction and electricity are often resorted to, in order to diminish the stiffness and to re- store tone and activity to the muscles. The diet should be generous, with a moderate amount of stimulants ; the pa- tient should be warmly clad in flannel, and every precaution taken to avoid chills. 576 GONORRHOSAL RHEUMATISM. GOl^OKEHCEAL RHEUMATISM. By Bernard Edward Brodhurst, F.R.C.S. The aflfection which is known as Gonor- rhceal Elieumatism consists of inflamma- tion of and about the joints, following upon urethral irritation, and preceded for the most part by a muco-purulent urethral discharge. Swediaur and Monteggria are said to have described this affection, and to have published cases illustrative of the disease; but there is not anything to be found in their writings which entitles them to the merit which has been claimed for them ; and indeed there ought to be no hesitation in saying that the disease does not seem to have been recognized until Sir Astley Cooper mentioned it in his lectures. Mr. South says: " Gonorrhix'al Rheumatism and gouorrhoeal ophthalmia were, I be- Ueve, first mentioned publicly by Astley Cooper, and the first of these affections he considers is not an infrequent disease ; but it appears to have been previously observed by the elder Cline, for, in reply to the question put to him by Cooper, whether he had ever seen rheumatism produced from gonorrhosa, he said, ' Sev- eral times.' " ' Sir Benjamin Brodie has given some pathological account of this disease, and having described its nature, he continues thus : — "The disease is usually described under the name of Gonorrhoaal Rheuma- tism, though it is plain, from the course of its symptoms and from the effects of remedies, that it differs from ordinary rheumatism in many essential circum- stances, and though there seems to be no doubt that, while it occurs in most in- stances as a consequence of gonorrhoea, it may take place quite independently of gonorrhceal infection.'"' Sir Astley Cooper relates the following case: — "An American gentleman came to me with a gonorrhoea, and after he had told me his story, I smiled, and said, 'Do so and so,' particularizing the treatment, and that he would soon be better ; but he stopped me, and said, ' Not so fast, sir ; a gonorrhoea with me is not to be made so light of ; it is no trifle ; for in a short time 3-0U will find me with inflammation in the ' A System of Surgery, by Chelius, trans- lated by John F. South, vol. i. p. 217. 2 Pathological and Surgical Observations on the Diseases of the Joints. 5th edit. p. 43. eyes, and in a few days after I shall have rheumatism in the joints. I do not say this from the experience of one gonorrhoea only, but from that of two, and on each occasion I was afflicted in this manner.' I begged him to be careful to prevent any gonorrhceal matter coming in contact with the eye, which he said he would. Three days after this I called on him, and he said, ' Now you observe what I told you a day or two ago is true. ' He had a green shade on, and there was ophthalmia of each eye. In three days more he sent for me rather earlier than usual for a pain in his left knee ; it was stiff and inflamed. I ordered some applications, and soon after the right knee became affected in a simi- lar manner. The ophthalmia was with great difficulty cured, and the rheumatism continued many weeks afterwards." That which is here so graphically re- lated may be observed in almost every instance of Gonorrhceal Rheumatism ; and, with the exception of the ophthal- mia, it is exactly the manner in which every first attack of Gonorrhceal Rheuma- tism arises and proceeds. Gonorrhceal ophthalmia is much less frequently ob- served than gonorrhceal articular rheuma- tism : probably it does not occur more than once in a dozen instances of Gouor- rhoeal Rheumatism. Gonorrhoea then being established, one or more joints become, in the course of ten days to three weeks, stiff, painful, and swollen, the patient having, perhaps, ex- posed himself to the weather, sitting or walking in wet clothes, or to a draught of cold air. At the same time the feet may be painful and the conjunctivae inflamed ; there will be considerable fever, with dry skin and a furred tongue. Probably, as the articular inflammation increases, the urethral discharge will diminish ; again it will become more abundant, and at length cease or degenerate into a gleet. The first attack of Gonorrhoea! Rheu- matism is invariably preceded by a spe- cific gonorrhceal discharge ; a subsequent attack may be preceded by urethral dis- charge which is not of a specific character; and, also, the same character of articular disease may be re-excited without the urethral discharge being developed. Both the robust and the debilitated suffer from this disease, but they suffer differently. The fever and inflammation GONORKHCEAL RHEUMATISM. 577 are proportionate to the plethora which may exist. In tlie young and pletiioric the inflammation is of an acute character, and lympli is for the most part deposited on the synovial membranes, giving rise to false ankylosis ; whereas, in the debili- tated, serum will probably alone be efl'used. In both cases the joints are liable to be destroyed ; in the former through the de- posit of lymph and the production of false ankylosis, and in the latter through the destruction of cartilage. The joint having become inflamed, a large effusion of serum takes place into the synovial cavity ; but, though there may be great tension, suppuration never occurs. Absorption of the effused serum takes place, and the joint may resume its healthy action. The limb remains in a semi-flexed position during the period of effusion into the joint ; for in the flexed position of the limb the surrounding structures are somewhat relaxed, and consequently they yield to the bulging membrane with its contained fluid. When, however, the hip is inflamed, the limb re- mains much more extended than in ordi- nary hip-joint disease. Tlie knee is more frequently affected than any other joint, being a large and complicated joint, and less protected by muscle from atmospheric influence. After the first attack of this disease, the patient is exceedingly liable to a recur- rence of it. Usually the second attack is, as the first, the result of gonorrhoea and exposure to cold and wet. But, although Gonorrhoeal Eheumatism will now almost certainly be excited by a specific discharge, any urethral discharge or urethral irrita- tion would seem to be suflflcieut to re-ex- cite the disease when the patient has once suffered from it. On this second occasion probably the inflammation will be less, but the joints will be longer in recovering mobility, and one or more will possibly remain anky- losed. Sir Benjamin Brodie relates the case of a patient who suffered from four attacks of this disease in the course of some few years, in whom he says that "inflammation of the urethra was in all of them the first symptom, which was fol- lowed by purulent ophthalmia, and after- wards by inflammation of the synovial membranes and swelling of nearly all the joints. In two of these attacks he attrib- uted the discharge from the urethra to his having received the infection of gonor- rhoea ; and in the two others to the use of the bougie.'" SUght stiffness may remain for several weeks, and a crackling sensation will pro- bably be communicated to the hand on moving the limb ; but this may also at VOL. I.- ' Op. oi(. -37 length cease, and the joint will resume its normal condition both in regard of size and motion. Each attack is more virulent in its cha- racter than the preceding, and in propor- tion to the debility of the patient. The female seldom sutters from this disease, but whenever I have observed an instance' it has always terminated in ankylosis. When gonorrhceal ophthalmia occurs, the conjunctiva, sclerotic, and iris may all become affected. It is not for the most part a severe form of ophthalmia, and it readily yields to treatment. Although the effusion into a joint may be very considerable, dislocation never occurs, and in this point the disease dif- fers widely from ordinary rheumatism, where the tendency is for the articular surfaces to become more or less displaced; but in this disease ankylosis is induced rather than dislocation. In no case that I have met with has there been so much effusion into the joints, and so much pain, as in the following in- stance ; neither have I met with a case where the patient enjoyed such redundant health. A dark-haired young man, who was attached as lieutenant to one of our regiments serving in a tropical climate, had contracted gonorrhoea, and having laid himself down on a low broad wall he fell asleep, and so remained for some hours, and until after sunset. He awoke in great pain, and, as it seemed to him, this pain was spread all over the body, but especially it was felt in one hip : here, however, the pain was so acute that it was with difiiculty he could be removed to bod. Besides the hip, the shoulders, knee, and ankle became affected ; but in none of these joints was the inflammation so acute as in the hip, and they all passed through this inflammatory condition with- out material injury, and recovered per- fectlv. In the hip the eftusion was so great that it was thought suppuration must take place : the swelUng, however, subsided at length, leaving_ the joint stiff and immovable. Until this effusion was removed he suffered an agony of pain. Occasionally the urethral discharge al- ternates with articular inflammation, or it degenerates into a gleety discharge, while the articular inflammation assumes a chronic character. Thus, a young Jew, who had contracted gonorrhoea, was soon after seized with pain in several joints. The urethral discharge ceased as the ar- ticular inflammation became developed, and it recurred as the pain in the jomts was removed. This continued for several weeks, until on a winter's evening he was exposed to cold, when, an access oi in- flammation occurring, he found during the night a finger-joint excessively pain- ful and somewhat swollen. The joint be- came ankylosed in the course of some lew 578 GONORRHEAL RHEUMATISM. days. All the other joints recovered well. The gleet remained for many weeks. The articular inflammation appears to be of a more injurious character when a second or third attack of Gonorrhoeal Eheumatism occurs. The first attack may leave no trace behind ; but a subse- quent attack seldom fails to do so : it may cripple the patient for life, as happened in the following case of a young man, nine- teen years of age, of a somewhat strumous diathesis. In this patient gonorrhoea ap- peared on the seventh day after infection. In the course of a fortnight the knees be- came painful and swollen, and they con- tinued in this state for about two months, when the inflammatory condition sub- sided, and the joints resumed their nor- mal condition. Two months after this first attack had disappeared, he was again infected with gonorrhoea. In ten days several joints became inflamed, as the right temporo-maxillary articulation, as well as the hips, the knees, the ankles, the shoulders, the elbows, and the thumbs. The upper limbs and the ankles recovered well and regained their mobility, but the hips, knees, and the jaw became anky- losed. The following is a remarkable case, in which, after several attacks of Gonorrhosal Eheumatism, the disease was again set up without urethral discharge appearing. A gentleman, twenty-five years of age, ac- quired gonorrhcea, which was soon fol- lowed by pain and swelling of the knees. The urethral discharge appeared on the seventh day, and some few days later sy- novitis supervened with great effusion into the knee-joints. The skin was hot and dry, and he suffered acutely, so that every movement was attended with much pain. The urethral discharge continued for two months, and then ceased entirely, and the swelling and stiffness of the knees also at length disappeared, having lasted for three months. After another interval of three months this individual was again affected with gonorrhoea. The urethral discharge again appeared on the seventh day, and it continued for two months. After some days the left hip-joint became inflamed, as well as the ankle and tarsal joints. This attack was of a much more severe character than the former one — the effusion was greater and the pain more acute. After a period of ten months my patient was able to walk with the help of sticks. Stiffness and a painful condition of the limbs continued yet, however, for many months ; but at length he regained the use of his limbs. After a lapse of sev- eral months, again he contracted gonor- rhoea. On this occasion the symptoms closely resembled those which occurred on former occasions ; but he never entirely recovered from the stiffness which resulted from this attack of articular inflammation. Now, both hips, both ankles, and one knee became inflamed, and he also suf- fered from ophthalmia. Ankylosis did not occur, but there was a certain amount of stiffness of the joints which prevented him from rising after he had been seated for some hours. About six months after he was able to walk about, he married. Painful attempts were made to consum- mate the marriage, but it was found to be impossible : Dr. Lever discovered that oc- clusion of the vagina had taken place. At this time, namely within a very short pe- riod of marriage, articular inflammation recurred. There was now, however, no urethral discharge whatever. But the articular inflammation proceeded, and at length produced ankylosis of every joint in succession ; so that in five years the whole skeleton was implicated : the atlas was ankylosed together with the axis, and in consequence the head could not be moved ; and all the vertebrae were anky- losed together ; and the hips, knees, an- kles, shoulders, elbows, wrists, and jaw were so firmly fixed that no movement whatever could be obtained, An interesting example of this disease has been for some time under treatment in St. George's Hospital, of which the fol- lowing are the principal points : Edward G , aged 46, having been treated as an out-patient by Dr. William Ogle for some time, was at length admitted into Pitzwilliam Ward, on account of effusion into and great thickening about the knee- joint. The left wrist was firmly anky- losed, and the spine in its entire length was motionless — ankylosis of all the ver- tebrse having taken place. The ribs also were ankylosed, and the breathing in con- sequence was purely diaphragmatic. In the year 1855 (thirteen years prior to his second admission), he was a patient of Dr. Wilson's, in Cambridge Ward, for Gonorrhoeal Rheumatism. Three months before he was admitted into the hospital, he was exposed in the hunting-field, being a groom, to wet and cold, at the same time that he was suffer- ing from an attack of gonorrhoea. He was admitted with pain in the feet and shoulders, in the right elbow, and over the clavicles ; but at this time the gonor- rhoeal discharge had stopped. Since that period he has never suffered from gonorrhoea ; but he has had pain in various joints, and gradually his back and neck have become stiff, as well as the left wrist and the right knee. He was scarcely aware that any "morbid process was going on in tlie spine, for there was little or no pain, and during the whole of the time between his discharge from the hospital and his re-admission he was able to per- form his duty as a coachman. TREATMENT. 579 Treatment. — "VVben Gonorrhoeal Rheumatism is vigorously treated in the commencement of tlie attack, the joints may become affected in a sliglit degree only. If there be much constitutional disturbance and inflammatory action, pur- gatives may be exhibited, and a small quantity of blood may be taken from the arm ; vfhile local fomentations may be employed, and a splint of gutta-percha to keep the affected joint perfectly at rest. After venesection, a full dose of opium gives great relief, and if it is administered with ipecacuanha, as in Dover's powder, the secretion of the skin is increased. The sweating which is thus produced is beneficial ; but this increased action of the skin is best promoted in the Turkish bath. I have known the pain about the joints to cease entirely in the bath. Some time since, I saw a gentleman who suffered very acutely from pain and inflammation consequent on this form of disease of the joints, and in whom the tension from effu- sion was also excessive. He was lodged by my desire in a house attached to a Turkish bath, and each day he was car- ried down into the bath. When profuse perspiration was obtained, the pain left him ; and absorption of the fluid within the synovial capsules was certainly pro- moted by exposing the body to the high temperature of the bath. In an acute attack, abstinence from ilesh meat, as well as from fermented and distilled liquors, is absolutely necessary. When such measures are promptly taken, an acute attack of Gonorrhoeal Rheumatism may generally be cut short. When, however, inflammation tends to become chronic, iodide of potassium may be given with advantage : thirty to forty grains being administered daily. It is preferable to abstract a small quantity of blood from a vein than to apply leeches to the inflamed joints : leeches not unfre- queutly aggravate some of the symptoms, and induce also suppuration in the cellular tissue. For these reasons, any benefit to be derived from their use is doubtful, and at times they certainly increase the evil they are intended to mitigate. After the first or second attack, or when the patient is debilitated, the treatment should be of a slightly stimulating and tonic character : depletion will aggravate all the symptoms, and increase the effu- sion. Opium may be given freely, and iodide of potassium in small doses. Gutta- percha splints should always be used dur- ing the period of effusion to prevent motion. So soon as pain and swelling have ceased, gentle frictions with shampooing should be employed to restore mobility. Much time will probably be required to effect this object, and it may be necessary, if adhesions have formed, to flex the limbs forcibly after chloroform has been inhaled. In many cases mobility may be restored, even after very firm adhesions have been formed. PART II. LOCAL DISEASES. inthoductiok BY THE EDITOE. A FEW words are necessarj'' to explain the priaciple of classification adopted with regard to the diseases which find their place in this, the first, section of "jjartial diseases," or "aifections of particular organs." The maladies which are treated of in these volumes have been in the first place divided into two large groups, "general" and " local," and the reason for such divi- sion has been assigned (Classification of Diseases, p. 32). Some diseases are "gen- eral," — that is to say, they appear so to aifect the whole body at once, that all its functions are impaired or altered ; and not only so, but they are implicated to such an equality of degree that it is always difficult, and sometimes impossi- ble, to say upon which system of organs, if upon any, the greater weight of the burden falls. Of such diseases Part I. of this System of Medicine contained the history. We have now to deal with an- other class of affections, the "local" or "partial," viz., with those in which we have little or no difficulty in localizing the disease ; maladies with regard to wliich we say at once that they are diseases of the nervous system, or of one portion of the digestive system. It is not intended that such diseases are accurately limited to the particular systems from which they derive their names ; for we know well that the digestion is, or may be, disturbed in epilepsy, in apoplexy, and in paraple- gia ; and, on the other hand, that no severe perturbation can occur in the stom- ach without the simultaneous develop- ment of some corresponding disturbance in the nervous centres. Furthermore, we know that there is sometimes great diffi- culty in determining whether we have to deal with a disease universal in its dis- tribution at its onset, or with some pri- mary lesion of a particular organ, the secondary effects of which are general ; or, even allowing that some particular organ is especially aflFected, the affection may b6 of such kind that it is sometimes a matter of grave doubt as to the system of organs to which that particular one, in this special instance, may be considered to belong. Tubercular meningitis has been mistaken for typhoid fever, and vice versA ; abscess of the brain has been con- founded with malarial poisoning ; and, again, tumors in the brain have been re- garded as diseases of the stomach ; while all the symptoms of cancer of the stomach have been explained away by the fiction of "spinal irritation." Each organ of the body has something in common with every other organ ; and although two viscera may be, locally, as remote as the limits of the human body will allow, there are between them bonds of union so inti- mate that they are, in reality, brought very close together in the minute con- ditions of pathologic change. Blood, bloodvessels, lymphatics, connective tis- sue, and nerves are common to all organs which take part in the more active pro- cesses of life, and in each of them there is in progress that common nutrition- change which is the necessary condition of all functional activity. Although, there- fore, the function of the stomach may be that of exerting a particular effect on food, it must not be forgotten that the stomach has nerves, vessels, and connective tis- sues, and that diseased processes, exhib- iting themselves mainly in its disordered functions, may be the expression of some- thing wrong in innervation, in blood sup- ply, or in general nutrition. And, again, although the brain is the organ which ministers to the higher functions of the nervous system, and records its diseases in changes of mind, sensation, or motility, it must be remembered that the brain has vessels which undergo nutrition-changes of degeneration or decay, and that many of its so-called special diseases are often but the outcome of a more general mal- (581) 682 INTRODUCTION. nutrition, which may have had its start- ing-point in heart, arteries, or veins. "While, then, we may speak of " softening of the brain" among the diseases of the "nervous system," it would be quite as correct, in many instances, to place it among the effects of disease or degenera- tion in the "vascular system." All the more important organs of the body are so complex in their structure, and all have so much in common, that we are bound to admit that the lines we draw between them, in regard to pathologic change, are often determined rather by the consideration of their practical utility than by the fact of their scientific accu- racy. Knowing, however, the inherent difficulties of the case — viz., those which arise out of the fact that all the systems of organs have marvellously close rela- tions with each other — and being aware, moreover, of those accidental hindrances which arise out of either our own ignor- ance or want of tact in the application of such knowledge as we have attained, we still hold it to be desirable that, in this vSystem of Medicine, we should maintain the distinction between "general" and " local" diseases, and that we should take as our basis for classification of the latter, the particular systems of organs. We believe this to be so, because the lines which are drawn in making these distinc- tions include groups of diseases, the indi- vidual members of each of which have inter se closer clinical relations than have those which belong to different, although contiguous groups ; and because in the vast majority of cases it is comparatively easy, and sufficient for all the practical purposes of "classification," to say that a particular disease under consideration is "general" in its character, or is " par- tial," in the latter instance especially affecting this or that great system of or- gans, such as the nervous, the respiratory, or the digestive. The principle of division thus estab- lished with regard to all diseases — viz., that of limitation or localization — is again applicable, as a means to be employed for the primary subdivision of the large group of diseases forming the first section to be considered in Part II. ; and accordingly "diseases of the nervous system" are dis- tributed under two headings — the "gen- eral" and the "special" or "partial." Under the former, the "general," are described those affections which exhibit their phenomena in all parts of the ner- vous system— those in which brain, spinal cord, and nerves seem to be all, more or less intensely, and more or less widely, involved ; while under the latter, the " partial, " are detailed those in which the brunt of the malady is borne by particular parts of the nervous system — the brain, the cord, the nerves, or their appendages. It will be seen at once, by a reference to page 5S4, that under the former, the "general," are enumerated, together with those which strictly merit that designa- tion, some diseases which appear to affect certain portions of the nervous system either more profoundly or more essentially than they influence others ; and further that some morbid conditions are described which, although limited in the distribution of their symptoms, have as yet no such definite pathological anatomy that we can aflBrra, with anything like satisfaction, what part of the nervous system is in them primarily at fault. The first large group, therefore, is made to include, together with those in which the whole nervous apparatus is equally disturbed, some dis- eases apparently partial in their distribu- tion, and others which, in the present state of science, are of " undetermined seat." Among the members of this first large group, for example, there are placed epilepsy, hysteria, and such diseases as show themselves in altered functions of the brain, cord, and nerves — occasionally one great division of the nervous system, and sometimes another, presenting the most marked derangement, but all divi- sions being more or less involved in mor- bid change of either function or structure, or both :— and in the same large group we find wasting palsy, chorea, writers' cramp, and allied affections, which, although they exhibit the maximum of their obvious symptoms in particular parts of the ner- vous system, are yet of such uncertain pathology, that it would be injudicious at present to describe them as diseases of either brain, cord, or nerves, exclusively. So far as the pathology of these will allow, they will, when examined in detail, be referred to their proper places ; hut it is thought, for the simple purpose of ar- rangement, desirable to keep within the limits of ascertained facts and principles, by retaining them in the positions already described. The other alternative, that of placing them under particular headings, while it might confer a greater amount of apparent scientific precision, would, I be- lieve, be attended by less real scientific accuracy ; inasmuch as it would give an undue prominence to many hypotheses, very valuable in themselves, as forming the framework of both thought and inves- tigation, but which, being as yet no more than hypotheses, are not entitled to hold high rank among the conditions upon which classification should be based. The diseases known, for example, as meningi- tis, myelitis, and neuritis, respectively, have clinical histories and well-known pathological conditions related to one an- other in a manner much more definitely ascertained than have such aflfections as ataxy, paralysis agitans, and wasting palsy. We have referred the symptoms INTRODUCTION. 58? of the first series to their anatomical changes, whereas it cannot be said that we have done so with regard to the second croup. Much more is Jjnown about the Tatter than was known a few years ago ; but observations, during life and after death, have to be multiplied and verified before we can ascribe those diseases, with scientific precision, to particular localities and special kinds of structural lesion. Again, the kind of distinction between hemorrhage into the corpus striatum and hemorrhage into the spinal cord, is, in its clinical relations, widely different from that which can be established between either of those two affections and ataxy, or chorea. In the one we are dealing with what is definitely known ; in the other, with what is as yet indefinite, and only approaching scientific arrangement. Upon these grounds, therefore, the prima- ry division is made into diseases of "gen- eral" distribution, or of undetermined lo- cality, and "partial" diseases, or those hkving a recognized pathological anatomy. In the second group of diseases of the nervous system— viz., those described as "partial" — the principle of arrangement is sufficiently obvious to need but little elucidation. In the fiist place, a subdivi- sion is made upon simply anatomical grounds— viz., into affections of tlie cra- nium, the spinal column, and the nerves ; and each of these is again subdivided up- on an anatomical basis— diseases of the cranium being distributed under the cate- gories of " meninges" and "nervous tis- sues," such as brain, cerebellum, and the like ; while diseases of the spinal column are distributed in a similar manner. The next principle of division is that deter- mined by the nature of the anatomical changes which these tissues, respectively, undergo. Here an attempt has been made to place in close proximity those affections which have the most highly- marked clinical similitude— an attempt, however, which is only carried to such a degree as shall not interfere with the more general arrangement. It is not necessary to enter further into the detail of this classification, as the principles upon which it is based are suffi- ciently obvious for all the practical pur- poses of this Sj'stem of Medicine. DISEASES OF THE NERVOUS SYSTEM. These diseases are divided into two large groups, viz., A, those of general distribution, or of uncertain seat; and B, those which are partial, arid which occupy known relations to particular portions of the nervous system. A.— General Nervous Diseases, and those of uncertain seat :— Insanity. Hypochondriasis. Hysteria. Ecstasy. Catalepsy. s03ixa3lbulis1i. Sunstroke. Alcoholism. Vertigo. Chorea. Paralysis Agitans. Writers' Crajip. Convulsions. Epilepsy. Locomotor Ataxy.' Muscular Anaesthesia. Wasting Palsy. Metallic Tremor. INSANITY. By Henry Maudsley, M.D., F.R.C.P. Synonyms. — Insanity; Madness; Men- tal or Cerebro-Mental Disease ; Mental Derangement ; Mental Alienation ; Men- tal Aberration ; Unsoundness of Mind ; Lunacy. Definition. — So many and various in kind and degree are the forms of mental derangement included under Insanity, that it is not possible to give a definition of it that shall be at the same time com- prehensive and exact. If the definition is wide enough to comprise all varieties, it will include eccentricities that fall short of disease ; if exact enough to be definite, then it must exclude many cases of un- doubted mental disease. As various as are the features or the voices of men, so various are the characters of their minds; and as no two pei'sons are exactly alike in mental character and development, so in no two instances of the degeneration of mind do the morbid features correspond exactly. The development of other or- gans of the body, taking place before birth after a common type, is very much alike in different persons, and the diseases of them have a great resemblance ; but (584) the real development of the brain as the organ of conscious life, taking place after birth in relation to surrounding circum- stances, and thus gradually issuing in the formation of individual character, is dif- ferent in different persons, and accord- ingly cerebro - mental diseases present manifold varieties of features. As re- gards any particular case of Insanity which we may have to decide about, it is necessary then to fix attention on two points : first, on the change of individual character — the alteration from the former self; secondly, on the want of harmony, or the discord, betvceen the individual and his surroundings. For although the morbid phenomena of the diseased mind witness in some measure to the degree of its previous development, yet the degene- ration which disease implies must needs display itself in an alteration in the kind of manifestation of feeling, thinking, and acting — in other words, in a changed self; while again the import, as morbid, of the phenomena displayed can only be rightly weighed in relation to the individual Transferred to description of Spinal Cord. CLASSIFICATION. 585 sphere of life. It is, for example, quite possible, though apt to be forgotten in practice, that sentiments and acts which are habitual in the lowest strata of life may be sure signs of mental disease when uttered and done by one in a high social sphere. Bearing in mind the difficulties inherent in the nature of the subject, which have led to every sort of deiinition by every writer who has not forborne the task in despair, I may declare Insanity to con- sist essentially in a morbid derangement, generally chronic, of the siqyreme cerebral centres — tlie gray matter of tlie cerebral con- volutions or the intellectoriuni commune — giviMj rise to perverted feeling, defective or erroneous ideation, and discordant canditct, conjointly or separately, and more or less in- capacitating the individmal for his due social relations. ' We may safely go so far as to affirm the mind centres to be in the vesic- ular neurine of the convolutions, and In- sanity to consist essentially in disorder, primary or secondary, of their functions —in disordered feeling, disordered intel- ligence, and disordered will. This definition has the merit of fixing attention, first, on the reception of im- pressions from the external world — the mode of /eeKiif/, or the affective lile ; sec- ondly, on the mental fashioning or elabor- ation of impressions — the modes of idea- tion or intellection, the intellectual life ; and, thirdly, on the reaction of the indi- vidual on the external world — the mode of action or conduct ; it answers also to the best psychological division of mind mto feeling, cognition, and will. How de- sirable it is not entirely to overlook the social relations, will be plain when we re- flect that it is in the irregularities of the individual, as an element in the social system, that the morbid character of In- sanity fundamentally consists. Certainly the definition is far from being perfect, as in the nature of things must be the case so long as it is impossible to draw the line where sanity ends and Insanity begins, or even to say positively whether a particu- lar person is insane or not ; but against its manifest defects may be put its posi- tive merits — namely, that it fixes the gray I. Mania II. Monomania. III. Melancholia. IV. Moral Insanity. V. Dementia . . VI. Idiocy, including Imbecility. VII. General Paralysis or Paresis. matter of the convolutions, the undoubted nerve-centres of intelligence, as the prin- cipal seat of morljid action in Insanity ; that it distinctly declares that Insanity may be exhibited either in moral perver- sion only, or in the actions of the patient, or in delusion ; and, lastly, that it sets forth how Insanity destroys the relations and responsiljilities of the individual in the social system, making him very much like what a morbid element is in the or- ganic system— something which cannot take its due place in the general harmony, and which must either be eliminated from it or sequestrated and rendered harmless in it. A man may certainly have dis- ordered feeling, may think and judge er- roneously, and act extravagantly, without being insane ; but ii' he does so as a regu- lar thing, and without any adequate cause in external circumstances — if he does so in fact by reason of a steadily act- ing internal cause, a derangement of his supreme cerebral centres — then he is in- sane. The standard by which to measure the perversion is, first, that of the land — that which is fixed by the general consent of mankind ; and, secondly, that of the individual — that which is justified by the degree of his previous mental develop- ment. Many and varied as are the forms which madness takes, there are still beneath superficial difterences certain characters of essential agreement ; and accordingly genuine groups or types nlay be described, notwithstanding the fact that cases mark- ing every grade of transition between one group and another are met with in prac- tice. Of Insanity may still be said what Burton long ago said of it : "I could give instances of some that have had all three kinds semel et simul, and some succes- sively AVhat physicians say of distinct diseases in their books, it much matters not, since that in their patients' bodies they are commonly mixed." Classification. — The classification commonly adopted in this country, and yet indispensable for practical purposes, IS a modification of that proposed by Es- quirol, and is as follows : — Acute, or Eaving Madness. Chronic. Eecurrent. Primary. Secondary. ' Ideation, now so commonly used, was first I Darwin, in his "Zoonomla," aptly designates suggested and employed by Mr. James Mill in the common centres of intelligence as the /n- tis "Analysis of the Human Mind." Dr. | tellectorium commune. 586 INSANITY. In Germany, the classification which finds most favor stands thus :' — I. Die Depressionzustande. 1. Die Hypochoiidrie. 2. Die Melancliolie. n. Die Exaltationzustande. 1. Die Tobsucht. 2. Der Wahnsinn. III. Die psychischen Schwachezustande. 1. Die Verriicljtheit. 2. Der Blbdsinn. 3. Idiotismus und Cretinismus. IV. Der paralytische Blodsinn, Die all- gemeine Paralysie der Irren. It is easy to perceive the defects of such purely psychological classifications. They are vague and artificial, embracing in the same class forms of disease distinct enough to demand a separate description ; more- over, there are forms of mental disease which, presenting the characters of two or more of the different classes, might be placed in one or the other, or cannot be placed satisfactorily in either. Dr. Skae has proposed to classify all the varieties of Insanity in natural orders or families, grouping them in accordance with the natural histm-y of each.^ Why, he asks, Idiocy, I Moral and intel- Imbecility, J lectual. Insanity, with Epilepsy. Insanity of Masturbation. Insanity of Pubescence. Satyriasis. Nymphomania. Hysterical Mania. Amenorrhoeal Mania. Post-Connubial Mania. Puerperal Mania. Mania of Pregnancy. Mania of Lactation. Climacteric Mania. Ovario-Mania (Utero-Mania). M. Morel, of Rouen, has propounded a classification of mental diseases according to their apparent causes — an etiological classification. He makes six principal groups, each of which has two or three classes under it: the^rsi group being that of hereditary Insanity ; the second con- sisting of Insanity produced by toxic in- fluences ; the third, of Insanity produced ' Die Pathologie und Therapie der psy- chischen Krankheiten. Von Dr. W. Griesin- ger. Zweite Auflage. 1861. — Die Pathologie und Tlierapie der psychischen Kranklieiten. Von Dr. M. Leideadorf. Zweite Auflage. 1865. ' On the Classification of the Various Forms of Insanity on a Rational and Practical Basis, by David Skae, M.D.; Journal of Mental Sci- ence, October, 1863. For a fuller account and a criticism of this classification, I may refer to my work on "The Physiology and Pathology of Mind," Second Edition. I. Conditions of depression. 1. Hypochondria. 2. Melancholia. II. Conditions of exaltation. 1. Acute Mania. 2. Monomania. III. Conditions of mental weakness. 1. Craziness or Incoherence. 2. Dementia or Fatuity. 3. Idiocy and Cretinism. lY. Paralytic dementia. General Paraly- sis of the Insane. should we attempt to group and classify them by the mental symptoms, and not, as we do in other diseases, by the bodily disease of which the mental perversions are but the signs ? In pursuance of this aim he has sketched the outlines of twenty- nine natural orders or families, having, as he believes, each its natural history, its special cause and morbid condition, a certain class of symptoms more or less peculiar to each, its average duration, and probable termination. They stand thus : — Senile Mania. Phthisical Mania. Metastatic Mania. Traumatic Mania. Syphilitic Mania. Delirium Tremens. Dipsomania. Mania of Alcoholism. Post-Febrile Mania. Mania of Oxaluria and Phosphaluria. General Paralysis, with Insanity. Epidemic Mania. Idiopathic Mania, { i^nic. by the transformation of other nervous diseases, such as hysteria, epilepsy, hy- pochondria ; the fourth, of idiopatliic In- sanity; the ffth, of sympathetic Insanity; and the sixth, including all cases of de- mentia. [What may be called a physiological classification has met with favor on the part of some modern authors, as follows : 1. Senswial Insanity ; in which halluci- nations of the senses are mistaken for realities, and so mislead {alienate} their subject, by getting him out of normal re- lation to the world around him. 2. Intel- lectual Insanity ; characterized by delu- sions, or confusion of the reasoning powers, upon one, many, or all subjects. 3. Emotional Insanity ; commonly called Moral Insanity, involving the affections, or propensities, with morbid impulses too strong for the will to control. The term Impulsive Insanity is sometimes applied to the same group of cases. Either of the CAUSES. 58T above forms may be acute or chronic; and they may be, and in most cases are, espe- cially the last two, combined together. Dementia, upon such a scheme, would be retained to indicate a failure or wreck of all, or nearly all, the psychical powers. — H.] Adopting for the purposes of description the classification in common use, artificial as it is, it will be most convenient to de- scribe the special features of the different varieties of mental disease in the course of the account of its causation, symptoma- tology, and treatment. Causes. — These are usually divided into physical and moral, though without any exactness in such discrimination be- ing really practicable. Two persons are exposed to like severe mental trials ; one of them becomes insane, the other does not. Has the madness, then, been pro- duced by a moral cause ? In the former case, there was probably some innate vice of nervous element — some predisposition of it to disease, or some accidental nervous depression, by reason of physical disease, or other cause, whereby Insanity has been produced by a moral cause that has had no such ill effect in the latter case. The entire causes have not, then, been in re- ality the same. What should ever be borne in mind is, that all the conditions which conspire to the production of an effect are alike causes, alike agents, and that there is, in most cases of Insanity, a concurrence of conditions, not one single effective cause. Mental alienation often appears as the natural issue of all prece- dent conditions of life, mental and bodily —the outcome of the individual character as affected by certain circumstances ; in such case, the germs of disease may have been latent in the foundations of the cha- racter, and the final outbreak is but the explosion of a long train of antecedent preparations. In vain, then, is it to try to fix always upon a single cause, moral or phys^ical ; a common mistake on the part of those who think to do so being to fasten upon that which is in reality an early symptom as the supposed cause. On this rock have hitherto foundered all etio- logical classifications of Insanity. It will be most convenient to set forth certain general considerations respecting sex, age, and the like, and then to proceed to treat of the proximate or exciting causes of In- sanity. It is obviously unscientific to enumerate sex and age as causes of In- sanity : no one goes mad because he or she happens to be a man or woman ; but because to each sex, and at certain ages, there occur physiological changes that are apt to run into pathological effects in those who are predisposed to nervous de- rangement. (a) General Considerations. — There are general causes, such as the climate of a country, the form of its government and Its religion, the state of its civilization, the occupation and habits of its inhabi- tants, which work together in the course of generations to the formation of a na- tional type of character, wherein there may be greater or less pronencss to In- sanity. Reliable data respecting the fre- quency of Insanity in different countries are, unfortunately, still wanting, and even the question whether it has increased with modern civilization has not been positively settled. Travellers certainly agree that it is a rare disease among barbarous peo- ple ; whilst in the different civilized na- tions of the world there is, so far as can be ascertained, an average of one insane person in 500 inhabitants. The undoubted steady increase, again, of the insane un- der care and observation, would seem to be greater than can be fairly accounted for by the greater attention now given to their welfare : while theoretical consid- erations indicate that the feverish activity of life, the numerous passions and the great strain of mental work incident to the multiplied industries and eager com- petition of an active civilization, cannot fail to augment the liability to mental dis- ease. Though not yet exactly provable by statistics, there is still some reason to believe that, with the progress of mental development through the ages, there is a correlative degeneration going on, and that Insanity is a penalty which our pre- sent civilization necessarily pays.' Sex. — Though Esquirol and Haslam thought Insanity to be a little more fre- quent among women than among men, it is now generally agreed that the converse is true. Dr. Thurnam affirms men to be more liable to mental disorders than women ; and Dr. Jarvis came to the same conclusion from the examination of the statistics of different countries. Recently, however, it has been stated that the fe- male sex is more liable to suffer from hereditary Insanity.^ Pregnancy, the puerperal state, the catamenial functions, and the climacteric change are conditions in women that will favor the disturbance > In 1859 the total number of lunatics in England and Wales was 36,762; in 1869 it had increased to 63,177. The proportion of lunatics to the population had risen from 1 in 536 to 1 in 411 of the population. In France the ratio of lunatics to the population was, in 1851, 1 to 796 ; and in 1861, 1 to 444. In both countries, however; it is certain that the main portion, if not all, of the increase has been due to the operation of the lunacy laws, by which more accurate registrations of the insane have been gradually brought about. 2 Statistics of Insanity of the Crichton Royal Institution, by H. G. Stewart, M.D. ; Journ. Ment. Science, 1865. Also, Hereditary Insanity, by H. G. Stewart, M.D. ; Journ. Ment. Science, 1864. 388 INSANITY. of the mental balance, especially where there is any predisposition thereto ; but against these must be weighed the larger exposure of men to mental wear and tear in the competition of life, and their more frequent addiction to intemperance and other excesses. Women, too, very seldom suffer from general paralysis. On which- ever side, male or female, the uncertain difference lies, it is probably inconsider- able. Period of Life. — Insanity is rare before puberty, though every form of it, except general paralysis, may occur even so early in life ; it is far more frequent between the ages of 16 and 25 ; but it is most frequent of all during the period of full mental and bodily development — from 25 to 45 — when there is the widest exposure to its causes. The internal revolution which takes place in women at the climacteric period leads to many outbreaks of Insanity in them between 40 and 50. In men there appears to be a climacteric period between 50 and 60, when Insanity sometimes supervenes : an old man may be found to be keeping a mis- tress in secret, or to be making foolish proposals of marriage, when, forerunning complete dementia, sensual impulses, clothed in the morbid habit of delusion, mock the extinction of sexual function. In childhood and early life idiocy and im- becility, moral and intellectual, are most commonly met with ; after puberty mania and, later on in life, melancholia ; in old age senile insanity occurs ; and general paralysis seldom before 30, the years be- tween 30 and 50 being the favorite years of its attack. Condition of Life. — The statistics hith- erto collected in regard to this point are of little or no value. Whether a particu- lar profession or trade favors the produc- tion of Insanity is generally a question of the habits incidental to its pursuit — whether those who follow it live soberly and temperately, or whether they are ad- dicted to intemperance and riotous living. On the whole, however, those who work with the head are more liable to mental disease than those who work with the hand, and they are less liable to recover when once attacked. It is an unproved and indeed ill-founded assertion that gov- ernesses are the victims of Insanity in greater proportion than other persons. The statement has originated in the fact that a great number of governesses are received into Bethlehem Hospital, as many as 110 having been admitted in ten years. The reason of this is that Bethle- hem is intended especially for persons of the class of governesses — those who are not paupers, but yet cannot pay for care and treatment. Other things being equal, it is certain that Insanity is proportionately more fre- quent amongst the unmarried than the married. Individual Predisposition. — The heritage which a man has from his parents may alone, or together with the circumstances of early education, give rise to an indi- vidual predisposition to mental derange- ment. Unquestionably some persons have what may be called the insane tempera- ment — a certain neurosis or diathesis, easily prone to degenerate into actual disease ; they feel impressions in a way which other people do not feel them, are disposed to sudden impulses of strange feelings and desires, to whimsical caprices of thought and eccentricities of action, and they not unfrequently carry in their countenance and bearing the marks of their evil heritage. They have what Willis long ago called the diathesis S2jas- modica, an irritable weakness of nervous constitution, in which, if tliere be not positive disease, there is the well-prepared ground of disease. Authors are not agreed as to the proportion of cases of In- sanity in which positive hereditary taint is detectable : some, like Moreau,' putting it as high as nine-tenths ; others, as low as one-tenth. The most careful researches fix the proportion as not lower than one- fourth, if not so high as one-half; and there can be no doubt that the tendency is to increase the proportion as investiga- tion becomes more searching and exact. When a person cannot endure the ordi- nary trials of life, or a natural physiologi- cal function, such as the development of puberty, it is plain that there must be some native infirmity or instability of nerve element. It must be borne in mind that hereditary predisposition may be of every degree of intensity, so as, on the one hand, to conspire only with certain more or less powerful exciting causes, or, on the other hand, to suffice of itself to give rise to Insanity even amidst the most favorable external circumstances. Again, not Insanity only in the parents, but any form of nervous disease in them —epilepsy, alcoholism, hysteria, and even neuralgia — may predispose to Insanity in the offspring, as, conversely. Insanity in the parent may predispose to other kinds of nervous disease in the offspring. Pro- creation during the temporary insanity of drunkenness, and too much interbreeding in families, are both recognized cause of a predisposition to mental degeneration. Some, like Lugol and Schroeder van der Kolk, have maintained that scrofula of parents may generate a predisposition to Insanity in the children ; and whether this be so or not, it can admit of no ques- tion that the undoubted transformation which diseases undergo through genera- tions is a subject deserving of further and ' Psychologie Morbide dans ses Rapports avec la Philosophie de I'Histoire. Par Dr. J. Moreau. CAUSES. 589 more exact study. ' Baillarger has proved, what Esquirol observed, that Insanity descends more often from the mother than the father, and from the mother to the daughters more often than to the sons. Children bom before the outbreak of an attack are less likely to suffer than those born after an outbreak. An injudicious education may aggravate an inherent mischief ; the parent not only transmitting a taint or vice of nature to the child, but fostering its increase by the influence of a bad example, and by a fool- ish training at that period when the young mind is very susceptible, and the direction given to its development decisive for life. Where there is no innate taint, mischief may still be wrought by enforcing an un- natural precocity, wherein is often planted the germ of future disease. Parental harshness and neglect, repressing the child's feelings, stifling its need of love, and driving it to a morbid self-brooding, or to take refuge in a world of vague fan- cies, is sometimes not less injurious than a foolish indulgence, through which it never learns the necessary lessons of re- nunciation and self-control. There can be no doubt that by the influence of good education .and sound training a predisposi- tion to Insanity might often be nmch neutralized and rendered almost harmless; but the mischief is that those who procre- ate children so afflicted are commonly least lit to train them well. (6) Exciting Causes. — The so-called moral causes are generally, though not universally, held to be more frequent than the pkijucal causes : Pinel thought them to be twice, Esquirol four times, as fre- quent ; while Guislain attributed 66, Par- chappe 07, out of 100 cases of Insanity to moral causes.^ It is not the way of great intellectual exercise, when unaccompanied by emotion, to lead to mental derange- ment ; mental exercise is favorable to length of days and health of mind ; it is when the feelings are deeply engaged, when the mind is the theatre of great pas- sions, that it is most moved and its stabil- ity EQost endangered. The depressing passions are most effective in this regard : grief, religious anxiety, disappointed affec- tion or ambition, jealousy, the wounds of an exaggerated self-love, and the painful feeling of being unequal to responsibilities, or other such conditions of mental agita- tion and suffering, are most apt to reach a \iolence of action by which the balance ' Die Pathologie und Tlieraple der Geistes- krankheiten auf anatomisch-physiologischer Grandlage. Von J. L. C. Schroeder van der Kolk. 1863. J' Pinel, On Insanity, translated by Dr. "^Tis; Esquirol, Traite des Maladies Mon- '*les; Guislain, Traite sur rAligjiation Men- '*le; Parchappe, Traite de la Folie. is lost. It is especially when the individ- ual has by a long concentration of thought alfection, and desire on a certain aim or object grown into definite relations with regard to it, and made it, as it were, a part of the inner life, that a sudden and entire change, shattering long-cherished hopes, is most likely to produce Insanity; for nothing is so fraught with danger to the stability of the strongest mind" as a sudden great change in external circum- stances without the inner life having been gradually adapted thereto. Hence, also, it is that a great exaltation of fortune, as well as a great afHiction, rarely fails to aftect for a time the strongest head and sometimes quite overturns a weak one ; though the strong mind succeeds after a time in establishing an equilibrium be- tween itself and its new surroundings, which the feeble mind cannot do. Men do not, however, often become insane from joy ; and when one of the expansive passions, as ambition, religious exalta- tion, overweening vanity in any of its Protean forms, leads to mental derange- ment, it does not, like a painful passion, act either directty as the sudden cause of an outbreak, or indirectly by producing organic disorder and subsequent Insanity, but it exhibits its effects slowly, as a grad- ual development or exaggeration of a par- ticular vice of character. Among the causes of mental disturbance which it would be difficult to pronounce other than moral, but which are really due to physical conditions, are those inci- dent to the great mental revolution pro- duced by the development of the sexual system at puberty ; when there occurs, as Goethe aptly expresses it, "an awakening of sensual impulses which clothe them- selves in mental forms, of mental necessi- ties which clothe themselves in sensual Images." The great moral commotion produced at this period is the cause of an unstable equilibrium of mind, which is just as dangerous as if it were produced by some external cause ; and which, if hereditary predisposition exist, may, with- out further auxiliary cause, issue in In- sanity. Of" the physirnl causes of Insanity, in- temperance occupies the first place ; acting not only as a direct cause, but indirectly through the emotional agitation incident to an irregular life of dissipation and ex- cess. Opium, Indian hemp, and other narcotics notably give rise to temporary disorder of mind, and, if abused by long indulgence, they may lead to permanent degeneration. Self-abuse in men is the cause of a particularly disagreeable form of Insanity, characterized by intense self- feeling and conceit, indolence and vacilla- tion of character, and profound moral dis- turbance in the earlier stage, and later, by failure of intelligence, nocturnal hallu- 590 INSANITY. cinations, and suicidal or homicidal pro- pensities. Epilepsy ib sometimes followed by a most violent and dangerous mania, and, when of long standing, produces loss of memory and general failure of intelli- gence. Sometimes an outbreak of mania precedes or takes the place of an epileptic attack ; and it may happen that a painful form of moral derangement, with periodi- cal exacerbations — a masked epilepsy — precedes for months the appearance of the genuine epileptic convulsions. In some instances hysteria produces or passes into Insanity. An attack of acute maniacal excitement, with great restless- ness, rapid and disconnected, but not entirely incoherent, conversation, some- times tending to the erotic or obscene, evidently without aboUtion of conscious- ness ; laughing, singing or rhyming, and perverseness of conduct, which is still more or less coherent and seemingly wil- ful, — may occur in connection with, or in- stead of, tlie usual hysterical convulsions. Or the ordinary hysterical symptoms may pass by degrees into chronic Insanity. Loss of power of will is a characteristic sj'mptom of hysteria in all its Protean forms, and with the perverted sensations and disordered movements there is always some degree of moral perversion. Tliis increases until it swallows up the otlier symptoms : the patient loses more and more self-control, becoming capriciously fanciful about her health, imagining or feigning strange diseases, and keeping up the delusion or tlie imposture with a per- tinacity that might seem incredible, and getting more and more indifferent to and impatient of the advice and interference of others. Outbursts of temper become almost outbreaks of mania, particularly at the menstrual periods. An erotic tinge is sometimes observable in the behavior. More or less dulness of intelligence and apathy of movement, giving the seeming of a degree of imbecility, is common enough in chorea, and in some cases there is a violent delirium or mania ; but be- sides tliese cases there are, I believe, in children others in which, without disorder of movements, there is a true choreic ma- nia : it is an active delirium of ideas which is the counterpart of the usual de- lirium of movements, and its automatic character and marked incoherence are very striking; hallucinations of the spe- cial senses, and loss or a perversion of general sensibility usually accompanying delirium. Chronic diseases, constitutional and lo- cal, favor the production of Insanity in many instances. Anasmia plays the same weighty part as in the causation of other nervous diseases. It is not without in- fluence in many cases of hysterical in- sanity, as well as in tlie asthenic form which occurs during lactation ; and when suddenly produced by great loss of blood, it may be the cause of an attack of puer- peral mania. The syphilitic virus is now known to affect nervous element inju- riously, and of late an extreme form' of dementia has been ascribed to a syphilitic exudation, circumscribed or diffused, on the surface or within the substance of the brain. Tuberculosis is frequently a.sso- ciated with mental disease, one-fourth of the deaths in asylums being due to phthi- sis ; and a form of suspicious mclancliolia, having something of the character of de- mentia about it, has been described as phthisical insanity.' The disappearance of a skin disease, or the suppression of an accustomed discharge, has of old l)een known to be at times followed by an at- tack of mania or melancholia ; and there are on record numerous cases of mania which have been caused by retrocedent gout. Of local diseases favoring the pro- duction of Insanity, the influence of those of the heart seems to have been over- rated ; out of 602 post-mortem examina- tions made in the Vienna asylum, the heart was found to be affected in one- eighth, and in some of these only very slightly. Abdominal diseases are some- times genuine causes of melancholia ; and diseases of the sexual organs in women have always had a liigh place assigned to them in the scale of causes. It is certain tliat an attack of mania has followed the suppression of the menses, and that the return of menstruation is often followed by the recovery from Insanity ; but it is certain also that outbreaks of maniacal fury, or of suicidal or homicidal violence, have coincided witli the period of men- struation. Schroeder van der Kolk had a patient profoundly melancholic, who suf- fered also from iDrolapsus uteri, and in whom the melancholia disappeared di- rectly the uterus was restored to its place. Flemraing relates two similar cases in which the melancholia was cured by the use of a pessary, in one of them regularly returning whenever the pessary was re- moved ; and I have seen, in one case, se- vere melancholia of two years' duration disappear after the cure of a prolapsus uteri. Instances are on record in which a woman has regularly become insane during each pregnancy; and, on the other hand,"Guislain and Griesinger mention a case, respectively, in which Insanity dis- appeared during pregnancy, the patient at that time only being rational. Under the name of Puerperal Insanity are frequently confounded three distinct varieties — the Insanity of Pregnancy, Puerperal Insanity proper, and the In- sanity of Lactation. The first and last > Tuberculosis and Insanity, by T. S. Clouston, M.D.; Journ. Ment. Science, April, 1863. POEMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 591 usually have the form of marked melan- cholia with suicidal tendency; the second appears as an acute and incoherent mania. The Insanity which sometimes breaks out at the change of life in women is com- monly a profound melancholia, with vague delusions of an extreme character. After acute febrile diseases, as typhus and typhoid fever, the acute exanthe- mata, acute rheumatism, and pneumonia, Insanity sometimes follows. In such cases it either takes the form of acute de- mentia, or of the mild delirium of nervous exhaustion, from which recovery takes place in a few days ; or it steadily passes into a chronic and persistent form, espe- cially if there be hereditary taint ; or it is acute, recovery taking place for a time, but, as happens after injuries to the head, being followed by subsequent marked change of temper, and Anally Chronic In- sanity.' Injuries of the head, when not followed by any immediate ill consequences, may still, after a time, lead to incurable In- sanity, through the degenerative changes which they induce in the cortical layers. Insolation notably acts perniciously on the cerebral centres, either by causing acute hyperseniia and oedema, or, as is more probable, by over-stimulation and consequent exhaustion of nervous ele- ment. Abscesses and tumors of the brain, cysticerci,^ effusions of blood, do not directly produce mental disorder, which is indeed often absent ; and when they do give rise to such disorder, they seem to act indirectly by a reflex or sympa- thetic action. Professor Gerhardt relates one case in which mental derangement was the first symptom of an embolism, the paralytic phenomena following later ; and in a case recorded by L. Meyer, chronic tubercular meningitis gave rise to mental disorder.' Instances are on record in which Insanity, like tetanus, has been caused by peripheric injury of nerve; and of great interest are those ' De la Folie Consecutive aux Maladies Aigues. Par le Dr. E. Muguier. Paris, 1865. — Griesinger, op. cit. — On the Delirium of Acute Insanity during the Decline of Acute Diseases, by Hermann Weber, M.D. ; Med.- Chir. Trans., 1848. ' On Cysticerci, Archiv der Heilkunde, 1862, Prof. Griesiuger. A case of insanity in which several cysticerci were found in the brain is related by Joire in the Gazette des Hopitaux, 1860; another by Dr. Snell in the Zeitschrift fur Psychiatrie, 1861 ; another by Baillarger in the Arch. Clin, des Maladies Mentales, 1860; and another by Dr. Saunders in the Report of the Devon County Asylum for 1864. ' Prof. Gerhardt, Wiener Med. Presse, No. 7, 1865; L. Meyer, Zeitschrift fur Psychiatrie, 1858, p. 716. cases, long since observed by Dr. Darwin, in which it occurs as the transference of disorder from the spinal centre. Let it be distinctly understood, how- ever, that of the above enumerated causes of Insanity, it scarcely ever happens that one acts singly ; many of them would have no such ill clfect, except throush the co- operation of hereditary predisposition, and the latent hereditary taint might remain happily dormant, but for the concurrence of unfavorable conditions, physical or moral. Whenever such inborn taint does exist, it is certain that any great revolu- tion in the system, whether arising out of external circumstances, or from internal causes, such as puberty, pregnancy, and the climacteric period, will be fraught with danger to the healthy balance of the mind. [As a fair representation of American statistics in regard to Insanity, we may refer to those of the Pennsylvania Hospital for the Insane, in Philadelphia. Dr. Kirk- bride, in his Annual Report published in 1876, states the supposed causes of 7167 cases of Insanity, treated in that Hospital during 35 years. To ill health of various hinds, 1290 cases are ascribed. To intem- perance, 637 cases ; loss of propertij, 230 ; disappointed, affections, domestic dijjiridties, grief, loss of friends, &c., in all, 570 cases. Mental anxiety is credited witlx 441 cases ; intense study, with 52 ; intense ap- plication to husiness, 56 ; want of employ- ment, 40 ; pjiierpercd state, 284 ; masturba- tion, 93 ; exposure to the sun, or other intense heat, 72 ; opium, 27 ; tobacco, 17 cases. Of the whole number thus reported upon (7167 patients), there were admitted between the ages of 20 and 30 years, 2080 cases ; between 30 and 40 years, 1951 cases ; in each of the other decades of life smaller numbers. — H.] FoEMS OF Insanity and their Symp- tomatology. — A glance at the symp- toms of the various forms of mental dis- ease reveals at once the existence of two well-marked groups: one of these including all those cases in which the mode of feel- ing or the effective life is chiefly or solely perverted — in which the whole habit or manner of feeling, the mode in which the individual is effected by events, is entirely changed ; the other, those cases in which ideational or intellectual derangement pre- dominates. More closely scanning the symptoms it is seen that the affective dis- order is the fundamental fact ; that in the great majority of cases it precedes intel- lectual disorder ; that it co-exists with the latter during its course ; and that it fre- quently persists for a time after this has disappeared. Esquirol rightly, then, de- clared " moral alienation to be the proper characteristic of mental derangement." " There are madmen," he says, " in whom 592 INSANITY. it is difHeult to find any trace of halluci- nation, but there are none in whom the passions and moral affections are not per- verted and destroyed. I have in this par- ticular met with no exceptions." This experience is in entire accord with that of every observer of Insanity, and with the principles of a sound psychology. It is the feelings that reveal the genuine nature of an individual ; it is from their depths that the impulses of action come, while the intellect guides and controls ; and ac- cordingly in a perversion of the affective life is revealed a fundamental disorder of the innermost nature, a disorder which will be exhibited in acts, rather than, as ideational disorder is, in words. To in- sist upon the existence of a delusion as a criterion of Insanity, is to ignore some of the gravest and most dangerous forms of mental disease. Melancholia. ■ — Here the fundamental fact is a deep, painful feeling of profound depression and misery, a great mental suf- fering. The patient's feeling of external objects and events is perverted, so that he complains of being strangely and un- naturally changed : impressions which should rightly be agreeable, or only indif- ferent, are felt as painful ; friends and relatives are regarded with sorrow or aversion, and their attentions with sus- picion ; he feels himself entirely isolated, and can take no interest in his affairs ; and he either shuns society and seeks solitude, lying in bed and unwilling to exert himself, or he utters his agony in sounds ranging from the moan of dull ache to the shrill cry of anguish, or in ceaseless gestures of misery, or even in gome convulsive act of desperate violence. All this while there may be no delusion ; the patient may be conscious of the change in himself, may grieve over his unnatural state, and strive to hide or fit- fully resist it ; but as he gets worse he becomes more and more self-absorbed, more and more indifferent to, or distrust- ful of, those around him, and, finally, suc- cumbs entirely to his affliction. Then it is, usually, that the vast and formless feeling of profound misery takes form as a concrete idea — in other words, is con- densed into some definite delusion : this now being, as it were, the expression of it. The patient believes that he has com- mitted some great crime, for which he must suffer death on the gallows ; that he has blasted the happiness of his fam- ily ; that he is possessed by the devil, or is the victim of a persistent and cruel per- secution, by magic or by magnetism; that he has committed the unpardonable sin, and is for ever damned. The delusion is not the cause of the feeling of misery, but is engendered of it, and takes different forms according to the degree of the pa- tient's culture, and the social, political, or religious ideas prevailing at the particular epoch : what the uneducated person at- tributes to witches or to devils, the man of some cultivation attributes to magnet- ism or to political conspiracy. In certain cases it is striking how disproportionate the delusion is to the extreme mental an- guish — how inadequate it is as the ex- pression of it : one, whose agony is that of the damned, will aver that it is because he has drunk a glass of beer which he should not have done, or because he has muttered a curse when he ought to have uttered a prayer. "With him who believes that he is doomed to infinite and eternal misery, it is not the delusion, but the affective disorder, that is the fundamental fact ; there can be no adequate or definite idea of the infinite or eternal, and the in- sane delusion of eternal damnation is but the vague and futile attempt at expressing an unutterable real suffering. It is note- worthy, again, how much the affliction of the melancholic subsides sometimes when a definite delusion is established : the vast feeling of vague misery which possessed the whole mind has undergone systemati- zation in definite morbid action ; and when the delusion is not active, but re- poses in the background, not otherwise than as ideas constantly lie dormant in the sound mind, the patient may be tole- rably cheerful. A suicidal feeling is so common that the possibility of its exist- ence should always be had in mind ; in 51 cases of Insanity in which suicide had been meditated or attempted, 28 were cases of melancholia. As many as are the varieties of mental pain or suft'ering, so many varieties are there of melancholia ; the essential cha- racter of all of them being an oppression of the self, the weight of a great suffering, out of which springs the delusion of being overpowered by some external agency, demoniac or human, or of salvation lost through individual sins. The classifica- tion of melancholia according to the acci- dental character of the delusion is, there- fore of little value. Two well-marked groups may be distinguished : the first, including those who have a definite delu- sion — liypemania; the second, those who have no definite cause of terror, but dis- play a fearful apprehension of everything possible and actual — Pantophobia. Hypochondriacal Melancholia represents one of the mildest but most persistent forms of melancholic depression ; the anxi- ety proceeding from an extravagant feel- ing of bodily disease and exaggerated notions of danger. The morbid feeling, which is not usually without some physi- cal cause in the organism, may be general, or it may be confined to single anomalous sensations. The patient is anxious and depressed ; he complains of anomalous FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 593 feelings, which he watches and analyzes very attentively ; his heart flutters fear- fully, a film passes over his eyes, and there are strange sensations in his head ; he examines his pulse, tongue, and evacu- ations, and rarely fails to find someiliing abnormal in all of them. He is commonly irresolute, sluggish, and indifferent to what is not related to the circle of his morbid ideas ; but in some cases parox- ysms of anguish and despair rise to such a height as to sweep away all power of self-control, and to issue in suicidal or homicidal violence. The intelligence, though generally sound in regard to all matters that are not overclouded by the morbid feelings, is still profoundly aflected through these. Hence, though hypochon- driacal melancholies do not often commit suicide or homicide, they may do both ; a man in the Somerset Asylum, for ex- ample, cut into his belly with a piece of glass, and dragged out his small intes- tines, in order to let the wind out. The transition is indeed gradual from the less severe forms to those in which the anoma- lous sensations are not merely exaggerated and misinterpreted, but are referred to some absurdly unreal cause, as to the pre- sence of a serpent in the stomach, or to a galvanization of the nerves, or even to those cases in which the patient supposes his legs to be glass, his bodj;- butter, or himself metamorphosed into a wolf. By this declension, hypochondriacal melan- choly undoubtedly passes into true melan- cholia. Climacteric Insanity usually takes the form of profound melancholia, with vague and vast delusions, as that the world is in flames, that it is turned upside down, that everything is changed, or that some very dreadful but undefined calamity has happened or is about to happen. The countenance has an expression of a vague terror and apprehension. In some cases short and transient paroxysms of excite- ment break the melancholy gloom ; these usually occur at the menstrual periods, and may continue to do so for some time after the function has ceased. In connection seemingly with the de- velopment of puberty, or at any rate soon afterwards, we sometimes meet with a fanciful and quasi-hysterical melancholia in girls, which is not very serious when it is properly treated. There are periods of depression and paroxysms of apparently causeless weeping, alternating with times of undue excitability, more especially at the menstrual periods ; a disinclination is evinced to work, to rational amusement, to exertion of any kind ; the conduct is capricious and soon becomes perverse and wilful ; the natural aftections seem to be blunted or abolished, the patient taking pleasure in distressing those whose feel- ings she would most consider if in health; VOL. I.— 38 and although there are no fixed delusions, there are unfounded suspicious or fears and changing morbid fancies. In some of these cases, when the disease has become chronic, delusions of sexual origin occur, and the patient, whose virginity is intact, imagines that she is pregnant or has had a baby. The Insanity of Pregnancy is, as a rule, of a marked melancholic type, with sui- cidal tendency : a degree of mental weak- ness or apparent dementia being some- times conjoined with it. Otber cases, however, exhibit much moral perversion, perhaps an uncontrollable craving for stimulants, all of which we may perhaps regard as an exaggerated display of the fanciful cravings, the capriciousness and the morbid fears from which women suffer in the earlier months of pregnancy. The Insanity of Lactation is an asthenic melancholia, often "^vith determined sui- cidal tendency. The time of its occurrence seems to show that the longer the child is suckled, the greater is the liability to it. Sensibility is commonly much affected in melancholia. There may be a general diminution of the sensibility of the skin, or a local complete loss thereof ; and com- plaints of prtecordial anguish and of strange abdominal sensations testify the perversion of organic sensibility. These anomalous sensations appear sometimes to have a relation to the confusion and an- guish of mind not unlike that which the epileptic aura has to the epileptic fit. Illusions and hallucinations of the special senses are frequent : the patient seeing those round him as devils, or smelling a corpse in his room, or tasting poison in his food, or hearing voices which revile and accuse him, or which suggest impious thoughts and prompt to violent deeds— it may "be to imitate Abraham, and sacrifice his child.' The bodily nutrition usually shares in the general depression of tone, although it is sometimes remarkable, considering the great apparent sufiering, how little it is affected. When it does suffer, digestion fails, and constipation is troublesome; the skin loses its freshness, becomes sal- low, dry, and harsh ; the temperature of ' If a person sees, hears, or otherwise per- ceives what has no existence external to his senses, he has a hallucination; if he sees, hears, or otherwise perceives that which has no such external existence as he perceives,^ or perceives it with (erroneous form or qualities, he has an illusion: and if, though perceiving external objects as they really exist, he be- lieves in the existence of such objects, or con- ceives such notions of the properties and relations of things, as are absurd to the com- mon sense of mankind, he has an insane con- ception or a delusion— the ground of the fa se- ness of conception being not error, but a morbid condition. 594 INSANITY. the body is lowered, and the extremities are cold ; the respiration is slow, moan- ing, and interrupted by deep sighs ; the pulse is feeble, sometimes very slow, and even intermittent ; and menstruation is generally irregular or suppressed. Sleep is usually deHcient, though patients are apt to assert that they do not sleep when tliey really do, so little do they feel re- freshed by it. Eefusal of food, which is common, and sometimes very persistent, may be due to other causes besides want of appetite : it may take place through a fear of being poisoned, or in consequence of a delusion that the intestines are sealed up, or in order to commit suicide by star- vation, or in fancied obedience to a voice from heaven, or from sheer wilful obstinacy . The behavior of the melancholic accords with, or fitly expresses, the character of his ideas and feelings ; and three well- marked groups of melancholia may be made according to the different relations on the motor side : — 1. Melancholia with stupor, M. attonita is interesting because of its close resem- blance to dementia, with which it has been confounded. The expression of the face is that of a vacant, self-absorbed amazement, or the fixed form of some painful passion ; the patient, as if in a trance, or as one only partially awake, scarce seems to see or hear ; there is par- tial or general insensibility of the skin ; consciousness of time, place, and persons is lost, and the bodily wants and necessi- ties are alike unheeded ; the muscles are generally lax, or some of them are fixed in a cataleptic rigidity. The patient — ■ — who, statue-like, muf.t usually be re- moved from place to place — is possessed with some terrible delusion, as that the whole world is in flames, or that he is standing on the edge of a sea of blood, and when he recovers his senses he is as one awakened out of a frightful dream. One lady under my care, who was in this state for two years, with the exception of an occasional break of lucidity for a few hours, and who ultiinately recovered her senses quite suddenly, believed that every one who approached her, and even lifeless objects, were threatening to murder her. As may easily be imagined, it is not always possible to distinguish this condi- tion from dementia : for as to live in one sensation would be equivalent to having no sensation at all, so for a mind to be entirely absorbed in one terrible delusion, to remain in one persistent state of mor- bid consciousness, is equivalent, for the time being, to there being no mind at all. As, however, recovery may take place rather suddenly, though it may sometimes last only for a few hours or days and then be followed by a complete relapse, it is plain that melancholia with stupor is dif- ferent from the stupor of real dementia. 2. Melancholia is often accompanied with destructive impulses, to sudden acts of violence against self or against others. Suicidal impulse is very common amongst melancholies, some sincerely and bitterly grieving over the horrible propensity as the sole cause of their unhappiness : but what is very remarkable is the sudden manner in vj'hich patients usually ca'm are at times surjirised and overpowi red by a desperate impulse, and hurried into a convulsive act of violence. A quiet man, having the delusion that his soul was lost, who had been for months under my care, and of whom no one suspected any mischief, suddenly started out of bed one night, without any warning, and flung himself out of a window through which it would have been thought impos- sible that any man could get. He was possessed with terrible hallucinations, thought that the world was come to an end, and in a fearful state of writhing agony cried, " Let me go 1 let nie go !" Like paroxysms recurred occasionally during the next few weeks, after which the man recovered. The time of waking from sleep is that at which the desperate impulse is most likely to arise, wherefore melancholies should never be left alone when getting up in the morning. In other cases the sudden act of violence may be directed against others ; the patient injuring or kilUng some one by reason of a sudden hallucination, or in consequence of his anguish having reached such a height of unendurable agony as to abolish all self-control, and irresistibly to utter itself in convulsive violence, either against a fancied persecutor or a completely indif- ferent person (Snjitus nielnnchnlicus). Of such are some homicidal lunatics. Others act in obedience to a delusion : an evil spirit instigates the demono-maniacs to desperate deeds in spite of the will; or its impulses intensify their misery and lead to determined suicidal attempts, in order to escape from the intolerable prompt- ings. A melancholic mother has killed herself to escape the desperate impulse to kill her child. Nor is it inconsistent with insanity in such cases that the violent deed should have been planned with sur- prising cunning and eft'ected with sus- tained ingenuity. So far from the morbid impulse or act constituting the insanity, it is but the out- ward and visible sign or expression of a profound affective derangement, the tend- ency of which is to manifest itself, not as ideational insanity does, in words, but in acts, and which for this very reason is much more dangerous than ideational in- sanity : it is truly an affective insanity, one symptom of which is homicidal or suicidal impulse : the delusion, when there is one, and the homicidal act, are both symptoms of a deeper-lying disease ; and FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 595 the morbid manifestation of one may be as little within control as that of the other, or as the suddenly arising hallucination is. In the one case the patient is the vic- tim of a morbid idea ; in the other, of a morbid movement — in both cases, of a convulsion more or less co-ordinated. Where the disease is less acute, it is the feeling of this affective perversion that sometimes drives the melancholic to com- mit murder in order to be hanged, or im- pels a mother to murder her children in order to send them from misery on earth to happiness in heaven. It admits of no question whatever, and should therefore be borne clearly in mind, that the calmest melancholic is liable to occasional unac- countable exacerbations of disease, during the paroxysms of which he may perpetrate violence against himself or others ; a won- derful relief, and even an apparent sanity, with endeavor to escape penal conse- quences, sometimes following the accom- plishment of the act. 3. There is a melancholia of acute cha- racter, with great excitement and rest- lessness, that may even pass into mania. It is certain that cases marking every step of the transition to mania do occur in practice : and it is not always easy, not- withstanding the painful character of the delusion, to distinguish excited melan- cholia from mania : there are truly mel- ancholies who are maniacal, as there are maniacal patients who are melancholic. The more activity of movement there is as the expression of the mental suffering, the more acute the utterance of the agony in gesture-language — in the wringing of the hands and the writhing of the body — the nearer does the case approach mania. The manifestations of excitement are, however, generally of a more uniform character than those of mania, and often even monotonous. The covrse of melancholia is generally chronic ; remissions are common, but complete intermissions rare. Still, it is striking sometimes how suddenly a great change may take place : Griesinger men- tions a case of deep melancholia in which there occurred a perfect lucid interval for the space of a quarter of an hour ; and I have more than once seen a profound melancholic awake in the morning cheer- ful and seemingly quite well, remain so for the rest of tlie day, and yet be as bad as ever on the following day. Such sud- den recoveries are, like sudden conver- sions, greatly to be distrusted. Still, I have met with two Instances in which sudden recoveries were permanent : in one, the patient, who had been acutely melancholic for six months, recovered suddenly after a flood of tears ; in the other, the patient was quite well in the morning, after a sleepless night of much mental anguish and excitement. When recovery really takes place, it is usually gradual, and from witliin four to twelve months from the conmieucement of the disease ; it is rare, but not impossible, after a year, although it may occur now and then after several years, especially if some great shock has aroused the patient to exertion. Half, or even more than half, of the cases of melancholia get well under proper treatment ; and of those which do not recover, about half decline into mental weakness or complete demen- tia — the rest remaining chronic or ending in death. Death may be caused directly by the exhaustion of excitement or re- fusal of food, or it may be due to inter- current diseases, phthiscal, cardiac, or abdominal. Gangrene of the lung was found by Guislain most frequently in melancholies who had died after long re- fusal of food. Mania. — In this form of mental disease there is an excitement or exaltation of the self-feeling of the individual, the expres- sion of which takes place either in the movements and conduct or in the charac- ter of the thoughts. Accordingly, two groups of cases may be broadly distin- guished, although they pass insensibly into one another and are not unfrequently mixed ; the first including all those cases of acute mania or maniacal fury in which the madness is mainly manifest in the actions of the patient, who sings, dances, declaims, runs about, pulls off his clothes, and in all ways acts most extravagantly ; the second group including those more chronic cases in which the derangement is expressed in the ideas, is sj'stematized in definite delusions — in which, therefore, the morbid action has taken deeper hold of the individual. The first group cor- responds in the main to acute mania, the second to monomania. It was held by Guislain that a stage of melancholic depression, of greater or less duration, almost invariably precedes an attack of mania ; and there can be no doubt that this sequence is traceable in many cases. But it is not so in every case, as some have maintained. What has been commonly overlooked is, that there is not only an affective disorder of a depressed or melancholic kind, but that there is also an affective Insanity which is rather of an excited, expansive, or ma- niacal kind— a deep derangement of the affective life, in which the individual's self-feeling is greatly exaggerated or mor- bidly exalted, without positive intellec- tual alienation. It is a maniacal dis- order, so to speak, of the feelings, senti- ments, and acts, without deUrium ; and it is expressed, as the corresponding affec- tive melancholia is. not in delusion, but in the conduct of the patient. As it is from the affective life that the impulses of 596 INSANITY. action come, while the function of the intellect is to guide and control, it is in strict accordance with reason that, when there is affective derangement or perver- sion of the mental tone, the morbid im- pulses that arise should be beyond control or guidance of the will, just as the con- vulsion of a limb is beyond control when there is derangement of the tone of the spina] centres. This inceptive maniacal state, which may unquestionably be pri- mary, though usually following that of melancholic depression, is displayed in a great change of moral character ; the par- simonious becomes extravagant, the mod- est man presumptuous and exnoting, and the affectionate parent indifferent to his family ; there is an extreme liveliness of manner, or a restless and busy activity, as of one half intoxicated ; an overween- ing self-esteem is a marked feature, and an extravagant expenditure of money or an excessive sexual indulgence is com- mon. Or the exaltation may be less and the perversion of the affective life more marked ; in other words, the moral aliena- tion more extreme, as witnessed in the profound moral derangement which some- times precedes a series of epileptic fits, or takes the place of an epileptic fit, and in most of those cases included by Pinel under mania sine delirio and by Prichard under moral insanity. In such cases, as with the cases of so-called irresistible homicidal or suicidal impulse, it has been too much the practice to fix attention exclusively upon the extravagant actions of the patient, to the neglect of the profound affective de- rangement out of which his acts spring ; so that they have been set apart as spe- cial and their real relations overlooked. They are truly of the same nature as that maniacal perversion of the whole manner of feeling sometimes forerunning an out- break of mania ; and their morbid expres- sions in single acts of vicious or violent conduct are of the same kind as those general symptoms of acute mania wliich are exhibited in the movements or actions of the patients. Acute Mania; Maniacal Fury or Frenzy; or Baring Madness. — It seldom breaks out without a preceding stage of affective derangement, the period of incubation being usually of a melancholic character, as though there were a painful forefeeling of the coming storm. After a shorter or longer feeling of such premonitory de- pression there follows a marked change in the inclinations, habits, and affections : the patient, " much, much different from the man he was," gets restless, and is prone to wander or travel about, is sleep- less at night, or is tormented with very vivid dreams ; he next becomes lively and excitable, as though half intoxicated, and the tone of his voice is sometimes strangely altered ; his actions are restless, extrava- gant, and turbulent ; and all the while he thinks liimself wonderfully well, and scorns the suggestion of medical aid. As matters become worse there is an irresist- ible propensity to utter the internal com- motion in outward gestures, acts, or words : the patient sings, dances, declaims, shouts, and laughs ; or he is industriously occupied in restless and aimless work, as in polishing the floor with his saliva, in tearing his clothes to shreds, or in chang- ing the place of every piece of furniture about him ; or he explodes in furious out- breaks of rage and raving of word and action. The organic appetites or instincts come markedlj' into the foreground, the veil of reason being withdrawn : the appe- tite is ravenous and indiscriminate, gar- bage, or even excrement, being devoured with apparent aviditj' ; and the patient, forgetful of decency, and abandoned to the promptings of the sexual impulse, sometimes masturbates as the monkey does, without shame or restraint. Withal there is often a certain consciousness of his state, so that he may restrain himself and seem reasonable for a time, and when seemingly at his worst he will sometimes yield to the show of energy and determi- nation. The mood of mind may be brisk and humorous, or bitter, angry, and scornful in the face of opposition. There is no fixed delusion, nor any fixed group of delusions ; but the ideas are rapid, con- fused, and transitory, and appear as fleet- ing delusions, or immediately utter them- selves in automatic impulses to words and actions ; the idea of an act, the moment it arises in the mind, becomes the act. Because of the rapidity of the flow of ideas in the early stages, the witty obser- vations, acute comparisons, and fluent rhymes then sometimes made, it has been said that there is an increase of mental power. But it is only the semblance of an increase : though there is a lively re- vival of the past with great vivacity of expression, tliere is no due assimilation of the present, but an incapacity to perceive rightly the relations of things around, to- gether with false judgment with regard to them, so that the unhappy suft'erer is extravagantly joyous in a madhouse ; there is an entire absence of that co-ordi- nation of the feelings and ideas which marks the highest mental power and is the condition of true will. The lively flow of scarce coherent ideas marks the excita- bility of an irritable weakness, and is the forerunner of a restless succession of iso- lated ideas and fragmentary associations in the more advanced stages, not other- wise than as convulsion is the forerunner of paralysis. It is striking how complete in some cases may be, during the attack, the memory of the past, and after the attack, FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 597 of all that has happened during it ; whilst, in other instances, the patient will forget altogether the events of his madness, like as a dream is forgotten, though he iiiay remember them again during a subse- quent attack. It may happen also that, immediately before a second attack, thoughts and feelings displayed on the occasion of a first attack, but latent since, will recur, so that even attendants recog- nize the evil presages, and can predict the outbreak. Hallucinations of the different senses are common in mania, and illusions still more so. In 178 out of 2'29 cases Brierre de Boismont professes to have met with such complications ; they are generally fleeting, like the other morbid phenomena. Some have thought that the long endur- ance of the great expenditure of energy in acute mania is owing to a perversion of the muscular sense, by reason of which the true condition of the muscles is not declared. There can be little doubt that illusions of the muscular sense are at the root of the delusions with regard to bodily movements sometimes exhibited in mania ; when a person lying in bed believes his limbs or himself to be flying through the air, it is certain that the muscular sense does not give correct information, but is affected with hallucinations. The bodily functions often bear the great mental agitation of acute mania in a surprising manner. The pulse may be a little quicker in the early stage, when there is perhaps some febrile disturbance ; but it is afterwards scarce raised in fre- quency. The temperature of the body is only shghtly increased ; but in cases of a typhoid type, where there is sleeplessness, restlessness, gradual wasting, and where the tendency is to death from exhaustion. Dr. Saunders has found it to be often raised from three to five degrees above the natural standard.' In the Insanity occurring after acute diseases, Dr. "Weber's observations show only a slight increase of temperature, although this had been raised several degrees during the previous disease, and immediately rose again on the occasion of a relapse.^ The skin may be either dry and harsh, or moist and of offensive odor. Constipation is common, but in some cases there occurs a continued ' Report of the Devon County Asylnm for 1864. — Dr. Clouston has recently made some careful researches respecting the temperature of the insane. He finds the evening tempera- ture of every form of insanity to be higher than the evening temperature of health, and excitement to be almost always attended by an increased temperature. (Journ. Ment. Science, April, 1868.) ' On the Delirium of Acute Insanity during the Decline of Acute Diseases ; Med.-Chir. Trans, vol. xlviii. and obstinate relaxation of the bowels The urine Dr. Sutherland found to con- tain an excess of phosphates in acute mania ; and if this were true, it would testify, like the increase of temperature, to an abnormal disintegration of tissue. More recent examinations of the urine, by Dr. Addison, result in the assertion that "the quantities of the urine, of the chloride of sodium, of the urea, phospho- ric and sulphuric acids, excreted during the course of a maniacal paroxysm, occui^ ring in acute mania, epilepsy, general paralysis, melancholia, or dementia, are less than the amounts excreted in an equal time during health.'" The course of mania is not often regu- larly progressive ; there are generally remissions, and sometimes complete in- termissions, or even so-called lucid inter- vals. The attacks may return at regular or irregular intervals, and thus constitute a periodic or recurrent mania ; or attacks of melancholia may alternate with them, and give rise to what the French have described as folie circulaire, or folie a double forme. The duration of an attack of mania may be for hours or months, and recovery may be sudden or gradual. There can be no question of the occasional occurrence of a short maniacal fury, a furor transitorius, lasting for a few hours or days, usually associated with vivid hal- lucinations, and comparable to an attack of epilepsy,^ and it is interesting to ob- serve that these attacks are sometimes preceded by a strange anomalous sensa- tion rising, like an epileptic aura, from some part of the body to the brain. "When recovery takes place, it is usually within the year ; it is rare after two years ; and, indeed, the longer the disease lasts the worse is the prognosis, which is always unfavorable in recurrent mania and in mania alternating with melancholia. Re- covery not taking place, the disease passes into chronic mania, or into dementia, or ends fatally. Death may be due to ex- haustion, or to some intercurrent disease, such as pleurisy or pneumonia. "When maniacal exhaustion proves fatal, the end may be very sudden and unexpected, so as to leave in the mind an anxious feeling of doubt whether a more energetic treat- ment might not have prevented death, or, if energetic treatment has been employed, whether that has not had something to do with hastening the fatal issue. 1 have described the general features of the typical form of acute mania, but we ' On the Urine of the Insane, by A. Addi- son, M.D.; British and Foreign Med.-Chir. Review, 1865. 2 Ueber Mania Transitoria, von Dr. L. Meyer. Virchow's Archiv, Band viii. Die Lehre von der Mania Transitoria, von Dr. R. Krafft-Ebing. Erlangen, 1805. 598 INSANITY. meet with several varieties in practice. There is a form of very acute mania, which might properly be called an acute delirious mania or acute maniacal delirium. It is characterized by intense excitement, great restlessness and jactitation, entire incoherence, there not being the co- herence of distinct and enduring delu- sion, and by only the briefest flash of momentary consciousness of what is going on around, or by apparent unconscious- ness, except so far as fragments of im- pressions are caught up, whirled and lost in the agitation of delirium. It runs a rapid course, very often to exhaustion and death, the pulse becoming quick and feeble, the skin hot, and the excitement and restlessness continuing to the last. [What is called by American writers upon psychopathology "Bell's Disease," from its especially careful study by Dr. Luther V. Bell, is thus described by Dr. Curwen, of the Penna. State Hospital for the Insane, at Harrisburg :' "In this there is excessive restlessness, incessant lo- quacity, the most remarkable incoherence of thought and expression (tireless bab- bling as it is expressed by the French), the pulse is rapid, weak, and very com- pressible, so as almost to be stopped, the skin is cool and also the scalp, and as a general rule dry, except after violent ex- ertion, and often even then, the tongue and mouth very dry from the incessant talking, and the attention can scarcely be attracted long enough to obtain an answer to any question. In ordinary cases of acute mania, or in inflammatory dis- orders, the attention may be arrested so long as to obtain answers to questions, or to cliange the current of thought, but in this it seems as if the individual was so impelled to give utterance to the words that crowd his mind that he had not time to stop for any purpose. The resemblance of this condition to the symptoms of acute meningitis or cerebritis as laid down in the books will mislead any one who will not give earnest heed to its peculiar diag- nostic symptoms, the freedom from all feverish heat, the peculiar weakness and softness of the pulse, and the physical state of depression of the whole sys- tem."— H.l Tuerperal Mania comes on within one month of parturition, and like the In- sanity of pregnancy, occurs most often in primiparse. It is of an acute and inco- herent character, marked by noisy rest- lessness, sleeplessness, tearing of clothes, hallucinations, and in some cases by great salacity, which is probably the direct mental effect of the irritation of the gen- erative organs. Suicide may be attempted in an excited purposeless way. The [' Transactions of Penna. State Medical Society, 1869.— H.] bodily symptoms, contradicting the vio- lence of the mental excitement, indicate feebleness ; the features are pinched, the skin is pale, cold, and clammy, and the pulse is quick, small, and irritable. Ee- covery takes place in three out of four cases of puerperal mania, usually in a few weeks ; the patient, after the acute symptoms have subsided, sinking into a temporary state of confusion and feeble- ness of mind, and then waking up as from a dream. Recurrent Mania reminds us of nothing so much as epilepsy in the regularity of its recurrence, in the uniformity of the symptoms of the attack, each being al- most an exact image of the other, in its comparatively short duration, and in the temporary recovery. The patient becomes elated, hilarious, talkative, passing soon into a state of acute, noisy, and self-con- scious mania, which may last for two or three weeks or longer, and then sinking into a brief stage of more or less depres- sion or confusion of mind, whence he awakens to calmness and lucidity. In vain we flatter ourselves with the hope of recovery : after an interval of perfect lucidity, of varying duration in different cases, the attack recurs, goes through the same stages, and ends in the same way, only to be followed by other attacks, until at last the mind is weakened and there are no longer lucid intervals. Could we stop the attacks, mental power might still be regained by degrees, but we can- not ; all the resources of our art fail to touch them, and I know no other form of Insanity which, while having so much the air of being curable, thus far defies all efforts to stay its course. When the acute symptoms of mania have subsided, and the disease has be- come chronic, it presents most varied characters, according to its cause and the degree of mental degeneration. When there is considerable intellectual power apart from the delusions, as there usually is when the disease has been produced by moral causes, then the case may properly fall under monomania, or partial derange- ment of the faculties ; when there is great loss of mental power together with delu- sions, as there often is when the disease has followed acute mania or a physical cause, then it may properly fall into one or other of the groups of dementia. On the one hand, then, chronic mania runs insensibly into monomania ; on the other, into dementia. It is remarkable in some cases how much intellectual power may coexist with extravagant J.jlusions : a person who fancies that not an cent in Europe happens which has not some hid- den relation to him, who detects a plot against himself in the meeting of a cabi- net, or in the journey of an emperor to his country palace, may yet have an exact FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 599 knowledge of all his aflairs, and be capa- ble of giving a good opinion with regard to them. But what such a person cannot be depended on to do is to control his conduct. The form of mental derangement pro- duced by self-abuse — the Insanity of nias- firtofioft— furnishes a good example of a chronic mania in which there are no acute symptoms, the onset of the disease being most gradual. The patient becomes offen- sively egotistic ; he is full of self-feeling and self-conceit ; insensible to the claims of others upon him and of his duties to them ; interested only in hypochondriac- ally vpatching his morbid sensations and feelings. His mental energy is sapped, and though he has extravagant preten- sions, and often speaks of great projects engendered of his conceit, he never works systematically for any aim, but exhibits an incredible vacillation of conduct, and spends his days in indolent and self-sus- picious self-brooding. His relatives he thinks hostile to him, because they do not show the interest in his sufferings which he craves, nor yield sufficiently to his pre- tensions. As matters get worse, the gene- ral suspicion of the hostility of people takes more definite form, and delusions spring up that persons speak offensively of him, or watch him in the street, or comment upon what passes in his mind, or play tricks upon him by electricity or mesmerism, or in some other mysterious way. Still he professes the most exalted moral or religious aims. A later and worse stage is one of moody self-absorp- tion and of extreme loss of mental power. He is silent, or if he converses he dis- covers delusions of a suspicious or obscene character, the perverted sexual passion still giving the color to his thoughts. He dies at the last a miserable wreck. This is a form of insanity which has certainly its special exciting cause and its charac- teristic features ; nevertheless, self-abuse seldom, if ever, produces it without the co-operation of the insane neurosis. Monomania; Partial Mania; Partial Insanity; Delusional Insanity. — The ex- alted self-feeling which in acute mania uttered itself chiefly in turbulent action gets embodied in a fixed delusion, or in a group of delusions, which fails not still to testify the overweening self-esteem. As in melancholia the feeling of oppression of self was condensed into a delusion of being possessed with a devil, or otherwise afflicted, so here the exaggerated self-feel- 11^ is clothed in a corresponding delusion of power or grandeur, and the personality of the patient is transformed accordingly: he would fain have us believe that he has resolved the most abstruse problems of science ; that he has devised an infallible scheme for reforming the world ; that he is king, prophet, or divine. Mouomauia is, then, a partial ideational insanity, with overweening estimate of self, and fixed delusion or delusions upon one subject or a few subjects, apart from which the pa- tient reasons tolerably correctly. Patho- logically it represents a systematization of the morbid action in the supreme cere- bral centres — the establishment of a defi- nite type of morbid nutrition in them. Having regard to the mode of origin of the delusion, the deep hold which the manner of its genesis proves it to have on the individual nature, it will be seen how erroneous it is to speak of the mind as sound apart from the delusion. As in melancholia so here, there is a funda- mental affective disorder incapacitating the individual from a just appreciation of those things that really affect the self, that touch to the quick those genuine feel- ings revealing his innermost nature and instigating his conduct ; and he is liable at any time to outbreaks of fury, which, like the delusion, are but expressions of the deep-rooted derangement. The mind is not unsound upon one point, but an un- sound mind expresses itself in a particular morbid action. Patients thus suffering often seem calm and harmless enough under the regular discipline of an asylum; but if they are exposed to the excitement of ordinary life, seriously crossed in some project, or subjected to the stress of ad- verse events, they are liable to outbursts of uncontrollable rage or of true mania ; so that one who may have been hitherto only interested by their harmless delu- sions, will be horrified at the utter mad- ness which they exhibit. The particular delusions of the mono- maniac ditfer according to his occupation in life and the degree of his culture, and are frequently colored by the events, social, religious, or political, of the epoch: Esquirol boasted that he could write tlie history of the French Revolution from the character of the Insanity which accompa- nied its different phases'. Hallucinations and illusions frequently accompany the delusions which they appear sometimes to generate and always to strengthen. The behavior of the patient accords with the character of his delusions : one makes sweeping plans and projects, enters upon vast speculations, and sometimes goes through an immense amount of patient and systematic work in perfecting some marvellous scientific invention ; another reveals in gait and manner the exalted character of his delusion ; and to a third, ordinary language does not suffice to ex- press the magnificence of his ideas, and he invents new and mysterious signs, which, unintelhgible to every one else, have wonderful significance for him. The coiirse of monomania, once estab- lished, is very seldom towards recovery ; for as it is rarely primary, it represents a dOO INSANITY. further decfeneration or more advanced morbid action than mania or melancholia, upon which it usually follows. E veu when it is primary, the outlook is not much more favorable, for it is then commonly secondary to some fundamental vice of character. Certainly recovery may take place, and the patient awake to sense as out of a dream ; aud in some rare in- stances it has taken place after years, especially under the influence of the revo- lution in the system produced by some intercurrent disease or at the climacteric period. When recovery does not occur, the disease becomes more chronic, lasting as such, or passes into actual dementia ; the more the exaggerated self-feeling which inspires the delusion wanes, and the more this, losing its inspiration, be- comes a mere form of words, the nearer the case gets toward incoherent dementia. As a general rule, it may be said that re- covery does not take place when a fixed delusion has lasted for more than half a year. Dementia. — It is the natural termina- tion of mental degeneration, whether going on in the individual or through generations ; and it is accordingly in the great majority of cases chronic, and sec- ondary to some other form of mental dis- ease. Dementia may, however, be both acute and primary, and is then not always distinguished from melancholia with stupor. Acute dementia sometimes occurs after an attempt at strangulation, after certain acute diseases, and after a series of severe epileptic fits ; and in one case under my observation a masked epilepsy seemed to take this form. As a primary disease, it sometimes follows a sudden and severe moral shock, and is now and then met with in young men and women, obscurelj' connected apparently with the state of the .sexual functions. Dr. Skae describes a sexual or post-connubial mania taking the form of acute dementia, met with both in the male and female sex, but more frequently' in the latter, and con- nected, he believes, with the effect pro- duced on the nervous system by .sexual intercourse. With these exceptions, de- i mentia is a chronic and secondary dis- ' ease presenting every possible variety in the degree of mental decaj'. After the disappearance of a severe at- tack of acute mania, the eft'ects of the shock are oftentimes visible in a certain condition of mental weakness without actual intellectual disorder : the force of character seems to have been sapped, and the finer moral and Eesthetic feelings, which are, as it were, the bloom of culture, are abolished; the physiognomy has lost its highest expression, and the individual pro- duces the impression of a certain child- ishness. This is one end of the scale oi degeneration ; but at the other extremity mental power is almost obliterated, the acquisitions of the past being completely razed out, aud no interest in the present possible, and the patient leads a mere vegetative life. Between these two ex- tremes every sort of transition is met with in practice, so that it is impossible here to do more than indicate certain prominent types. Most of the permanent residents in asy- lums consist of tho^e who, after mania, monomania, and melancholia, have sub- sided into a chronic state of more or less feebleness and incoherence of mind— the crazy people, who represent the wrecks of these forms of mental disease. Some there are who exhibit a few striking delu- sions which seem to be automatically ex- pressed ; the strong self-feeling which underlies or inspires these in monomania has faded away, and they are no longer full of self-assertion, nor eager, earnest, and consistent in carrying out their plans. The old paths of associations are broken up, and memory is almost abolished ; all liveliness of feeling is gone, and there is little or no interest in what is going on around ; and the only momentary ex- citement which occurs is when fixed delusions are attacked. It is remark- able, however, how even in these cases the excitement of a fever will sometimes restore temporarily the functions of the mind which seemed to have gone for- ever. The countenance no longer ex- presses any fixed passion ; there is a want of harmony, or, as it were, a dislocation of its features, and the most which it manifests is the shivered expression of a passion or the shattered wreck of a smile. There is a corresponding imbecility on the motor side : some can certainly con- tinue their former occupation, or can do a little simple manual work, but there is no systematic correspondence of action to delusions, and there is not uufrequently a useless and busy industry in gathering stones, pieces of paper, and sticks. Strange propensities of all kinds are ex- hibited, as, for example, to stand or crouch in a particular corner, to walk backwards and forwards for a certain dis- tance on a particular slip of ground, or to fantastically ornament the person with feathers or flowers. The mood may be of surly depression, or of more or less exalta- tion. Ilallucinations and illusions of the extremest kind are frequent, and tend to sustain the delusions : one woman has in her belly the whole tribe of the apostles, prophets, and martyrs ; another lovingly nurses as her child a lump of wood decked in rags ; a third person, whose singular movements seem unaccountable, is busy spinning threads out of sunbeams ; while a fourth continues the most violent move- FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 601 ments of his arms in order to prevent the motion of the universe or of his own blood from coming to a stand. The bodily health is usually good, the patient fre- quently getting stout as the active symp- toms of mania or melancholia subside into the calm of dementia. This group repre- sents for the most part dementia following on monomania. In another group of cases there is greater external activity, with a more general incoherence or craziness. There are no fixed delusions, although there is evidence in the patient's incoherent ex- pressions, or in his senseless, parrot-like repetition of certain vvords, of the wreck of such as existed in the maniacal stage. The senses are open to the reception of impressions, but these do not seem to be further fashioned into ideas. There is sometimes entire indifference to surround- ings, together with great insensibility to pain ; or there are short outljreaks of in- coherent passion or fury; or there may be desperate and unaccountable homicidal violence. The predominant mood is dif- ferent in different cases : some are gay, happy, and prone to laugh and chatter ; others are gloomy, weep, and display the mimicry of sorrow ; while others again are malicious, spiteful, and addicted to a purposeless mischief with a monkey-like cunning and persistence. The loss of memory is marked : some have entirely forgotten their former life and their own naines, while others, who perhaps forget instantly the last thing said, can repro- duce the distant past with fidelity. In the movements of some there is marked feebleness, or the indication of commenc- ing paralysis ; while others are restless, agitated, and run about with ceaseless activity. The bodily health is usually good : they sleep well, and eat well, often gluttonously and without discrimination, and are sometimes prone to get fat, until an attack of excitement and agitation, to which some are periodically liable, re- duces them. The physiognomy is blank and expressionless, especially so when the patient is addressed ; it is also prematurely aged. Lastly, there is a group of demented patients, in whom the mind is almost ex- tinguished ; who must be fed, clothed, and cared for ; who manifest little or no sensibility ; whose only utterance is a grunt or a cry ; and whose only move- ments are to rub their heads or hands. ) Their existence is little more than orga- nie, and if not carried off by pneumonia, tubercle, or some other disease, as they frequently are, they die from effusion on the brain, serous or hemorrhagic, or from atrophy of the brain, or from the effects of accident, to which, through their apathetic helplessness, they are much exposed. Senile dementia is characterized by weak- ness of mind, inability to grasp the pre- sent, and great loss of memory, especially of recent events ; the patient talking of events long past as if they had just hap- pened, perhaps believing himself to be in daily intercourse with persons who have long been dead, and confounding his pre- sent hfe, the events of which are almost innnediately forgotten, with his past life. The course of secondary dementia is from bad to worse : it is impossible that recovery should take place, although the condition and habits of a patient may be much improved by proper care. Those who suffer from acute primary dementia get well generally ; but, of course, senile dementia, though primary, is beyond the reach of remedy. Death may be due to eflusion on the brain, or to atrophy of it, or it is produced by accidental disease, as tubercle or pneumonia. Dementia is the only form of Insanity in which the aver- age temperature is below that of health. Moral Insanity. — Under this unfortu- nate name,' Dr. Prichard described cases of real mental disorder, in which, without hallucination, illusion, or delusion, the derangement is exhibited in a perverted state of those mental faculties which are called the active and moral powers — the feelings, affections, propensities, and con- duct. He never meant that a vicious act or crime, however extreme, should be deemed proof of moral insanity ; for he expressly insists on tracing the disorder to certain recognizable causes of disease. "There is often," he says, "a strong hereditary tendency to Insanity ; the in- dividual has previously suffered from an attack of madness of a decided character ; there has been some great moral shock, as a loss of fortune ; or there has been some severe physical shock, as an attack of paralysis or epilepsy, or some febrile or inflammatory disorder, which has pro- duced a susceptible change in the habitual state of the constitution. In all these cases, there has been an alteration in the temper and habits."^ In reality, how- ever this moral insanity is no special form of disease, but a variety of that mental derangement alreadj^ described as affective or pathetic ; and briefly to enumerate the varieties of this affective form of derange- ment, all which were confounded by Pinel under mania sine delirio, will best exhibit the nature and relations of moral insanity. (o) There are attacks of derangement in which the moral or affective alienation is very great, and in which the intellect [• Impulsive Insanity is reasonably pre- ferred by some writers. — H.] 2 A Treatise on Insanity and other Disor- ders affecting the Mind. By J. C. Pritchard, M.D., F.R.S. 602 INSANITY. is only secondarilj' affected through the moral perversion, the patient reasoning very well from the premises of his per- verted feeling ; he has no delusion unless his whole manner of thought in reference to self be called a delusion. Tliese attacks are often associated with epilepsy, which they may immediately precede, as they sometimes precede an outbreak of mania ; or they may occur at periodical intervals for months before actual epilepsy, and sometimes take the place of the true epileptic seizure afterwards ; or again, the epileptic tits may cease entirely, and he followed by such attacks of profound moral derangement, occurring at uncer- tain periods, and perhaps passing into dementia. It is important to bear in mind that when associated with the epileptic neurosis they represent a con- dition in which vivid hallucinations and irresistible impulses of a desperate kind, homicidal or suicidal, are apt to arise in- stantaneously ; that they, in truth, em- brace the most dangerous forms of the so-called impulsive insanity — the mono- mania instinctive of Esquirol. (6) There is the melancholic depression of the affective life already described — simple melancholia, in which the anguish ri^L-s to such a pitch as to issue in an ex- plosion of convulsive violence, homicidal or suicidal, no fixed delusion being pre- sent. Some of the cases of so-called im- pulsive insanity are examples of this form of disease. (o) The moral insanity proper of Pri- chard (nwiiomanie raissonnante, Esquirol) occurs in most instances as the result of hereditary taint, aggravated or not by unfavorable conditions of life. It is a more advanced stage of degeneration than that which has been described as the in- sane temperament, but it does not reach actual intellectual derangement : the moral feeling being the highest acquisi- tion of human culture in the course of de- velopment through the ages, its loss is one of the earliest effects of degeneration. Moreover, it will always be necessary to consider the social condition of any one suspected to have moral insanity, inas- much as it is in the loss of the social feel- ing by reason of disease that the alienation essentially consists. If a person in a good position, possessed of the feelings that be- long to a certain social state, does, after a cause known to be capable of producing every kind of Insanity, undergo a great change of character, lose all good feelings, and from being truthful, temperate, and considerate, become a shameless liar, shamelessly vicious and brutally perverse, then it is impossible not to see the effects of the disease. Friends and relatives may remonstrate with such a one, and punish- ment may be allowed to have its due course ; but in the end both friends and every one who has to do with him must confess that he is the victim of disease — that his proper place is not the prison, but the asylum. Such moral alienation may occur after previous attacks of Insanity, after acute fevers, after some form of brain disease, or after injury to the head. After an attack or two of melancholia with sui- cidal tendency, from which recovery has taken place, the patient is perhaps attacked with genuine moral insanity, which ulti- mately passes into intellectual disorder and dementia. Or there has been more or less congenital moral defect, and mani- acal exacerbations of actual moral insan- ity, without positive intellectual disorder, take place, dementia following aftera time; these outbreaks may occur at puberty, or at the menstrual periods. A moral in- sanity again is in some instances the first stage of mental degeneration that is pro- duced by self-abuse or sexual excesses : it now and then occurs in consequence of a severe moral shock, as the forerunner of more marked Insanity ; and it not unfre- quentl}' precedes general paralysis. If the evidence from its own nature and causation were insufficient, the simple fact that it is often the forerunner of the severest mental disease, might suffice to teach the right interpretation of moral insanity. (fZ) There are certain beings who are truly moral imbeciles, the original defect being due, as in idiocy, to some cause act- ing either before birth, or during the first years of life. With such moral defect there is often associated more or less intel- lectual imbecility, though not always plainly so ; it is remarkalDle indeed what an acute intellect may sometimes coexist with an entire absence of the moral sense. Some of the notorious gaol-birds amongst the criminal classes belong to this group ; and in higher social spheres there are now and then met with unhappy creatures who, from their earliest years, have been ad- dicted to lying and stealing, or every sort of vicious act — who have been expelled from school after school, the hopeless pupils of many masters, and who finally end in an asylum. They are instinctively vicious or criminal, exhibit a complete moral insensibility, and commonly mas- turbate ; and they sometimes decline into mania and dementia. Here, then, may conveniently be sum- med up in groups, according to their most prominent symptoms, the various forms of Insanity described, idiocy and general paralysis, which yet remain to be described, being added ; — FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 603 I. Affective or Pathetic Insanity. 1. Maniaaxl perversion of the affective life. Mania sine delirio. 2. Melancholic depression, or Simple Melan- cholia. 3. Moral alienation proper; approaching which, but not reaching the degree of positive insanity, is the insane tempera- ment, or the neurosis spasmodica. II. Ideational Insanity. 1. General: 1 Acute. Chronic. Recurrent. b. Acute Melancholia. 2. Partial: a. Monomania. b. Melancholia, Lypemania, 3.De— •ajf"^ 4. Idiocy. 5. General Paralysis. In making use of this or any other pro- visional classification of symptoms, it should be clearly understood that the forms of Insanity are not actual pathologi- cal entities, but different degrees or kinds of the degeneration of the mental organi- zation — in other words, of deviation from healthy mental life : and they are conse- quently sometimes found intermixed, re- placing one another, or manifested in suc- cessive order in the same individual. There is a strong propensity not only to make divisions in knowledge where there are none in nature, and then to impose the divisions upon nature, making the reality thus conformable to the idea, but to go farther than that and to convert the generalizations from observation into posi- tive entities, and then to permit these creations to tyrannize over the thoughts. A typical case of madness might be de- scribed as one in which the disorder, com- mencing in emotional disturbance and ec- centricities of actions — in derangement of the affective life, passes thence into melan- cholia or mania, and finally, by a further declension, into dementia. This also is the natural course of mental degeneration proceeding unchecked through genera- tions. The necessity of describing differ- ent forms of Insanity under different names should never lead to a neglect of the real relations which they have to one another as different stages of deviation from that mental life which we agree to regard as ideal or typical. Idiocy. — It is an arrest of mental devel- opment by reason of some defect of cere- bral development which is either congeni- tal or occurs soon after birth. It will not appear strange that such defect is not al- waj's detectable when we reflect that the development of the brain as the minister- ing organ of the mental life really takes place after birth, and that an arrest there- of would take place within the recesses of the intimate activity of nervous element to which our senses have not gained access —where the subtlety of nature yet far ex- ceeds the subtlety of human research. Marked imperfections of the brain are un- doubtedly often met with in idiots. It is sometimes abnormally small, the general arrest of growth being due either to some condition of defective bodily nutrition, or to a premature ossification of the sutures of the skull and a consequent prevention of the growth which normally takes place actively during the first years of life. While it may be that there is no other defect than the abnormal smallness, it happens much more frequently that there are other anomalies, as hydrocephalus, unequal size of the hemispheres, and defi- cient development of the convolutions. All degrees of unequal size of the hemi- spheres have been met with, from that slight difference which is natural, to that extreme degree where a whole hemisphere has been replaced by a meshwork filled with fluid. Again, there is scarce a par- ticular part of the brain which has not occasionally been found wanting : the corpus callosum may be defective or ab- sent ; there may be a deficient develop- ment of the anterior lobes, and a simplicity of the convolutions, such as belong to the lower animals ; or the posterior lobes may not extend far enough back to cover the cei'ebellum, as normally they do not in some monkeySj and in all the animals below them. Chronic hydrocephalus, apparent- ly primary in some cases, but in many others secondary to the atrophy or defect of brain, is frequent in idiots, and some- times makes them large - headed ; the serous fluid may exist in large quantity within the ventricles without being fatal, and death ultimately occur suddenly from a slight increase of it.' Sclerosis of the brain-substance often accompanies atro- phy, or defect of development. The irregularities of the skull in idiocy have been much studied of late. When the development of the brain is simply arrested, the growth of the bone may be arrested also, and then the skull is micro- cephalic. More often it would appear that owing to some constitutional defect of nutrition the arrest of the growth of the bone is primary, and a premature clo- sure of the sutures takes place, whence follows a narrowing or shortening of the ' On Serous Effusion from the Membranes and into the Ventricles of the Brain, by John Sims, M.D. ; Med.-Chir. Trans, vol. xix.— Clinical Notes on Chronic Hydrocephalus in the Adult, by S. Wilks, M.D. ; Journ. Ment. Science, January, 1865. 604 INSANITY. skull. Compensating enlargements there- | upon take place in some cases, the growth of the brain being in the direction of least resistance, and increasing the cranial de- formity though making the mischief less. According to the suture prematurely closed, and to the amount and character of the compensating enlargement, will be the degree and kind of the deformity, of which many kinds have been described. Virchow has investigated with great care what he calls the tribasilar synostosis, •which, occurring at the base of the skull, is the anatomical condition of the skull of Cretinism. The causes of idiocy are sometimes traceable to parents. Frequent inter- marriages in families lead to a degenera- tion that manifests itself in deaf mutism, albiuoism, and idiocy; parental intemper- ance and excess, according to Dr. Howe,' occupy a high place as causes ; and the natural term of Insanity proceeding un- checked through generations is, as MoreP has shown, sterile idiocy. During foetal life great fright or mental agitation in the mother, or irregularities and excesses on her part, may lead to mental defect in the child. But perhaps the most frequent causes of an arrest of mental development are those which operate after birth up to the third or fourth year : they are epi- lepsy, the acute exanthemata, perhaps syphilis, and certainly conditions of bad nutrition, such as are produced by over- crowding, dirt, and want. Cretinism is an endemic idiocy arising out of unknown territorial conditions. The extremest idiots are destitute of any intelligence whatever ; they are apa- thetic, torpid beings, having a human semblance, whom it is necessary to feed, to move, to clothe, to take care of in every particular ; who can attend to nothing, and remember nothing ; who cannot speak a word ; who grunt, make unintelligible sounds, and are unquiet if their appetites are not satisfied, or mechanically continue some automatic movement of hand, head, or body. The senses are almost invaria- bly defective or wanting, the sensibility of the skin being commonly very imper- fect, the hearing feeble, and smell and taste so deficient or perverted that the most acrid or filthy matters are eaten with indifference. The muscular devel- opment shares in the general defect; there are cramps of the limbs, contractions or paralysis of certain muscles, and epileptic convulsions. In Scotland there were, five years ago, 22.36 imbeciles and idiots, of wdiom 4.3 were paralytic, 46 hemiplegic, 10 paraplegic, 17 choreic, and not less ' Report on the Causes of Idiocy. 2 Traite dea Deggngrescenoes physiques, intelleotuelles et morales, de I'Espfeoe hu- maine, par Dr. B. A. Morel, 1857. than 207 epileptic' In less extreme cases there is e\'ident want of power over the muscles ; the walk is" staggering and un- certain, the eye rolls vacantly, strabismus is common, the speech is defective, and there is slavering at the mouth. Sexual power is absent in the worst cases, and notwithstanding the self-abuse practised by some idiots, feebleness is in all cases more common than excess. At the other end of the scale stand the so-called imbeciles, the highest of whom are only a little lower than those simple- minded people not deemed imbecile. The diflereuce again between imbecility and idiocy is only one of degree, so that it is impossible to define it. In all sorts and conditions of idiocy two principal types may be broadly distinguished : one em- bracing the torpid and apathetic beings, who have usually some bodily deformity, and who give feeble signs of life ; the other, those lively and excited beings who, rarely observably deformed, are un- quiet and restlessly respondent to a rapid succession of impressions, who shriek, laugh, weep, gesticulate, clap their hands, get into mischief, and sometimes pass by a turbulent declension into true maniacal fury. Even the quiet idiots are occasion- ally liable to sudden attacks of fur}', in which they bite, shriek, scratch, kick, beat their heads against the walls, and in other ways act viciously enough. Spe- cial talents or aptitudes of a remarkable kind, for remembering, for drawing, or for music, which seem quite inconsistent with the general character of their intel- ligence, are sometimes exhibited by idiots whose disease is of hereditary origin. Esquirol divided idiots into three classes, according to the condition ol speech. The first division included those who could use words and short phrases ; the second, those who could only utter monosyllables and certain cries ; the third, those who had neither speech nor monosyllable. Dr. Hack Tuke^ proposes a physiological division of them into, first, those who exhibit only reflex or ex- citomotor movements ; secondly, those whose acts are sensorimotor and ideomo- tor ; and thirdly, those who manifest vo- lition. It is a division which, not perhaps practically available, serves to mark the different degrees of degeneracy. By Grie- singer, idiots are grouped in certain types : 1. Well-formed children in whom the mental development, which remains at the lowest grade, is the only apparent de- • The Psychology of Idiocy ; Journ. Ment. Science, April, 1865.— Epileptics : their Men- tal Condition, by W. A. F. Browne, Commis- sioner in Lunacy for Scotland ; Journ. Ment. Science, October, 186.'). ' Manual of Psycholoccical Medicine, by Dr. Bucknill and Dr. D. Hack Take. FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 605 feet, the defect not being due to any hereditary, but to some aucidental cause of degeneration. 2. The cases in which both bodily and mental development have been palpably arrested : these are the dwarfs in mind and body. 3. The Cretin, or basilar-synostotic type of idiocy or im- becility. Cretinism generally manifests itself a few months after birth, and is frequently associated with bodily de- formity and goitre ; and it is supposed to be due" to some miasmatic influence pri- marily affecting the growth of the bones of the skull. It is most common amongst the mountains of Switzerland, but is met with sometimes in badly-drained places, and now and then sporadically. 4. The Aztec type, consisting of the true micro- cephalic idiots. 5. The theroid idiots, who have a sort of resemblance to some animal. Pinel, for example, gives a striking account of an idiot who was very like a sheep in habits and manner ; and some idiots irresistibly bring to mind the monkey. Still, however degraded an idiot may be, he never really reverts to an animal type ; for he represents a new and morbid variety, which but for the fostering care of higher beings, would speedily be extinguished. Tliough idiots can never reach a nor- mal development, their condition in many cases may be much improved by perse- vering training. The faculties which they do possess may thus be brought out in a remarkable manner, and they be made automatically skilful in certain tasks. When epilepsy has coexisted with the idiocy, and has afterwards disappeared, marked improvements may take place. Idiots very seldom attain old age ; they are " old in their youth, and die ere mid- dle age," apparently from lack of vitality. In some cases, the disease of brain — atro- phy or hydrocephalus — directly leads to death. General Paralysis. — It is a form of In- sanity, first described by Bayle and Cal- meil, which is characterized by a progres- sive diminution of mental power, and by a paralysis which gradually increases and invades the whole muscular system. It is far more frequent amongst men than women, and its most frequent cause is in- temperance of some kind. Two of the best marked examples of this disease which I have seen, occurred, however, in teetotallers, who never had been given to alcoholic excess ; but in both there was hereditary taint, and in both there was reason to suspect enervating, though marital, sexual excess. Much discussion has taken place as to whether the mental symptoms precede the paralytic phenomena, or whether the latter first appear — whether the Insanity is primary, or whether, as Baillarger holds, the paralysis is the primary and main aft'ectiou, the Insanity secondary and accessory. There can be no question in the minds of those who, unbiassed by any theory, simply observe cases, that the mental disorder does sometimes ap- pear simultaneously with the motor dis- order ; that far more frequently, indeed most frequently of all, the mental symp- toms are observed some time before there is any trace of paralysis ; but that in some few cases the paralytic phenomena do precede by a short period the mental symptoms. In fifty-one cases out of eighty-six observed carefully by Par- chappe, he found the paralysis and mental disorder to be simultaneous ; in twenty- seven cases the paralysis was subsequent, and in eight the precedence was undeter- mined. Leidesdorf has related one case in which the earliest sjmptoms were spinal ; and one or two similar cases have been recorded.' The motor symptoms are first witnessed in the tongue, which has to execute the most delicate and complex movements with so much precision, and especially in the articulation of words abounding in consonants, where the most complex co- ordination is required. When the patient speaks earnestly, he does not articulate exactly, and there is a certain pause or indecision detectable in his utterance, as if there was some difficulty in bringing out the word ; in some cases the speech is slower, more deliberate, with a strong ac- centuation of and a lingering on the syl- lables, as if the patient were speaking with great consideration. When the tongue is put out, which is done with some difHculty, there is a fibrillar quiver- ing or trembling of its muscles, but it is not pulled to one side. There is a tremu- lousness, also, in the muscles of expres- sion when put in action — especially in those of the lips, which quiver as in one just about to burst into tears. These, phenomena, which are of fatal omen, may not be apparent at first, when the patient is calm and collected ; but if he has had a sleepless night, or if he is much excited from any cause, then they become evi- dent. An inequality in the size of the pupils is often an early symptom, but it is not a characteristic one ; it is some- times present in other forms of Insanity, and it is not always present in general paralysis. A transitory squint is observed occasionaDy at the commencement of the disease, and at a later period a slight ptosis of the upper eyelid. As the dis- ease increases, the patient's walk becomes affected : the feet are not properly raised and firmly put down on the ground ; he easily stumbles at a step or on uneven ' Beitragezur Diagnostik der Geisteskrank- heiten. Von Dr. M. Leidesdorf. 606 INSANITY. ground, and if asked suddenly to turn round when walking straight forward, he will stagger like a drunken man. He may nevertheless be very active in walk- ing, and commonly thinks himself won- derfully well and strong. Precise co- ordination of movement, such as is neces- sary for writing, sewing, and like acquired automatic acts, is lost. The disease still advancing, the articulation becomes less distinct, the walk more and more totter- ing ; the knees fail : the patient frequently tumbles, and finally cannot get up again without help. At last the primary auto- matic or reflex movements fail ; the pu- pils become dilated, but unequal in size ; the sphincters lose their power, and the patient may be choked by a lump of food getting into his larynx. Sometimes there are transitory contractions of arm or leg, and a grinding or gnashing of the teeth is not uncommon. The contractiUty of muscles to the electric stimulus is re- tained. Cutaneous sensibility is usually dimin- ished in the early stages, and at a later period it is sometimes lost. Yet there are occasionally transitory conditions of extreme hypersesthesia, so that the pa- tient shrieks out in great agony, or the slightest touch produces reflex movements or even convulsions. The muscular sense is especially affected, so that the sufferer, deprived of power of executing all com- plex and delicate movements, deems him- self not less skilful than when at his best state, or, quite paralyzed, believes himself to have a giant's strength. The special senses are connnonly unaffected until near the end, when smell and taste are dimin- ished or lost, and vision fails. Sometimes, however, the patient has vivid hallucina- tions in the night : there were glorious visions of angels descending from heaven on ladders of gold in one patient under my care, and an agonizing vision of his own wife in the act of adultery rendered another frantic for a time. A great in- crease of sexual desire and an" excited display of it are not unfrequent at the beginning of the disease, but there is not corresponding power ; and what power there may be is soon quite lost. The mental derangement is commonly marked by an exaggerated feeling of per- sonal power and importance. After a brief stage of melancholic depression there is a notable change in the character, man- ifest in different ways : in one there is great mental excitement, and he is joy- ously and actively busy with wide-sweep- ing projects and speculations, indifferent to stern realities, and in all ways eager and ready to accomplish the impossible : in another there is a lack of former energy, and he is painfully troubled about little things, dull and confused in his thoughts. and demented in behavior ; while another exhibits unwonted perversities of feeling and conduct, such as mightily astonish his friends ; he breaks out into sexual ex- cesses quite foreign to his usual sober character, or orders numerous articles of jewelry for which he can never pay, or even steals what strikes his fancy. Begin as it maj', the mental disorder, when un- checked, generally issues in incoherence and extravagant delusions as to personal power and grandeur : the miserable suf- ferer who can scarce support his tottering body avers that he has the might ana vigor of Hercules ; while industriously hoarding up pieces of rag, paper, or glaps as articles of value, he will sign a check for countless millions, or make an easy present of New York ; maintaining that he can command a king to do his pleasure, in the same breath he prays piteously to be allowed to go to his own humble home ; or, with sexual power extinct, boasts exultantly that a princess shall be his wife and princes be born of his loins. An extreme loss of memory is in striking contrast with the semblance of exaltation ; the patient forgets entirely how long he has been in confinement, or denies angrily that he has a wife, though recognizing her gladly when she visits him. In some cases the delusions are of a terrific charac- ter and accompanied with great emotional depression ; and a day of melanchohc de- pression may now and then intervene in the course of the exalted form. There is a class of patients who present In physi- ognomy and habit of body a mixture of stupidity and the deepest depression, and exhibit sad delusions of as extreme a character as the delusions of grandeur : they think themselves bodily transformed in whole or in part ; that their body has been immensely enlarged, that their eyes cannot see, their ears cannot hear ; that their throat is sealed up. Dr. Cloustnn has pointed out that there is an intimate relationship between this form of general paralysis with depressions and tuberculo- sis. In another variety, of rare occur- rence, the mental disorder consists in a regular decline of intellisjence — a gradu- ally increasing stupidity from the first. Attacks of great excitement and blind violence frequently occur during the pro- gress of the disease. During them L. Meyer has observed the temperature of the head to be raised, and after them the mental decay is found to have increased. As the disease approaches its end— the end of life — the dementia is extreme, and the face becomes an expressionless mask across which now and then flickers the broken ripple of a smile, or it is fixed in a ghastly, sardonic grin ; but even in the last stage of mental disorganization, when the capability of a distinct delusion is DIAGNOSIS. 607 gone, the muttered words are oftentiiiies about golden carriages and millions of money. ThecoMrse of general paralysis is towards death, though not steadily so. Undi-r proper treatment a great improvement takes place in the early stages, and the disease seems to be arrested. Some have thought that actual recovery does now and then take place ; and certainly there have been in exceptional cases intermissions of such a length that the disease has lasted for ten years. On the whole, however, it is irregularly progressive, its duration being usually from a few months to about three years. It hardly ever occurs before the age of thirty. In the more advanced stages sudden attacks of loss of conscious- ness, with epileptiform convulsions, are not unfrequent, after which the paralysis and mental decay are both found to have increased. Dr. Saunders has observed that the temperature of the body in gen- eral paralysis is generally one or two degrees below the average, but that it rises during the excesses of maniacal ex- citement, falling again as calmness re- turns. During the so-called congestive attacks, again, where there is complete coma or epileptiform convulsion, there is generally a considerable rise of tempera- ture : in one case the temperature was for some time 98°, but it rose an hour after one of these attacks to 105°, and next day to 106°, the patient dying in thirty-six hours from the commencement of the at- tack. ' Dr. Clouston has found that in general paralysis there may be a dilfer- eaco of 5 '8° in the same individual ia different stages of the disease. In the last miserable stage of all, when life flickers before extinction, large sloughing bedsores form, notwithstanding the best care, and diarrhoea or pneumonia hastens the long-expected ending. Diagnosis.— The diagnosis of Insanity is as difficult in some cases as it is easy in others. Acute mania cannot well be con- founded with any other disease, and the only doubtful question in regard to it will be in the event of an impostor attempting to simulate it. He must be a clever im- postor, however, who can simulate the wild restless eye, the quick fragmentary associations of ideas, the rapid capricious movements, and the volubility of utter- ance of acute mania, so as to deceive an experienced observer ; nor can he, how- ever skilful, pass days without sleep, and even weeks with only a few hours' sleep, maintaining a constant activity the while, as the maniac does. The skin in acute mania is dry and harsh, or clammy, but the skin of a pretender who tries to keep ' Report of the Devon County Asylum for 1864. up the muscular agitation will hardly fail to be hot and sweating. Meningitis will be known from mania by its own positive symptoms, — by the premonitory rigors, when they occur, the cephalalgia, the fever, the contracted pupil, and" tlie in- tolerance of Hght ; by a muscular activity, paroxysmal, hot continuous, and by fre- quent spasms or convulsions ; by the acute severity of the delirium and the vivid illusions of the senses ; and by its rapid progress either to recovery or death. Deliriuintreme-ns will also be distinguished by its characteristic symptoms — the mus- cular tremors, the peculiar fearful illusions and hallucinations, the cold skin, feeble pulse, and white and tremulous tongue. It must not be forgotten, however, that persons who have a strong predisposition to Insanity, or who have been insane, or who have suffered at some time from a severe injury to the head, do sometimes after an alcoholic debauch become truly maniacal for a time. In this condition, which may be of short duration, dan- gerous hallucinations sometimes arise, and the sufferer may perpetrate crime, not knowing afterwards what he has done : of this fact a searching investigation of in- stances can leave no doubt. The result again of continued intemperance, or of a long debauch, is sometimes to produce, not a delirium tremens, but a true mania, marked by active and violent delirium. Chronic mania is the most likely form of Insanity to be feigned, and if feigned with the skill of Hamlet, the very elect may be deceived. A vulgar impostor will, however, generally " o'erstepthe modesty of nature," and overact the part in the extravagance of what he says, and in the absurdity or violence of what he does, while he will almost of a certainty fall short of his part in the emotional expres- sion of the maniacal countenance. Hav- ing the popular notion that a lunatic is widely different from a sane person, he will entirely fail to understand the char- acter which he wishes to represent, so that an experienced person may detect his ignorance ; and believing that he must make a great display in order to produce an adequate impression, he will, like a bad actor, exaggerate and rant, so that any one with "insight, though without special experience, may discover his in- competency. He will pretend that he cannot remember the simplest things, that he cannot reckon correctly, and will act extravagantly, and answer stupidly or wronijly, when a real lunatic would act calmly and answer intelligently or rightly ; he will moreover show no irritation or anger at the suspicion of his sanity. It may not be amiss to suggest incidentally in his hearing some symptoms which he ought to exhibit, and to take notice I whether he subsequently adopts the liir.t. 608 INSANITY. If he refuses to converse, feigning apathe- tic dementia with dirty liabits, whicli is perliaps tlie form of insanity most often feigned, tlie diagnosis becomes more diffi- cult, and a long observation may be neces- sary in order to establish it. It is truly astonishing how long an impostor will sometimes persist : one man, whose story Dr. Bueknill tells, kept up the pretence of Insanity for more than two years, and then broke down in his part. The two important considerations to be kept in view are, first, the existence of any motive for feigning, and secondly, the consistency or inconsistency of the symptoms with a definite form of mental disease. Perhaps it would not be far from the truth to say that he who can feign madness so com- pletely as to deceive an experienced ob- server, is not far from being the character which he represents ; for unless there be real madness beneath the feigned phe- nomena, there will be some want of coher- ence in them as a whole, and an incon- gruity with any recognized form of men- tal disease. The discovery of chronic mania or mono- mania where it does exist, hut where the patient is suspicious and strives to hide it, may be a very difficult task. There is generally some sign of the disease in the countenance and bearing of the patient : " The principal characteristic in some is," says Dr. Bueknill, "a peculiar want of harmony in the expression of the fea- tures : in others, the fixed expression of some intense emotion is remarkable — of defiant pride, of sullen obstinacy, of smirk- ing vanity, or of leering sensuality." The demeanor may be defiant, sullen, restless, or absorbed, and the clothing untidy and neglected : in both demeanor and dress there are sometimes peculiarities which, when bottomed, open up a secret mine of madness. To detect any delusion the pa- tient should be examined carefully on all matters intimately touching himself, any- thing peculiar or notable in his expres- sions or any obscure references, being watched for, noted in the mind, and sub- sequently quietly followed up. If he seems to pass hastily over, or to avoid, some subject, he should be unobtrusively but steadily pressed upon it ; and if he declines to speak of the matter, or gets angry, the refusal or irritation is alike significant. All this should be done in as quiet and amiable a manner as possible, ST as to avoid giving unnecessary offence, and to make it a difficult matter for the patient to take offence and break off the interview. It is an intellectual contest between a sound and an vmsound intel- lect, in which the weakness of the latter is compensated by its acting on the defen- sive, the superiorityof -the" former lessened by its acting on the offensive. Ileinroth has affirmed, what is popularly thought. hat though the insane may often cmiceal their delusions, they cannot deny them. This is by no means true of all eases ; some will deny their delusions with as much energy as Peter showed when he denied the dangerous truth, or will even labor to explain them away as jokes. When all else fails, it may be worth while grievously to offend the patient's self-love, and to make him extremely angry, and in the fury of passion he will sometimes, notwithstanding his suspicion, reveal the hidden delusion. Failure will be rare with the expert who likes to be persistent and patient enough. In doubt- ful cases, it will always be well to get the patient to write, for it is truly surprising what extravagant delusions may be ex- hibited in a letter by one who manages to conceal them in conversation. Careful research should of course be made into the previous history, in order to discover whether there is hereditary taint, and what degree of it ; whether there has been any previous attack of Insanity, and whether there has been any observed change of feelings, character, and habits, especially after some efficient cause of Insanity. At the outset a patient some- times has a suspicion that he may be thought mad, and is very earnest and vehement in accounting for his morbid feelings, and at great pains to convince those around him that he is not mad.' Melancholia is not usually difficult to recognize, as patients in most cases do not care to conceal their painful delusions ; still there are some who do not only con- ceal but deny them. A patient afflicted with homicidal and suicidal impulse, and intensely miserable in consequence, will positively conceal and deny the morbid impulse, in order to throw those around off their guard and the better to effect his purpose ; and more than one such, fool- ishly removed from under control by ignor- ant but well-meaning friends, has after- wards committed suicide or homicide, or both. Another, who cannot entirely con- ceal his disease, will even attribute his depression to the confinement which he is undergoing, and asseverate most earnestly that he will be quite well at home ; this intense eagerness to be delivered from control being truly the surest sign that he is not fit to be from under control. In all such cases it is necessary to watch pa- tiently from day to day ; iror it will some- times happen that a delusion, denied on one day, is predominant on another, and it is very apt to become so, if the patient does not see a prospect of release through his simulation of sanity. ' There are some excellent observations hy Dr. Bueknill in the Manual of Psycliological Medicine, on the mode of conducting the ex- amination of an insane person, p. 310. DIAGNOSIS. 609 It may be important to distinguish be- tween the hypochondriac and the melan- cholic, as the former, committing a mur- der, would certainly be hanged, the latter probably not. The hypochondriac refers his sufferings to some organic disturbance or disease, in which there may be more or less reality ; he displays an exaggerated sensibility in regard to all his organic pro- cesses, or to some one of them in particu- lar, so that he has either many delusions respecting his health, or his whole habit of thought respecting it is perverted ; he is fond of talking of his sufferings, and of consulting medical men ; he e\'inces a great love of life, and no disposition to commit suicide ; his intellect is sound, and his feelings are not perverted, apart from questions" touching his health. The mel- ancholic, on the other hand, refers his sufferings to some groundless extraneous cause, either operating from without, or having taken possession of body or soul, or both, so that he has frequently a single and fixed delusion ; his anguish is a men- tal anguish, and he asserts that medi- cine can do him no good ; he is often suicidal ; his affective life is profoundly implicated, and he is incapacitated from intellectual activity, though there may be no marked intellectual derangement apart from the delusion. It must not be over- looked, however, that hypochondriasis may pass into true melancholia, as well as coexist with it, and that a true hypo- chondriacal melancholy may rise to such a pitch as to render the individual irre- sponsible for his actions. Melancholia with stupor may easily be confounded with acute dementia ; nor is it always possible to distinguish them at the outset. The expression of the melan- cholic is that of one astonied, or as if fixed in a painful trance — the mind veiled, as it were, by a great cloud let down between it and the external world. The patient stands or sits in one place, or moves slowly to and fro ; he often offers a pas- sive resistance to being moved, or to being fed ; sometimes he exhibits a strong tendency to suicide, and, now and then, a temporary excitement ; on recovery, he remembers his suffering as a painful dream, or as a strange and fearful trance, during which he was partly conscious of things around, but unable to express him- self. In dementia, the countenance is expressionless ; there is no resistance to being moved, or to food ; the patient is not suicidal ; the bodily functions are less affected ; on recovery, there is no memory of the attack. In certain criminal or civil trials, it may be necessary to distinguish between eccentricity and Insanity. There is a great gap between them : the truly eccen- tric man has a strong individuality, but little vanity ; he has broad and original VOL. I.— 39 views, and great moral courage ; he is emancipated from vulgar prejudice, and heeds not much the world's blame or cen- sure ; he difters from the majority per- haps because he is in advance of the hab- its and superstition's to which it is in bondage ; and he is not at all likely to become insane. But there is a weak affec- tation of eccentricity which is very apt to end in Insanity: with it are infected certain feeble-minded beings, often badly bred or badly trained, who are empty of any true individuality, but inflated with an excessive vanity ; who have a small intellect which the^' use in the service of their passions ; who do silly and eccentric things, not unconsciously as the spontane- ous expression of their nature, but out of a morbid craving to attract attention ; who represent a condition of mental de- rangement that is the forerunner of In- sanity ; who, when they are not given up to sexual excesses, are often masturbators. In the diagnosis of so-called moral in- sanity, it is necessary to look for a suffi- cient cause of mental disease from which the vicious or violent acts may be logically traced through a train of symptoms, such as marked change of character, feelings, and habits. Neither vice nor crime, how- ever extreme, is proof of Insanity. To be so, it must be proved through a chain of morbid symptoms to flow not from pas- sion, but from disease ; and attention should not, therefore, be entirely occupied by it, but should carefully traverse the whole affective life, in order to reveal the perversion of nature detectable in a case of real moral Insanity, and the connection of the morbid change with an efficient cause of disease. A man may get into the police-court for stealing, in whom one may perceive instantly the earliest symp- toms of general paralysis ; another may commit murder, apparently without mo- tive, or from a very inadequate motive, in whom a melancholic anguish has risen to a convulsive explosion ; and a third may perpetrate violence in a state of affective derangement, which skilled observation recognizes to be premonitory of, or vicari- ous of, an attack of epilepsy. When it is a question of the existence of an irresistible impulse in any caae of homicidal or other kind of violence, it is very necessary to keep in view the possi- bility of epilepsy, either in the form of epileptic vertigo or in its convulsive form. When an epileptic person has done a murder without discoverable motive, with- out advantage to himself or any one else, without premeditation, without mahce, openly, it is almost certain that he has been driven to the crime by an irresistible impulse. General paralysis is easily recognized after it has passed its earhest stage. ^ It is not always easy of diagnosis before 010 INSANITY. the physical signs appear ; and yet a man may at this stage get into trouble — get into the police-court, or get married fool- ishly — entirely by reason of the disease. It is necessary to weigh carefully the cha- racter of the act, whether it is anywise explicable, or motiveless and quite unac- countable ; to mark well the state of the patient's articulation under excitement or after a sleepless night ; to note his happy and elated mood of mind ; and to attend to the great exaggeration and general ex- travagance of his conversation on all mat- ters concerning himself, even when there is no fixed and positive delusion. General paralytics, in the early stage, speak so ex- travagantly and absurdly regarding things whicli they have seen, or events in which they have been concerned, that an inex- perienced person might be apt to put down the whole as a delusion. It is need- ful to bear in mind that there may be some foundation of fact in what they say of themselves — that they do not at first so much invent as outrageously exaggerate. It is needful also to remember the alter- nations of calmness and apparent sanity which occur in the early course of the dis- ease. The main points to direct attention to are, first, any indications that there may be of altered speech and of loss of memory and mental power; and, secondly, the light in which the patient regards these symptoms when they are pointed out to hnn. If they are positively present, and there is on his part an entire uncon- sciousness of them, or if he laughs at and makes light of them, as is often the case, afliirming that he was never better in his life, then it is almost certain that he is the victim of incipient general paralysis. Pathology. — Though it may be that there are no morbid changes detectable in the brain of one who has died raving mad, it is none the less certain that, with change of energ}', there is a correlative change in the nervous substratum. Nothing is yet known of the intimate constitution of nervous element, or of the mode of its functional action ; and it is beyond ques- tion that the difference in its condition may be the difference between life and death, without any appreciable physical or chemical change. As the means of research improve, however, the instances of Insanity in which morbid changes are not found are more and more rare ; and those who have most studied the matter are those who are most certain and speak most confidently of the invariable exist- ence of such changes. When a morbid poison acts with its greatest intensity, there are notably fewer traces of struc- tural alteration than where its action has been less intense and more prolonged ; and, in like manner, apjireciable organic cbiinges in Insanity may be justly ex- pected only when the degeneration has been extreme and long continued— in chronic mania, in chronic dementia, in general paralysis, and epileptic Insanitv. Where this has been the case, morbid changes are seldom looked for in vain, Investigations into the electrical pro- perties of nerves, and into the phenomena of conduction by them, have not only rendered conceivable the existence of im- portant, though undetectable, molecular changes among their ultimate elements, but have proved the necessity of dismiss- ing all metaphysical conceptions of ner- vous function, and of making positive research into the physical and chemical conditions which, whatever its nature, de- termine its manifestations. So far from conduction by nerve being due to the in- stantaneous passage of some imponderable principle, it depends upon a modification of its molecular constitution, for which a certain time is essential ; for it has been shown that a definite period of time, vary- ing in different persons and at different periods in the same person, is necessary for the propagation of a stimulus from the peripheric ending of a nerve to its central ending in the brain; and when the stimu- lus has reached the brain, a certain time must elapse before the will can transmit a message to the muscles so as to produce motion. No investigation has yet been made of the time-rate of activity of the cerebral centres, but there is assuredly a considerable variation in the time in which the same mental functions are performed by different persons, or by the same per- son at different times. " The mind in health," says Locke, "will boggle and stand still, and one cannot get it a step forward, and at another time it will press forward, and there is no holding it in." Appreciable and variable, then, is the time-rate of thought, and the measure probably of that intimate molecular ac- tivity which is the condition of its mani- festations. That such molecular activity does take place, the " waste" after func- tion proves ; the chemical reaction of nerve becomes acid after activity, owing probably to the formation of lactic acid in the retrograde metamorphosis ; and the increase of phosphates in the urine, and the bodily exhaustion after great mental work, are only to be explained by sup- posing an idea to be accompanied by a correlative change in the nerve-cells. Here, indeed, is a region of most delicate activity, which, like that of thermal oscil- lations, or of undulations of light, is yet impenetrable to sense ; and so far from its being improbable that undetected morbid changes may exist in Insanity, so far from its being wonderful that morbid appearances are sometimes not found, the wonder truly is that they should have been expected always. Where the sub- PATHOLOGY. 611 tlety of nature so much exceeds the sub- tlety of humnn investigation, to conclude from the non-appearance the non-exist- ence of change, would be analogous to the blind man asserting that there are no colors, the deaf man that there arc no sounds. Not only have erroneous ideas been entertained respecting the kind of organic change that might suffice to give rise to Insanity, but the nervous element itself, as a living individual entity with intrinsic properties, has been commonly ignored ; the main stress having been laid upon the bloodvessels, as if tliey were the primary agents in exciting and keeping up the mental disorder. The truth is, that the first step in Insanity often is, as it is in inflammation, a direct change in the indi- vidual elements of tissue, the change in the bloodvessels being secondary. The experiments of Lister' have proved that in the case of mechanical or chemical in- jury to some tissue, the individual elements are directly injured, and that a determina- tion of blood, a dilatation of the vessels, and an adhesion of the corpuscles follow the local mischief; and it is easy to con- ceive that damage to the nervous element of the brain, however caused — whether from overwork or emotional anxiety, or from poison in the blood, or by direct in- jury or reflex irritation — may in like man- ner declare itself in disordered function, and be accompanied or followed by vascu- lar disturbance. The nervous element is brought to a lower state of life, and mani- fests its deviation or degeneration from its normal kind by an abnormal or degenerate energy, while the disturbance of circula- tion takes place as a coincident or sequent effect of a common cause. "Where this is hereditary taint, there is innate vice or defect in the constitution of nerve element, and it will accordingly break down more easily under adverse stress. The effects of strychnia may serve to illustrate the pre- sumed course of events : when a dog is poisoned with strychnia, there may be no morbid appearances ; but if there be any, they are such as congestion of the spinal cord, aneurismal dilatation of the capil- laries, and perhaps small effusions of blood into the gray matter. The congestion is plainly a secondary result of the intense morbid activity of the directly poisoned nervous element. Here, then, is the ab- stract and brief chronicle of the order of events in many cases of Insanity. Trans- fer the convulsive action from the spinal cells to the cortical cells of the hemi- spheres, the result is a violent and acute mania in which the acute determination of blood is certainly not the cause, if it be ' On the Early Stages of Inflammation, by- Joseph Lister, F.R.S. ; vol. xxxi. Philosophi- cal Transactions, 1858. not the consequence, of the degenerate function. In what is called mania transi- toria, the patient falls suddenly into a vio- lent fury, in which he raves and often ex- hibits destructive impulses ; his face is flushed, his head hot, and there is plainly an active determination of blood to the brain ; and in a short time the fury sub- sides,_and the man is himself again, scarce conscious, or quite unconscious, of what has happened. Was the rush of blood the primary and active agent in the pro- duction of the fury ? Was it not rather secondary to the intense morbid or degen- erate action of the nervous centre ; the attack representing a sort of epilepsy, and the congestion taking place not otherwise than as it takes place in the spinal cord poisoned by strychnia ? So in chronic insanity, the congestion discoverable may not be the cause, but the efi'ect and evi- dence of the morbid action of nervous ele- ment. And in those cases of Insanity in which there is no special morbid appear- ance after death, though there has been fixed delusion during life, it is because the definite morbid action which does exist takes place in that innermost region of activity of individual element to which our senses have not yet gained access. Only by fixing attention on the individual ele- ments will a just conception be formed of the mode of that degeneration which re- veals itself in mental disorder, but at pres- ent is not otherwise revealed ; and only thus will the morbid appearances that are met with receive their riglit interpreta- tion. It would be one-sided and mischievous, in another way, to overlook the fact that disturbance of circulation, of extraneous origin, may directly favor and even pro- duce Insanity. Having regard to the ex- treme susceptibility of nervous element, and the abundance of the supply of blood to it, there can be no question that the quantity and quality of the blood play a weighty part in the pathology of Insanity. Quantity and Quality of the Blood. — Since the time of Hippocrates, it has been known that similar symptoms are pro- duced by too much and by too little blood in the brain. In that continued active relation between the blood and the ner- vous element, whereby due reparative material is brought and waste matter carried away, it amounts to much the same thing whether, through stasis of the blood, the refuse is not carried away, nor the supply brought to the spot where it is wanted, or whether the like result ensues by reason of a defective blood or a defi- cient circulation. Now, although tempo- rary irregularities in the cerebral circula- tion may, and often do, pass away with- out leaving behind any abiding ill eflects, yet when they recur frequently, and be- come more lasting, their disappearance is 612 INSANITY. by no means the disappearance of the entire evil ; they are etlicient to initiate a degeneration, -which thenceforth continues of itself and leads to permanent mental derangement. Once the habit of a definite morbid action is fixed in a part, it con- tinues almost as naturally as, under better auspices, the normal physiological action. A vitiated state of blood, by reason of matters bred in it, or introduced from without, may act perniciously on the supreme cerebral cells. The rapid recov- ery which takes place after moderate doses of alcohol, opium, Indian hemp, seems to show that the damage they in- flict is transitory ; but it admits of no question, that when nervous element is repeatedly exposed to their poisonous agency, it acquires a disposition to a de- generate function. The intense gloom produced by the presence of bile in the blood, and the extreme irritability pro- duced by some urinary constituent in the blood of a gouty patient, serve to show what effects upon the supreme nervous centres may be due to the non-evacua- tion of the waste matters of the tissues. When, furthermore, it is remembered that the blood is itself a living, developing fluid ; that, " burnished with a living splendor," it circulates rapidly througla the body, supplying the material for the nutrition of the various tissues, receiving the waste matter of their activity, and carrying it to those parts where it may either be appropriated and so removed by nutrition, or eliminated by secretion — it is plain that multitudinous changes are continually taking place in its constitu- tion and composition, that its existence is a continued metastasis. There is the widest possibility, then, of abnormal changes in some of the manifold processes of its complex life and function, such as may generate products injurious or fatal to the life of nervous element. Poverty of blood undoubtedly plays a weighty part in Insanity, as in other nervous diseases ; and there is, in the efiects of the viruses of acute fevers, ample evidence that mor- bid poisons, bred in the organism, or en- tering it from without, may act in the most baneful manner on the nervous cen- tres. In some cases of malignant typhus, and in the putrid infection after surgical operations, the virus generated is directly fatal to the life of nerve element ; and when it acts with less intensity, it gives rise to the delirium of fever, and predis- poses probably to the Insanity following acute fevers. Beftex Action, or SymiMthy. — The su- preme cerebral centres may — like other nervous centres — suffer secondarily from morbid irritation in some other part of the body ; though why they should do so at one time and not at another, we know not any more than why epilepsy should be caused by an eccentric irritation at one time and not another. That they do so, many recorded instances clearly testify.' When a chronic insanity is brought about in this way, the delusion has sometimes a relation to the primary morbid cause ; the secondary derangement of the cerebral centres testifying to the special effect of the particular diseased organ — as, for ex- ample, when a woman, with uterine or ovarian disease, believes she is with child by supernatural means, or, with morbid irritation of the sexual organs, has sala- cious delusions. There is the most perfect harmony, the most intimate connection or sympathy, between the different organs of the body, as the expression of its organic life — a unity of the organism beneath con- sciousness ; and the brain is quite aware that the body has a liver or a stomach, and feels the effects of disorder in any one of the organs, without declaring it directly in consciousness. This unconscious, but not unimportant, cerebral activity, which is the expression of the organic sympa- thies of the brain, receives its most strik- ing illustrations in the influence on the mind of the development of the sexual organs at puberty, and in their subsequent influence on dreams ; and it is of great weight in the production of morbid men- tal phenomena. A just appreciation of its importance will not fail to teach the lesson which a true conception of the or- ganism as an individual whole, formed of differentiated parts harmoniously co-or- dinated, teaches also, that every organic motion, visible or invisible, sensible or in- sensible, ministrant to the highest aim or to the humblest function, does not pass issueless, but has its due effect upon the whole, and is felt throughout the most complex recesses of the mental life.^ The primary morbid centre, which gives rise to secondai'y derangement by a reflex or sympathetic action, may not be in a distant organ ; it may be in the brain itself A tumor, abscess, or local soften- ing does not interfere with the mental processes at one time, while it produces the gravest disorder of them at another ; and it is not uncommon in abscess of the brain for the mental symptoms, when there are any, entirely to disappear for a time, and then to return suddenly in all ' References to such cases may be found in Griesinger'a work. There is a remarkable case also cited by Dr. Brown-SSquard in his Lectures on the Physiology and Pathology of the Nervous System. 1860. * "Man is all symmetric, Full of proportion one limb to another, And to all the world besides. Each part calls the furthest brother ; For head with foot hath private amity, And both with moon and tides." George Heebeet. PATHOLOGY. 613 their gravity, the derangement or aboli- tion having been clue to a sympathetic or retlex action. Here, then, should be distinguished the different kinds of disorder of the cerebral centres to which a morbid cause may give rise. The sudden appearance and equally sudden disappearance of extreme mental derangement prove that it is functional ; it being impossible to conceive the exist- ence of serious organic change in such case. Although, then, the functional dis- order necessarily implies a molecular change of some kind in the nervous ele- ment, the change may well be one alfect- iag the polar molecules, such as the re- searches of Du Bois Raymond have proved may rapidly appear and rapidly disap- pear. At any rate the induction, by de- finite experiments, of recognizable transi- tory changes, in the physical constitution and the function of nerve, warrants the belief in similar modifications producible by morbid causes which are not artificial, but which are just as abnormal as if they were artificial. The modification of mole- cular constitution, which vanishes at first with the removal of the cause, will not fail, if too great or too prolonged, to de- generate into actual nutritive change and structural disease, just as an emotion which alters a secretion temporarily may, when long enduring, lead to nutritive change in the secreting organ. Excessive functional activity. — The dis- play of function being the waste of mat- ter, it is plain that if there be not due in- tervals of periodical rest, degeneration of nervous element must take place as surely as when directly injured by morbid poi- son, or mechanical irritant, or as surely as a fuelless fire must go out. It is sleep which thus knits up the ravelled struc- ture of nervous element ; for during sleep, organic assimilation restores as statical or ''latent" the power which has been expended in function, or made "actual" in energy. Sleeplessness is, accordingly, one of the troubles following intense men- tal anxiety, or too great mental activity, and forerunning Insanity : that which should heal the breach is rendered impos- sible by the extent of the breach. Like Hamlet, aiccordiug to Polonius, the indi- vidual falls into a sadness, thence into a watch, then into a lightness, and by this declension into the madness wherein he finally raves. To provoke repose in him is the prime condition of restoration ; the power of its " closing the eye of anguish, " and healing " the great breach in the abused nature" of nervous element. [It requires some courage to question, for a moment, the almost unanimous con- clusion of psycopaths at the present day, that Insanity always results from a physi- cal lesion or disorder of the brain. But some cases occur, which (in the absence of a fatal result to allow of actual inspec- tion of cerebral conditions) may, with the greatest probability, admit of a dillerent j explanation. Accepting the fitness of the Prench term, alitiic, any one may be held to be insane who, from any cause, be- comes so "beside himself," so estranged from accordance in his judgment, appre- hensions, motives, and actions with the reahties of the world around him, as to be incapable of what all recognize as sane conduct and conversation. As with mani- festly physically produced Insanity, there may be a close limitation of delusions and consequent actions, to one subject, or group of subjects, in persons who have become subjected to gross and injurious errors of opinion, so as to "believe a lie." Cases of Insanity produced by spiritualism may be named as of this kind. Those so af- fected continue, sometimes, for years, in a state of general health, almost incom- patible with any marked disease of the brain ; and yet obviously much astray in their judgment of facts and conclusions, and often led to do very strange actions in consequence. Superstitions of various kinds may account for similar mental alienations ; as in the instance of a man who took the life of his child, in 1879, in one of the Eastern States, under the be- lief that he was divinely commanded to do so ; his wife and some fellow-believers also justifying his conduct. One of the most distinguished American chemists presented, some time since, a sad instance of spiritualistic derangement in his latter years ; and, more recently, a case perhaps equally remarkable has occurred, in a man in the prime of life, a Superintendent of Public Education in one of the largest cities in America. If, in every such case, it be insisted that there must be a causa- tive lesion or disorder of the brain, such a statement is to be accepted rather as a matter of pathological theory or dogma, than of necessary inference from the facts observed. In some instances, coming under the knowledge of the present wri- ter, the opinion above implied was first suggested by the history of the mental aberration, and afterwards confirmed by the restoration of those affected after a considerable period, simply through their being enabled to find the clue which led them out of the labyrinth of delusion in which their reason was astray. Certainly the diagnosis of brain lesion, in such cases, would have been difficult to make out, on any other ground than that of an axiom in psycho-pathology. — H.] Thus much from a pathological point of view concerning the causation of Insan- ity : it now remains to enumerate the morbid appearances that have been met with in the brain and its membranes. 614 INSANITY. Morbid Anatomy.— The broad i-esult of investigation is, tliat tlie morbid cliauges most constantly met with are sucli as aflfect the surface of the iDraiu and the membranes immediately covering it ; and of these changes, those in the layers of the cortical substance are the principal and essential. The signs of more or less inflammation of the membranes, especi- ally milky opacities of the arachnoid, are common enough in the bodies of those who have not died insane. But there would appear to be some hindrance to intlamma- tion spreading eaisily to adjacent parts that are of different structure, whereas, when they are of the same structure ; it passes readily from element to element of the same kind, as it were by an infection ; the intercostal muscles are scarcely affected in acute pleurisy, the muscular walls of the intestines scarcely affected in peritonitis, and inflammation takes place in the mem- branes of the brain, without seriously im- plicating the cortical layers. If these are involved, there can be no question that the mind suffers. Deaths in the acute stage of Insanitj' are not usual ; but if an opportunity presents itself of examining the brain at this early stage, the morbid appearances are those of acute hypersemia — namely, great injection of the pia ma- ter, with spots of ecchymosis, and more or less discoloration and softening of the cortical layers, which may be separated easily with the handle of a scalpel from the white substance beneath ; the discol- oration being in red streaks or stains, with spots of extra vasated blood, and the soft- ening of a violet or pinkish hue ; the puncta vasculosa of the white substance are also increased. There are no observ- able differences between the morbid ap- pearances met with in acute mania and in acute melancholia ; and though such fact ill agrees with their different symptoms, it is not entirely singular, forasmuch as alcohol makes one man lively and another melancholic. A differential pathology would involve the knowledge of what con- stitutes individual disposition or tempera- ment. It must be confessed that in both mania and melancholia morbid changes are sometimes wanting. The instances of chronic insanity in M'hich no morbid lesions appear are rare: the longer the disease has lasted, the more evident they usually are. There is mostly some degree of thickening or opacity of the arachnoid, which may form a white opaque layer through which the convolu- tions are scarce visible ; and many of the more advanced cases exhibit some degree of atrophy of the brain, especially of the convolutions — these appearing shrunk, pale, and anaemic, or as if some were wanting and replaced by an effusion of clear serum into the subarachnoid space. The atrophic change may be, according to Dr. Wilks, a simple degeneration, or a degeneration associated with the changes resulting from chronic inflammation. The pia mater is at times adherent to the sur- face of the brain, so that there is some difliculty in stripping it off without bring- ing portions of gray matter away with it. This adhesion is not peculiar to general paralysis, as some have thought, though most often met with in it ; for it is now and then found in other forms of chronic insanity, particularly those following epi- lepsy and drunkenness. The ependyma of the ventricles is thickened, and some- times covered with fine granulations, such as have been described also Ijy L. Meyer on the arachnoid and inner surface of the dura mater.' Dr. Wilks has seen a mi- nutely granular condition of the lining of the ventricles, in a case of acute mania ; he has often seen it in epilepsy— once, when the granules were as large as peas, and "the whole surface of the ventricles had very much the appearance of an ice- plant." In some eases, the exudation is in flattened scales or patches.'' The morbid changes most frequent m general paralysis, though in rare instan- ces there are scarcely any detectable, are great adema of the membranes, adhesion of the pia mater to the gray substance beneath, local discoloration or softening of the cortical layers, or superficial indu- ration of them. More or less atrophy of the whole brain, and particularly of the convolutions, is common, and is accom- panied with greater firmness of its sub- stance, enlargement of the ventricles, and serous effusion into them. Diffuse pachymeningitis, effusion of blood into the membranes, or rather into the layers of exudation (Virchow, Rokitansky), and degeneration, atheromatous and calcare- ous, of the arteries, are not unfrequently met with. Though these changes are more common in general paralysis than in any other form of Insanity, they are by no means peculiar to it, nor are they constant in it ; in some cases the evidence of meningitis is most marked, in others that of atrophy.'' A diffuse albumino-fibroid exudation of low form, glueing the membranes to the surface of the brain, has been declared by some to be characteristic of syphilitic in- sanity. Instead of being diffused, the gum-tike exudation, or syphiloma, as it has ' Virchow's Archiv, B. xvii. s. 209. 2 Clinical Notes on Atrophy of the Brain, by S. Wilks, M.D. ; Journ. Ment. Science, October, 1864. ' A compact account of the morbid changes in general paralysis, with exhaustive refer- ences, will he found in a paper by Dr. E. Salomon on the Pathological Elements of General Paresis ; Journ. Ment. Science, Octo- ber, 1862, MORBID ANATOMY. IJlc been called, may be circumscribed so as to form a tumor, and press into the sub- stance of the brain, causing softening im- mediately around it ; or again, it may be met with as a diffuse infiltration or a tumor within the brain, the membranes being unaffected. At the outset it con- sists of an exuberant growth of connective tissue, which afterwards undergoes more or less fatty degeneration ; and it certain- ly has not any character by which it can be distinguished as a specific product. ' Researches have been made into the absolute weight and specific gravity of the brain in Insanity, but they have not been sufiftciently exact. ^ Dr. Skae and Dr. Boyd found the absolute weight to be slightly increased in the insane, the in- crease being greatest in mauia, and least in general paralysis. The specific Gravity is also increased, the lowest specific gra- vity, which is still above the average, occurring in dementia, the highest in epilepsy. Dr. Bucknill observed that the mode of death influenced the results, and found also that the increase of specific gravity was due, in some cases, to a de- posit of an inert albuminous matter amongst the proper nervous elements, and the consequent shrinking of these, — • a condition seemingly not unlike that since described by Prof. Albers as paceii- chymatoiis infarction of the brain, and met with after typhus, in some cases of old In- sanity, and in imbecile children, especi- ally those of a scrofulous habit of body. A fibrinous or albumino-flbroid exudation would appear to be a not uncommon re- sult of the degeneration of extreme In- sanity ; it is the condition probably of the increased consistency, or sclerosis, which is the final result of atrophy ; and it is comparable with the product of what is described as chronic inflammation in other organs, as the liver and spleen. A similar exudation is the cause of the so-called hypertrophy of the brain from which children sometimes die, and which is now ' Des Affections Nerveuses Syphilitiques, par Dr. Leon Gros et E. Lanoereaux, 1861. Ueber die Natur der Constitutionell-syphl- litlsclien Affectlonen, von Rudolf Virchow ; Archiv, B. xv. Das Syphilom, oder Die Con- stitutionell-sypliilitisohe Neubildung, von E. Wagner; Arcliiv der Heilkunde, 1863. Ueber Constitutionelle Syphilis des Gehirns, von Dr. Ludwig Meyer ; Zeitschrift f. Psychiatrle, 1861. Des Affections Nerveuses Syphilitiques; M. Zarabaco. Wiener Medizinal-Halle Zeit- sclirift, February, 1864; Dr. Leidesdorf. Zeit- schrift f. Psychiatrle, 1863 ; Dr. Westphal. ' Dr. Bastlan's recent researches seem to prove that the specific gravity of different parts of the gray matter differs considerably in health. "On the Specific Gravity of the Human Brain;" Journ. Ment. Science, Janu- ary, 1866. and then met with in single cases of In- sanity and epilepsy. The microscope has of late years added something to our knowledge of the nature of the morbid changes in Insanity. The most constant result has been to establish a rank or exuberant growth of connecti\o tissue, and a coincident or sequent decay or destruction of the proper nervous ele- ments, in Insanity of long standing, and especially in general paralysis. The re- searches of Kokitansky and Wedl reveal a more or less diseased state of the capil- laries of the cortical substance in general paralysis ; these exhibit aneurismal dila- tations, and tortuosities varying from a single twist to a more complex twisting and even to little knots of varicose vessels.' Bound the capillaries, small arteries, and veins there is a hyaline deposit of embry- onic connective tissue beset with oblong nuclei ; this afterwards becoming more and more fibrous, so that the vessel may look like a piece of connective tissue, in which granules of fat or calcareous matter ultimately appear. Other products of the retrograde metamorphosis, such as amy- loid corpuscles and colloid corpuscles, are also found in connection with the hyper- trophied tissue, which, whether called in- flammatory or not, is itself essentially the result of a vital degeneration. The degen- eration appears to be of two kinds : first, there is a defective nutrition, a retrograde nutritive process, whereby the vitality not reaching the height necessary for the pro- duction of the proper elements of the structure, there are engendered from the germinal nuclei elements of a lower kind — connective tissue instead of a nerve ; and, secondly, there is a retrograde meta- morphosis of the formed elements of the part— a colloid, fatty, or calcareous de- generation. Be this as it may, there are at any rate three principal stages of the degenerative process: (1), a morbid change in the vessels, whereby there must be a great hindrance to regular nutrition ; (2), atrophy of nerve element, either in conse- quence of the hindrance to nutrition (Eindfleisch^), or from the rank growth of connective tissue (Kokitansky) ; (3), the increase and subsequent retrograde meta- morphosis of connective tissue. Recently it has been asserted by Dr. Tigges, that there is, even at an early stage, an in- crease of nuclei in the ganghonic cells ; the numerous scattered nuclei, usually ' Ueber Bindegewebeswucherung im Ner- vensysteme; Rokitansky, 1857. Wedl, Bel- trage zur Pathologie der Blutgef asse ; Wien, 1859. 2 Hlstologisches Detail zu den grauen De- generation von Gehirn und Euckenmark. Von Dr. E. Kindfleisoh. Virchow's Archiv, B. vi. 616 INSANITY. thought to belong to connective tissue, he cousiclers to have escaped from ganglionic cells at a later stage of their inliammatory degeneration. ' Such changes are not pe- culiar, as .some have said, to general paral- ysis ; like changes have been described by vVedl " in the brains of three congenital idiots, and have been met with in demen- tia following on long-continued Insanity, and in tabes dorsalis ; and there can be little doubt that the morbid product in syphilitic dementia is of a similar nature. Briefly summed up, then, the kinds of degeneration met with in the brain, after Insanity, are as follow : 1. There is in acute insanity an acute hypersemia, or the early stage of iiijlammatory degeneration. 2. There is that degeneration which con- sists in the increase of connective tissue, and in the atrophy of the nervous ele- ments, and which might be called connec- tive tissue degeneration. Whether called sub-inflammatory or not, is not of much moment, so long as we keep in mind the true relations of organic element to the supply of blood, and the degenerate nature of inflammation, whether acute or chronic. 3. Fatty degeneration takes place not only in the small vessels, as in atheroma, and in the new morbid products, but also in the broken-up nervous elements, and even in the nerve-cells. 4. The amyloid de- generation is undoubtedly pathological. Wedl holds that the amyloid corpuscles should be ranked along with the so-called colloid bodies, and viewed as the result of an increased exudation that may take place without hypersBmia. Rind'fleisch, on the other hand, believes that he has traced their production from the nucleated connective-tissue corpuscles ; while some, like Kokitansky, maintain that the gangli- onic cells themselves are converted into colloid bodies. 5. Pigmentary degeneration is sometimes met with. In senile atrophy the ganglionic cells are sometimes richly filled with brown pigment molecules ; and, in one case of dementia, where there was partial paralysis of the tongue, Schroeder van der Kolk found the cells forming the nuclei of the hypoglossal nerves in such a state of blackish-brown degeneration that he at first mistook them for little points of blood, but they were filled with granular, dark-brown pigment. ' Zeitsohrift fiir Psyohiatrie, B. xx. In Virohow's Archiv, 1865, Dr. Franz Mesohede has striven to prove that hyperaemla and parenehymatoug swelling of the inner layer of the cortical substance are the beginning, and fatty degeneration the end, of the organic changes in general paralysis. 2 Histologische Untersuchiingen iiber Hirn- theile dreier Salzburger Idioten. Von Prof. C. Wedl ; Medizinische Jahrbiicher der K. K. Gesellschaft der Aerzte in Wien. 1863. Heft 2 und 3. I Dr. Lockhart Clarke has observed similar I pigmentary degeneration of the cc41s in I general paralysis. It is worthy of remark, that cases of pigmentary degeneration of the retina are often found to occur in the same family, to be accompanied with gen- eral defective development, mental and bodily, occasionally with mutism and Cretinism, and to occur in those who, like albinos, are sometimes the degenerate offspring of marriages of consanguinity.' 6. Calcareous degeneration is common enough in the hypertrophied connective tissue and in the small bloodvessels ; and it has been observed in the ganglionic cells themselves. Erlenmeyer 'met with calcified cells in the optic commissure of a monomaniac ; Fbrster figures calcified cells found in the gray substance of the lumbar enlargement of a boy whose lower extremities were paralyzed ; Ileschl found what he calls ossified cells in the brain of a patient who died melancholic ; and Wilks believes certain bodies, found in the brain of a general paralytic, in whom the small arteries were calcified, to have been ganglionic cells that had undergone calcareous degeneration. Those who duly weigh the pathological import of the kinds of degeneration enu- merated, who reflect on the great gap which there is between a calcareous gran- ule and a nerve-cell in the economy of nature, or between a connective-tissue corpuscle and a nerve-cell in the histo- logical scale of life, must admit that the dift'erence is not less great than that be- tween dementia and sound mental action, and will scarce venture to assert that the morbid appearances throw no light what- ever upon the nature of Insanity. Even the comparatively slight signs of hyper- semia are of weighty significance, if their true relations are recognized, if they are viewed as results and evidence of that degeneration of individual nervous ele- ment, of which the mental disorder is also result and evidence, if they and the In- sanity are viewed as, what they often are, concomitant efiects of a common cause. Prognosis.— Two questions at once present themselves : the first, whether the disease directly endangers life ; the second, and perhaps raore solemn one, whether there is any prospect of recovery. Be- specting the first question, it may be said in general terms that Insanity does cer- tainly reduce the mean duration of life, and much more so in its recent acute forms than in its more chronic forms. Oi' all forms, general paralysis is the most fatal, other varieties not being, as a rule, ' On Retinitis Pigmentosa, by J. Laurence; Ophthalmic Review, No. 5, April, 1865. The observations of Prof. Graefe and Liebreieh are q^uoted. PROGNOSIS. 617 directly dangerous to life. Still, certain cases -of acute mania and acute melan- cholia do terminate suddenly in death, owing probably to exhaustion, and it may be utterly impossible to say beforehand whether they are going to do so or not. When the temperature of the body rises several degrees above the natural stan- dard, the prognosis is bad ; and any indi- cation of motor paralysis, or any kind of hybrid epileptiform convulsion, in the course of the disease, is of evil omen, while an attack of genuine epilepsy, un- favorable as regards recovery, is not so as regards life. A long-enduring refusal of food may sometimes end fatally, both in mania and melancholia. What prospect there is of recovery in a particular case will depend greatly upon the cause of the attack, upon its form, and upon its duration. The more recent the outbreak, the better the chance of reco- very, the expectation of which from proper treatment adopted within three months from the commencement is about four to one, while it is less than one to four after twelve months' duratipa of the disease. Certainly there do occur in- stances in which patients recover after being insane for years, but they are ex- ceptional. When the stage of secondary dementia, incoherent or apathetic, has been reached, all hope of recovery is gone. Primary dementia is generally curable. Of the acute primary forms of mental disease, melancholia is more curable than mania, although some have thought other- wise, deceived probably by the experience of an asylum into which simple cases of melancholy do not usually come. Next to melancholia acute mania is most cura- ble; when attacks of melancholia and mania alternate, the prognosis is very un- favorable. A day of great depression and weeping intervening in the course of acute mania, is of good omen. When the ma- niacal fury is subsiding, the prospect is good if the patient is sad and depressed, begins to inquire about his family, and to show other signs of a return to his for- mer feelings ; it is bad if the feelings re- main unmoved, and the intellect is calm in its disorder — if, in other words, there is evidence of the organization of disor- der. Even the disappearance of intellec- tual disorder is not a certain sign of re- covery, unless there is a return to the old healthy feelings, and the patient recog- nizes that he has been mad. A periodi- cal recurrence of attacks of Insanity, with long intermissions, is of decidedly unfa- vorable augury; the attacks commonly become longer, the intermissions briefer, and the outlook gets more and more gloomy. Monomania is far less curable than mania, the fixed delusions marking the estabUshmeut of a definite type of morbid action of a chronic nature. Eecovery does sometimes take place under the in- fluence of systematic moral disciphne, or from a great shock to the system, whe- ther emotional or produced by some inter- current disease. In melancholia, where there is a fixed delusion that the cause of misery is in some external agency, the prognosis is unfavorable ; but it is more favorable in the melancholic who attrib- utes bis aflliction to his own imaginary backslidings. In Mke manner the homi- cidal melancholic, who believes himself the victim of persecution, seldom recovers; the suicidal melancholic, who is not so in consequence of any definite delusion, fre- quently does recover, especially after some serious and almost successful suicidal at- tempt. In moral insanity the prognosis is bad ; for these symptoms usually mark the tyranny of a bad organization. General paralysis may be pronounced incurable. When Insanity has been slowly devel- oped, the prognosis is more unfavorable than when it has been of sudden origin — this probably being a part of the larger truth, that when Insanity is slowly de- veloped it is produced by the egoistic passion of some peculiarity of character, as pride, ambition, avarice ; but when it is suddenly caused, it is by the shock of an altruistic emotion, as, for example, grief about others. For a like reason a frequent alternation of active symptoms is more hopeful than a steady persistence in a particular group of quiet symptoms. Hereditary insanity is generally deemed most unfavorable, but recent researches prove that it is not so much so during a first attack, although the disease is more liable to recur than when not of heredi- tary origin. In the acute mania some- times produced by drunkenness ^ve may reasonably look for recovery, but by no means so in those cases in which a con- tinued intemperance has resulted in men- tal weakness, loss of memory, and loss nf energy of character. When Insanity has been caused by habits of self-abuse or by sexual excesses, the prognosis is unfavor- able in all but the earliest stages. If re- ligious excitement purely has been the cause of an outbreak, tlie prognosis is most favorable ; but it is necessary to bear in mind that a form of religious insanity is the vicarious satisfaction of unsatisfied sexual love, that more or less nympho- mania is oftentimes associated with it, and that the outlook then is hopelessly bad. AYhen disease of brain, or injury of the head, or epilepsy, has been the cause, the derangement is practically incurable ; but where it occurs during the decline of some acute disease, it is generally soon curable. The prognosis is bad in Insanity after sunstroke ; nevertheless Dr. Skae mentions one case under his care in which 618 INSANITY. recovery took place, being one of the vi'ry few recoveries on recoi'd from Insanity produced by tiiis cause. The prognosis is favorable in hysterical insanity; as it is also in puerperal mania, in the insanity of pregnancy, of lactation, and of the cli- macteric change. A decidedly bad symp- tom is a fixed hallucination, as is also a complete preservation of bodily health •with persistence of mental disorder; when there is palpable bodily disorder, as diges- tive disturbance, anaemia, menstrual ir- regularity, there is good hope that with the restoration of bodily health the mind may be restored also. AVhen Insanity has followed the sup- pression of an eruption or an accustomed discharge, the prognosis is favorable ; when associated with phthisis, it is unfa- vorable as regards recovery and as regards life. The most favorable ago for recovery is j'outh, the probability of it diminishing with the advance of age, and few recover- ing after fifty ; as many as 86 per cent, of males and 91 per cent, of females, at- tacked with mania under twenty years of age, recovered at the Somerset Asylum. This proportion will appear the more favor- able when we reflect that children under ten or twelve years of age do not recover from mental derangement, it being often dependent upon defective organization, and associated with epilepsy. The re- coveries amongst women exceed those amongst men, by reason probably of the frequency and fatality of general paralysis among men. The general conclusion of Dr. Thurnam from his careful statistics is that, "as re- gards the recoveries established during any considerable period — say twenty j"ears — a proportion of much less than 40 per cent, of the admissions is under ordi- nary circumstances to be regarded as a low proportion, and one much exceeding 4.5 per cent, as a high proportion." The liability to recurrence of the Insanity after recovery from the first attack can- not, he thinks, be estimated at less than 50 per cent., or as one in every two cases discharged recovered. On the whole, then, he holds that, of ten persons at- tacked, five recover and five die sooner or later. Of the five recoveries, not more than two remain well during the rest of their lives ; the others have suljsequent attacks, it may be after long intervals, during which at least two of them die.' TherApetjtics. — The treatment of In- sanity is moral and medical, the two methods properly being combined. It must again be individval, as the case is ; ' In an elaborate paper on Vital Statistics and Observations, in tlie Journal of Mental Science, January, 1865, Dr. Boyd records the for the varieties of the insane character demand difi'erent moral means, as the varieties of causes call for different medi- cal treatment. It is necessary to pene- trate the individual character, with the design of influencing it beneficially, and carefully to investigate the concurrence of conditions that have issued in Insanity, with the object of removing them. Herein lies the chief difficulty of treatment ; in no other disease are there so much conceal- ment and so much misrepresentation, witting and unwitting, on the part of friends. It is before all things necessary again that treatment should be begun early, before the habit of a definite morbid action has been fixed ; but, though early, it must not be rashly vigorous and ener- getic, with the aim of effecting any sudden revolution, but rather patient and system- atic, in the hope of a gradual change for the better. Whilst in other diseases time is reckoned by hours and days, it must in Insanity be reckoned by weeks and months. Moral Treatment. — To remove the pa- tient from the midst of those circumstances under which Insanity has been produced, must be the first aim of treatment. There is extreme difficulty in treating satisfac- torily an insane person in his own house, amongst his own kindred, where he has been accustomed to exercise authority, or to exact attention, and where he continu- ally finds new occasions for outbreaks of anger or fresh food for his delusions. An entire change in the surroundings will statistics of the Somerset Asylum for many years :- Recovered Relieved . Not improved Died . . Remaining Of 1000 Males. 252 55 47 324 192 Re-admissions 870 130 1000 Of 1000 Females. . . 276 . . 79 . . 35 . . 258 . . 223 . . 871 . . 129 1000 The cause of death in 539 cases out of 2000 — 295 males and 244 females — in wliich post- mortem examinations were made, were as follows : — Males, Females. Diseases of Respiratory organs in 148 . 104 Nervous system Digestive organs Vascular system Genito-urinary . Locomotor organs Fevers . . . Accidents . . . 112 18 11 2 1 295 73 41 18 1 3 2 2 244 The diseases of the respiratory organs which proved fatal were principally pneumonia and phthisis. THERAPEUTICS. 619 sometimes of itself lead to recovery; if the patient is melancholic, he no longer re- ceives the impressions of those whom, having most loved when well, he now most mistrusts, or concerning whom he grieves tliat his affections are so much changed ; if he is maniacal, he is not spe- cially irritated by the opposition of those whose acquiescence he has been accus- tomed to, or encouraged by their submis- sion to his whims ancl their indulgence of his follies. Travelling may be recom- mended in the early stages, in order to secure change of place and scene ; or if the patient cannot travel, he may be removed from his own home to another residence, and systematically treated there. If the pecuniary means do not admit of the adoption of either of these expedients, or if the patient is furious, or desperately suicidal, or persistently refuses food, it will be necessary to send him to a suitable asj-lum. It must be borne in mind that an insane person cannot, from the very nature of his disease, have his own way, and that to allow him to do so would be directly to aggravate his disease. To put him under restraint in some way, to exer- cise for him that control which he cannot exercise for himself, is indispensable so long as there is a hope of cure : to let him distinctly understand that this is legally done will of itself have a beneficial effect. The melancholic who finds himself in an asylum finds a real grief to alternate with or perhaps to take tlie place of his fancied affliction ; and the maniacal patient, feel- ing his wild spirit of exultation to be rudely checked by the influence of a sys- tematic control, can scarce fail to have more sober reflections aroused. It is ex- tremely objectionable except in an emer- gency to entrap a patient into an asylum ; there should be no deception about the matter, if possible, but all should be done openly and firmly, in the spirit in which an act of obedience is inculcated upon a child, and in any ease inflexibly insisted upon. The patient having been removed from those influences which have contributed to the production of the disease and tend to keep it up, and having been made to recognize from without a control which he cannot exercise from within, it remains to strive persistently and patiently by every inducement to arouse him from his self-brooding or self-exaltation, and to en- gage his attention in matters external— to make him step out of himself. This is best done by engaging him earnestly in some occupation or In a variety of amuse- ments ; and this will be more easily done now that the surroundings are so entirely changed. The activity of the morbid thoughts and feelings subsiding in the new relations and under new impressions, more healthy feelings may be gradually awak- ened ; and the activity of healthy thought and feeling will not fail in its turn further to favor the decay of morbid feeling. It is not by arguing against a delusion or directly contradicting it that any good will lie done : it were almost as well to argue against the east wind or a convul- sion ; but l)y engaging the mind in other things, and substituting a healthy energy for tlie morbid energy, this will be most likely to aljate and finally die out. But though it is of little use talking against a delusion, it is desirable to avoid agreeing with it : by quiet dissent or a mild expres- sion of incredulity when it is mentioned, the patient sliould be made to understand clearly that he is in a niinoritj' of one. It is most necessary to avoid any harsh word or act, a tone of ridicule, or a look of dis- gust ; an angry speech will often be re- membered when the frenzy has passed off, and will leave a sore feeling in the pa- tient's mind. It is a mischievous and silly practice too to speak to insane per- sons as if they were babies : they are often more sensitive to such impertinences than sane persons, while they seldom fail to be influenced beneficial!}' by a sincere, sensi- ble, and sympathetic address. Medical Treatment. — There is no specific agent in the treatment of any form of In- sanity. A truly scientific treatment will be grounded on the removal of those bodily conditions which may appear to have acted as causes of the disease and on the general improvement of nutrition. An attack of melancholia occurring in a gouty subject, and perhaps taking the place of an attack of gout, is sometimes cured by the treatment proper for gout ; and there are cases on record in which acute mental derangement has affected persons living in a malarious district in regular tertian or quartan attacks, and has been cured by quinine. The morbid sensations, so common in Insanity, should not be overlooked, as they often arise from some real bodily derangement, and tend to keep up the delusion. Now, bodily disease is not always easily de- tected in the insane ; for tlic usual symp- toms are very much masked, and they, like animals, make no intelhgent com- plaint. "Insanity," says Dr. Bucknill, "is not confined to the brain, and when it is confirmed, a man becomes a lunatic to his finger ends." It is necessary, there- fore, to examine carefully into the state of the different bodily functions and to pay particular attention to the physical signs of disease : there may be no cough, no expectoration, when the thermometer or the stethoscope reveals advancing phthisis. General bloodletting is now rarely, if ever, used ; even in the most acute and seemingly sthenic insanity it is not simply useless, but it is positively pernicious. Violent symptoms may abate for a time, 620 INSANITY. but the disease is very apt to become chronic and to pass rapidly into dementia. Local abstraction of blood by leeches or by cupping may be useful where there appears to be great determination of blood to the brain ; by withdrawing blood from the overloaded vessels the opportunity of rest is aflbrded to the struggling aud suf- fering nervous element. It may be well to add here that in Insanity it is not judicious but mischievous to shave the patient's head, to confine him to bed, to shut out the light, and to treat him in all ways as if he were suffering from an acute inflammation of the brain or its mem- branes ; on the contrary, in almost all cases it is necessary to enjoin abundant exercise in the open air. The continued application of cold to the head by means of a douche pipe, or by pouring cold water upon it, while the patient lies in a warm bath, is often suc- cessful in calming excitement and in pro- curing sleep in acute insanity. The warm bath alone, taken for about half an hour, has a soothing eftect, and may induce sleep ; and its efficacy' has been supposed to be wonderfully increased by the addi- tion of several handfuls of mustard, so as to produce a general redness of the surface of the body. Brierre de Boismont pro- fesses to get very good results from employ- ing the warm bath for eight or ten hours at a time ; and Leidesdorf has used for three or four hours, and in many cases with marked calming efl'ect, a bath con- structed by Prof. Hebra, in which patients may be kept night and day at a definite temperature. Such a use of the bath nmst obviously be avoided where the pulse is feeble and where there is anything like commencing paralysis, and it is of no avail in cases of chronic insanity. The prolonged use of the shower bath and of the cold bath, at one time much in fash- ion, is now justly abandoned. The shower bath or cold douche may certainly be use- fully employed in certain cases of melan- cholia, where reaction does not fail to take place after it, and in cases of chronic insanity, with the purpose of rousing the patient and giving tone to the system ; but its use should never be continued fin- more than three minutes, and it should not be with the aim of producing any special eflfect, but on general principles of improving the bodiljr health. Pouring water on the head from a hand shower bath, or a common garden watering-pot, or sponging the forehead and face with cold water, is refreshing and grateful to the patient suffering from acute excite- ment, and has sometimes a good effect beyond what might be expected from a measure so simple. The virtues of the Turkish bath were at one time much vaunted by its advocates, but an exact discrimination of the cases in which it is useful j'et remains to be made. Pack- ing in a wet sheet has sometimes a bene- ficial effect, and is commonly rather grate- ful to the patient. Counter-irritants are not much used now in Insanity. Schroeder van der Kolk, however, put much faith in the applica- tion of strong tartar-emetic ointment, or of a blister to the shaven scalp ; and Dr. Bucknill has found it useful to rub croton oil into the scalp in the passage from acute to chronic insanity or dementia, and in chronic melancholy with delusion. Bhsters to the nape of the neck appear to have little other effect than to increase mental irritation; and the benefit of setons and issues in the neck is very problemat- ical. After errors of digestion and secretion have been duly attended to, the diet of the insane should be good ; and it wiU be desirable in most chronic cases, and in many acute cases, to allow a moderate use of wine. There can be little doubt that an attack of Insanity might sometimes be warded off by a generous diet and free use of wine at a sufficiently early stage. It is at any rate a truth worthy of all acceptation, that energetic antiphlogistic treatment in the course of Insanity is energetic mischief. Leeches may be applied to the head, and a patient may be kept on low diet, in order to subdue maniacal excitement, without any other result than an increase of the excitement with the increase of exhaustion; and the most active purges may be given, and given in vain, to overcome an obsti- nate constipation, — when brandy and beef-tea, reducing exhaustion, will sub- due excitement, and a simple enema will produce full action of the bowels. [Per c/mirc in many instances. In the latter stages of the malady there can be no doubt that the mental depression reacts with great force upon the machinery of organic life, disordering secretions and rhythmic mo- tions very extensively. The Pathology of Hypochondriasis, in the strict sense of the word, does not exist, for there are no anatomical or physiological facts upon which it can be based. Morbid anatomy has revealed ab- solutely nothing which in the slightest degree explains the occurrence of the dis- ease, and the physiology of the symptoms is to the last degree obscure and uncer- tain in its interpretation. It is only in those cases which develop into true insan- ity, more especially those which pass into dementia, that the brain exhibits any notable changes ; and tliese alterations, when they occur, are no proper part of Hypochondriasis. It is neither impossible nor unlikely that the improved modern methods of examining the nervous cen- tres, if they could be applied to the cen- tral ganglia of certain visceral nerves (and especially to the nucleus of the vagus), might detect appreciable changes even in the early stages of the disease. But the opportunities for carefully ex- amining the nervous system of patients in the early periods of Hypochondriasis can rarely be obtained, and it is probable enough that the question as to the pre- oecurrence or not of structural changes will never be thoroughly cleared up. The Treatment of H3rpochondriasis consists of the use of moral and constitu- tional remedies and of remedies for symp- toms. It is obvious that the first duty of the physician is to encourage the hypochon- driac to forget his woes ; but nothing is so difficult in practice, and that for the best of reasons. It is a fallacy to suppose that the sufferings of the patient are unreal ; on the contrary, they are most vividly real, and it is impossible that he should forget them till they cease. Yet the mind has a reflex influence upon the bodily dis- order, which may be as effective for good as for evil ; and this fact may be taken advantage of. The key to the moral treatment is the breaking down of the patient's morbid self-concentration, and this object may be achieved to some ex- tent in many cases by a change in the course of his daily life. The class of pa- tients with whom this may be most readily carried out are those in whom the consti- tutional tendency to Ilypoehondriafsis is aggravated by the ennui of an idle life : for these an active career or pursuit of almost any kind is an immense gain ; only the new occupation should be one which forces them to mix with the world. The isolated activity of the student is no real diversion from the fancies of Hypochon- driasis, as the case of Dr. Johnson, and of many other famous intellectual work- ers, abundantly proves. It is needless to say that all actively depressing influences should be removed, such as immoderate venereal indulgence, of whatever kind, or alcoholic intemperance. On the other hand, the influence of new emotions which tend to lift the patient out of himself can scarcely fail to be beneficial ; and it would be a real good-fortune to a hypochondriac if he could fall in love in a natui-al and healthy manner, or if he could interest himself warmly in philanthropic schemes or other plans of public usefulness. And, above all, something like a police super- vision should be exercised as regards his studies, in order that he may be rigor- ously kept from the perusal of medical or other books which might remind him of his miseries ; for though we do not believe that these things can create Hypochon- driasis, yet they can certainly prevent its cure. It is well understood, however, that no good can be effected by simply laughing at his narrative of suffering, or bantering him on his fancifulness ; on the contrary, it is necessary for the physician to be interested and to believe in the reality of his painful sensations. If the patient once thinks that the doctor is taking pains to get at the secret of his troubles, he will be inclined to accept the first word of encouragement the latter throws out ; and the reflected influence of reviving hope will be certain to assist recovery. The constifAitifmal treatment is to be directed towards improving the general nutrition ; and the task here is partly that of aiding the primary process of diges- tion of food, and partly that of rendering more active the processes of decomposi- tion and exchange in the tissues gener- ally. The hynochondriac either has a de- ficient, a capricious, or a ravenous appe- tite, but in any case the primary function of digestion is almost always markedly impaired if the disease has lasted for any length of time ; and when this depends on a want of tone mainly, or a condition of irritation of the stomach (such as is indi- cated by a coated tongue with a rod or strawberry tip), the use of vegetable liit- ters and mineral acids will often do great good. Defective secondary assimilation, which will be especially indicated by the condition of the urine, is generally much benefited by the use of cod-liver oil for a 630 HYSTERIA. rather prolonged period, if the remedy can only be tolerated bjf the stomach. In cases where the oil cannot be borne, cream, butter, or some other form of fat, will often agree, and may be made the first stage to inducing the stomach to re- tain the cod-liver oil. Nor is it by any means only in cases where there is gen- eral emaciation that the administration of fat does good ; it is probable that the nutrition of the nervous tissues is directly improved by this treatment in many in- stances. The administration of iron is doubtless of great use to some anaemic patients, and sea-bathing frequently ap- pears to exercise a very beneficial in- fluence : but the first of these remedies is generally most efficacious when taken in the form of the chalybeate waters of some foreign spa ; and there is good reason to doubt whether both mineral waters and sea-bathing do not owe most of their ap- parent power to the moral influences of travel and change of scene and mode of life. The more specific nervous tonics, such as strychnia, quinine, or phosphorus, seem to exercise but a doubtful and acci- dental influence. The treatment of symptoms is a thing to be eschewed in Hypochondriasis, with certain special exceptions. While, how- ever, it is desirable to avoid concentrating the patient's attention on parts which are the apparent seat of mere morbid sen- sations, it is important to relieve him of the distress caused by real (though mere functional) disorders of the digestive sys- tem. Decided acidity of the stomach should be counteracted by the use of anti- dotes, of which none is more eflicaeious than magnesia ponderosa, in ten-grain doses thrice daily, or Brandish's solution of potash, ten minims three times a day, with gentian or cascarilla. The exces- sive or too long continued use of alkalies is, of course, to be avoided. The dis- tressing flatulence, which is often one of the earliest, and also one of the most an- noying symptoms, is greatly relieved by creasote (one drop in a pill twice or thrice a day), or the infusion of valerian. Alco- holic tinctures should be very cautiously employed, if at all ; for there is a real danger of the patient coming to appreciate the comforting sensations given by the spirit so highly, that he gradually takes to drink : this is especially true in the case of hypochondriacal women, as it notoriously is in hysteria. We may add that it is particularly likely to occur in patients exhausted by masturbation, or other venereal indulgence. The consti- pation, which is frequently so obstinate and troublesome, must be remedied, if it be anyhow possible, without the use of drugs ; for it is most dangerous to stimu- late the patient's love of self-doctoring in the direction of the habitual use of purga- tives. The prescription of fruit, green vegetables, &c., as articles of daily ibod, is a far more desirable mode of accom- plishing our object : and the habitual practice of active bodily exercise is a powerful aid to the same end. The question of the quantum et quale of physical exercise which may be beneficial in Hypochondriasis forms a fitting subject with which to conclude our remarks" on treatment, since this is a remedy which directs itself alike to the moral, the con- stitutional, and the symptomatic condition of the hypochondriac. The only rule, however, which it is possible to lay down for our guidance in this matter, is the direction to employ physical exercise in such a manner and to such an amount as shall fully exercise the muscles without ever producing severe fatigue, and shall also be amusing to the patient. It is a very dangerous error to carry exercise to the fatigue point ; a short continuance of such malfractice will usually sufBce to produce a profound deterioration of the vigor of the nervous system, and an aggravation of the hypochondriacal fan- HYSTEEIA. By J. Russell Ebynolds, M.D., F.R.S. The most characteristic feature of Hys- teria has been held to be a particular form of convulsion, which will be described hereafter in detail ; but there are many phenomena, some falling far short of con- vulsion, even when they resemble it in kind, and others diifering widely from it in their form, and these have been termed "hysterical." If, therefore, by the word " Hysteria" is intended a definite disease, the term "hysterical" should be employed with a no less definite aim ; but it has un- NATURAL HISTORY: CAUSES. 631 fortunately been sometimes used to de- note either a mere variety of tlie " ner- vous temperament," a mood or disposi- tion of the health of both body and mind, or sometimes a vague condition of disor- dered function which cannot be conveni- ently placed elsewhere. The employment of the word "hysterical" may sometimes be found indicative of the state of the mind of the practitioner rather than of that of the patient's health. It simply conveys a doubt as to what is the matter, but expresses a prevailing conviction that it is nothing very serious as to life, and that it might culminate in an attack of convulsions of the kind called "hysteric." The vast preponderance of Hyj^teria in the female sex has given rise to its name, and to a theory as to its essential nature and mode of production. It has, how- ever, and especially of late years, been so distinctly shown that Hysteria may exist among men, that the older nomenclature, although retained on account of its prac- tical utility, is virtually exploded as to its etymology. Hysteria is not necessarily associated with disease or derangement of the generative organs of either sex : such association may and does very commonly exist ; but the true nature of the malady may be overlooked if regard be paid ex- clusively to that particular relation. The hysterical condition may exist for many years, and yet be unattended by any distinct convulsive paroxysm. The latter never exists without the former. There are at the present time numberless individuals whose lives are, to themselves and their friends, the sources of more or less constant misery, from the fact of their being distinctly and definitely hysterical, but in whose history there has never oc- curred a single attack of characteristic convulsion. We cannot, therefore, draw the line of deflnition so as to include the paroxysm and exclude all beside ; but must, on the other hand, regard as essen- tial that which is constantly present, and recognize as the disease Hysteria a pecu- liar condition of the nervous system of which the paroxysm is only one, although a highly important feature. The mental state of the hysteric patient is more con- stantly and as characteristically altered as is the condition of the muscular system. There is a defective or perverted will ; an increased activity of emotion, and some- times of thought ; an altered and aug- mented general sensibility ; an exaggera- tion of all forms of involuntary motiUty — ideational, emotional, sensational, and reflex ; and usually some distinct perver- sion of the physical health. It is almost impossible to frame an accurate " defini- tion' ' oi the disease ; and it seems to me more desirable to make the above general statement than to attempt a less detailed description for the purpose of giving it the form of a defirition. Natural History.— I. Causes.— Sex. Doubtless the most frequently pre- disposing cause is that condition of the nervous system which is more or less characteristic of the female sex. Hyste- ric women are met with daily ; hysteric men and boys are of comparatively rare occurrence. When Hysteria is found in either a man or a boy, it is to be observed that such person is, either mentally or morally, of feminine constitution, or that he has been overworked mentally, exposed to much emotional disturbance, or greatly reduced in physical power. It is well known that men have frequently become hysterical as the result of some severe accident, such as a fall from a horse or a collision in a railway train. The predis- position to Hysteria does not exist in the fact of an individual having the organs of one or the other sex, but in the possession of a nervous state — an habitual, constitu- tional, or induced relation between the several elements of mental, moral, and physical life — which is common to, but not always possessed by women ; unnatu- ral to, but sometimes exhibited by men. Some women are as little likely to become hysterical as some men are to fall preg- nant; they are of masculine build, both mentally and bodily, and their existence and their predispositions to disease furnish another proof of the truth of the general proposition, that it is in the nervous en- dowments, and not in the nature of the reproductive apparatus, that the special predisposition lies. Age. — In the female sex. Hysteria usu- ally commences at or aljout the time of puberty, i. e., between twelve and eighteen years of age ; but when once developed, the symptoms may remain throughout life. At the climacteric period Hysteria may become developed in a previously healthy person ;— this is, however, com- paratively speaking, rare ; but examples of extreme Hysteria may be met with after the climacteric period has been passed— and that without unusual discom- fort—in some women who were hysterical in earher life, but whose hysterical symp- toms were then less pronounced. Of 351 cases analyzed by Landouzy,' the ages at commencement were distributed as fol- lows : — From 10 years to 15 years . 48 cases. " 16 " 20 " . 105 " "' 21 " 25 " . 80 " " 26 " 30 " . 40 " 1' 31 " 35 " . 38 " " 36 " 40 " . 15 " Above 40 years of age ... 25 " 351 Boys sometimes exhibit hysteric symp- toms at puberty, but thejnost marked ' Traits complet del'Hysterie, Paris, 1846, p. 184. 632 HYSTEETA. cases of the disease that I have seen in males have been at a more advanced age, ] viz. from thirty-Hve to fifty and upwards. ' It will be seen therefore that Hysteria i may occur at any age ; and it niu.st be ! remembered that many of the symptoms ; of senile decay, and many of those which accompany chronic degenerative disease of the brain in middle life, are often called "hysterical," because they correspond very exactly with those which, when they occur in earlier years, are described, and without hesitation, by that word. As de- caying life passes on to a " second in- fancy," we see the signs of a "second childishness :" but often, before either of these terms would be strictly applicable, we may observe something that resembles, in its nervous characters, the period of commencing puberty ; for often the first sad signal of faltering power is either un- due emotional disturbance or deficient control of its display. We call these states "hysterical," and may perhaps sometimes use that word very loosely ; but the resemblances are real, and may help us to appreciate the pathology of the disease "Hysteria." Temperament. — If by nervous tempera- ment be meant simply an hysterical con- dition, it is unnecessary, and would be wrong, to speak of the one as a predispo- nent to the other. The two expressions are sometimes used interchangeably ; but this is a great mistake : the truly nervous temperament implies no disproportion, inter se, of the several nervous endow- ments ; all are alike active. There may be in tho-^e of nervous temperament a higher but a shorter life ; an intense vitality, which burns itself out before its time : but the hysteric condition is essen- tially one of disproportion, and it is not. encountered with any especial frequency in those who have previously exhibited the exaltation described. This latter is peculiar to some individuals, but is not necessarily morbid. Sexwd Condition. — Undoubtedly Hyste- ria is more common in the single than in the married, but it is not limited to the former, and it may exist to its highest ' degree in the latter. It is said that the wives of incompetent husbands, and bar- ren women, as well as widows and old maids, are frequent victims of the hysteric malady ; but statements such as these do not convey the whole truth in regard of the etiology of Hysteria, and it must be remembered that Hysteria is met with in those who are happily married, in preg- nant women, and in nursing mothers.' From what has already been said in regard of the age at which the disease begins, it is obvious that age, rather than sexual ' Vide Niemeyer, Handbuch, p. 356 ; Hasse, in Virchow's Handbuch, p. 212. condition, is the predisposing cause. Hysteria commences at a time of life when girls are, in this country at least, held to be too young for marriage. The fact of its existence, to a high degree at any rate, does not increase their social chances in this particular ; they often remain single because they are hysteric, and this prob- ably quite as often as that they become hysteric because they are single. Such a condition does not tend to improve itself, and the disappointment of being left alone may keep up and exaggerate the morbid state. The facts that there are to show that marriage has sometimes cured the malady are not so numerous, nor are they of such character, as to outweigh the evi- dence to be derived from the persistence, and even aggravation, of Hysteria after marriage. Moreover, it is well known that hysterical women who are iharried are often frigid, and averse to sexual in- tercourse, and that their aversion is not necessarily due to pain. It is compara- tively easy to shrug the shoulders and utter innuendoes over a case which baffles treatment by well-directed regimen and medicine ; but does it not sometimes hap- pen tliat such hints are only a clumsy ex- cuse for the failure of therapeutics ? That marriage may be of use in Hysteria is not denied, but it is asserted that it may be so by other than its mere sexual relation- ships ; there may be a number of circum- stances which are changed by taking this step in life — annoyances may be removed, new purposes conferred, work given to do, and strong help rendered kindly for the doing it ; and all these may concur to lift the hysteric woman out of her former self. If, then, we are regarding Hysteria etio- logically, all these points should be con- sidered, and the argument from the effects of marriage should not be based upon one element alone. Sexual excesses are held to be some- times productive of Hysteria ; and doubt- less they are so occasionally in men, but there is a deficiency of evidence to prove this in regard of women. According to Duchatalet, Hysteria does not exist with especial frequency in women of the town, and in those who are exposed to excesses of this kind. T'Hiipcratiire, C'iriiate, and Season. — There are many fact^ to show that warmth of climate and the seasons of spring and summer conduce to a production of the hysteric condition, but it has yet to be shown what is the element comprised un- der those terms which is of etiologic mo- ment. Ocnijiotion. — It is demonstrable that absence of employment, as it is commonly met with among the upper clas.ses, favors the .production of Hysteria in women ; and it is equally clear that overwork, anxiety, and great "strain" upon the in- NATURAL HISTOKY: CAUSES. 633 tellectual and moral faculties, lead to the development of Hysteria in man. It is, however, questionable whether the mere fact of occupation, or its kind, is either favorable or unfavorable to health, or to Hysteria. The unoccupied life of woman is one of exposure to numberless disturb- ing causes, as is also the over-occupied life of man. The woman, or the young girl, who has nothing to do — nothing se- rious to which her mind is turned — finds "time" to be egregiously tedious; and she has to choose between two evils, either that of "doing nothing" with it, or that of "getting rid of it" by utterly frivolous pursuits, the distraction of reading silly books and doing the sillier things that ' ' so- ciety" prescribes. She thus brings upon herself all the petty annoyances of selfish- ness and wounded pride, and all the tease and turmoil of unreal and extravagant emotions. The man who is " overworked" finds, commonly, in that work itself, and in that which leads to it, much more than mere mental occupation, viz., anxiety, suspense, and worry, with their concomi- tants, loss of both appetite and rest ; and it is these which, by the nature of their operation, develop the hysteric condition, rather than the amount of simple work which has to be undertaken or pursued. It is then, I believe, neither the presence nor absence of occupation, %ier se, which conduces to the development of Hysteria in either sex; but in the one sex the "nonsense" that takes the place of sober work, and, in the other, the emotional disturbance that attends upon over-exer- tion. These lead, under apparently dis- similar circumstances, but in a really analogous manner, to the production of the same result. That which is common to the two conditions is an excess of emo- tional disturbance ; but in the one case it is the outcome of idleness, in the other it is often the cause and motive of overwork. Absence of occupation may give time and opportunity for the manufacture of feel- ings that are tormenting and unreal ; over-exertion may be the means taken to reUeve the anxiety and emotion which are already pressing. Either condition may be met with in either sex, but the common distribution of work and idleness in relation to Hysteria is that which is indicated above. Menstruation. — It has already been said that Hysteria breaks out most frequently at or about the time of the commence- (ment of puberty ; but it has not yet been shown that it has any definite relation to the varying conditions of menstruation. In an individual already hysterical there is or may be more than usual disturbance at or near the monthly "periods," and this is exaggerated by any k^nd of irregu- larity which may exist. Jfenorrhagia, by reducing the vital power, through loss of blood ; dysmenorrhaja, by affecting the same result through nervous exhaustion ; or amenorrhoea, by its physically direct, and mentally and morally indirect influ- ences, may, either of them, conduce to the increase, or even development, of the hysteric state : but it has yet to be shown, that either one of these is of itself suffi- cient to produce the disease. For it must be remembered that Hysteria may exist to its hijjhest degree— it commonly has done so in the cases i\-hich have fallen under my own observation— in individuals who have presented no anomaly whatever in regard of the menstrual functions; and, yet further, that it is found in the male sex, which may be influenced much by sexual conditions, but which exhibits nothing analogous to those perturbations that have been mentioned. All that I can add to the above is, that I have found no one condition, either of excess, defect, or perversion of the menstrual function, so commonly or prevailingly associated with Hysteria as to give to it any special claim to consideration in the etiology of the disease. Some people become more or less hysterical about everything that is wrong in the performance of their func- tions : it is both obvious and notorious that the uterine functions are invested in the minds of women with an amount of importance that is more than their phy- siological due ; and hence it is that men- strual derangements are regarded by them as exerting much more influence than those of the digestive or the excretive functions, and are therefore brought promi- nently forward in the statement of their cases. That they do exert this excessive influence may be due partly to their in- trinsic nature, but partly also to the re- sults of thought and feeling about them ; and it is important to bear in mind, for etiologic purposes, this latter element in their mode of action. Hereditary taint has not been shown to exert any marked influence in the devel- opment of Hysteria. It is well known that members of one family occasionally exhibit similar symptoms, but then it must be remembered that many condi- tions besides those of blood-relationship are ordinarily common to the individuals of one family ; they may share equally in what is good or bad in respect of exam- ple, education, and surrounding circum- stances. M. Briquet states that those who are born of hysterical parents are twelve times more liable than others to the outbreak of Hysteria. "Very different numerical statements are made by others, and we must remember that besides i;he direct transmission of an hereditary taint there is much contingent upon having an hysterical mother. The most frequent determininrj rauxe of an outbreak of hysteric symptoms is some 634 HYSTEKIA. mental or moral disturbance ; cither a violent and unexpected commotion, or more commonly the occurrence of a trivial circumstance which takes the individual by surprise, overcomes tlie power of re- straint, and gives evidence of what is often an ill-understood, but long con- cealed, annoyance or distress. Some- times the determining cause is physical, e.g., an accident, a loss of blood, or an attack of acute bodily illness, such as one of the exanthemata, pneumonia, or pleu- risy. It then appears, and sometimes to the surprise of e\'en the most intimate relatives, that there is a morbid condition of both mind and body which is difficult to describe, and often much more difficult to manage. There may be the extreme symptoms of the hysteric paroxysm, or some of tlie marked features of the hys- teric state. These have now to be de- scribed. II. Symptoms. — It is convenient to separate the paroxysmal symptoms from those which exist in the intervals of at- tack ; and the former will be best under- stood by those who have become ac- quainted with the latter, for the hysteric state does much to explain the hysteric paroxysm. It will bo well to divide the interparox- ysmal symptoms into several categories, describing separately the condition of the mental and emotional, the sensorial, mo- torial, and general health. [a] Interparoxtsmal Stjiptoms. — Ilental and Emvti(yiial State. — The will is perverted and defective, while ideas and emotions exhibit excessive activity. The patient sajs that she cannot do this, or cannot l)car that ; and, while under the belief that these things are impossible, they are so. It is often obvious to others that no physical impossibility exists ; but it must not be supposed, therefore, that the patient is pretending or "acting a part." For the time being it is often true that the hysteric patient states the fact. What she wants is motive, and this may be sometimes supplied by a sudden alarm, or by an accidental circumstance ; but under ordinary conditions the motive is wanting, or is held in abeyance by some imperious idea or emotion. There is an exaggeration and perpetuation of what exists in all people under certain circum- stances. Fear paralyzes the strong man, while sudden alarm may make the weak man strong. A prevailing idea may limit as well as induce movements which the will can neither counterfeit nor hinder. Let this be remembered, therefore, at the outset in describing the symptoms of Hysteria. The patient asserts that she cannot control her thoughts, emotions, expres- sions, or general movements ; that she cannot move this or the other limb ; can- not open the eyes ; cannot stand or walk ; cannot relax the rigid spasm of the hand or of the leg ; and what she sa^fs is true under the existing conditions. But often, under the influence of some unexpected idea, or emotion, or sensation, she does the very things that were said to be im- possible. A patient may be carried into the room, and may fall when left for a moment to herself; tell her to walk, and a wooden doU seems as capable of movement ; but, under the stimulus of a wish that what she is saying should not be overheard, she walks to the open door and closes it. Cer- tain ideas seem rampant in her mind ; she cries about them, and gesticulates in the wildest manner : tell her to be silent, to keep them to herself, or to control her feelings, and you find them exaggerated, and she affirms that "all the world shall hear" what she has to say ; but a gentle rap at the door, that may come from the , hand of some one from whom she wishes to conceal her state, is sufficient in a mo- ment to hush this stormy talk, to com- pose her face, to dry her ej-es, and make her speak and smile with placid compo- sure. Sometimes she speaks in a whisper only, and if asked to " exert herself," or "make an effort, " so that some particular friend who is a little deaf may hear what she has to say, the only effect is that the whisper becomes quite inaudible, that she makes less sound than ever, and often none at all — she moves her lips, but not even the ghost of a sound is heard to pass them ; and yet this self-same person may, when no attention is directed to the voice, speak loudly enough to be heard and understood in the adjoining room. The fact seems to be that the will can be called into exercise only by some one dominant idea or emotion ; and that it is this which determines the A'arying phases of the mental state. Under its influence the hysteric patient may submit to pain, an- noyance, and privation such as a healthy person would shrink from without con- cealment ; and under its influence, also, she may be unable to do what any one else could accomplish without either dif- ficulty or fatigue. Ideation is often excessively active in regard of certain classes of thought ; there is sometimes quite a preternaturally acute condition of intelligence in certain direc- tions, i. e. , in those directions wherein lie the morbid notions which are at the foundation of the malady. Often the hysteric patient makes many mistakes, and attributes to people and circumstances motives and meanings which they do not possess ; but very often she exhibits mar- vellous instenuity in perceiving the ideas of others, and in unravelling the intention NATURAL UISTORY: SYMPTOMS. 635 of complicated conditions, wlien tliese have happened in any way, or to any degree, to have had relation to herself. Apart from these direct personal relation- ships the mind often is, or seems to be, a perfect blank ; the patient is listless, apathetic, and dull ; a most uninteresting specimen of humanity; becoming of value only when her vagaries atibrd curious illustrations of certain pathological laws. There is a prevailing belief in the import- ance of self, and the patient thinks that she diflfers from every other human being ; that ordinary laws do not apply to her ; that she is "not understood," as the phrase is ; and that only some very mUre or utterly novel mode of treatment can do her any good. She believes all this, and acts upon it with a pertinacity "worthy of a better cause," exhibiting as much energy of purpose in a wrong direction as would serve to cure her were it rightly ordered. Emotion is commonly excessive in itself, and also in its expression. The patient is hurried from one extreme to the other with almost ludicrous rapidity ; and often she walks, as it were, constantly upon that narrow line where tears and laughter meet. Laughter and sobbing not only alternate, but coexist ; and often without any obvious and sufficient reason for either. There is sometimes listless indif- ference to everything of ordinary interest ; sometimes absorption in some trivial ob- ject : often great restlessness and impa- tience, with extreme irritability of temper on any attempt being made at control, or any suggestion being offered of change. These mental and emotional conditions are liable to much variation. Sometimes the patient exhibits them for a day or two, and then becomes like an ordinary mortal ; sometimes they are persistent, and vary only in the degree of their intensity. In Hysteria we occasionally meet with somnambulism, cataleptic conditions, and syncopal attacks, which latter sometimes pass into the state of " trance," or appar- ent death, of which several cases are on record. These are, however, among the rarer features of the malady. Sensorial Condition. — An exaltation of sensibility generally may be the earliest, and sometimes the only sign of the hys- terical condition. It may, and more com- monly does, exist in association with other symptoms, or in the intervals of their re- currence. But sensibility may be altered in several distinct directions ; there may be increased, painful, perverted, or dimin- ished sensation, or there may be absolute though partial anaesthesia and analgesia. Hypersesthesia is very commonly con- founded — nominally and perhaps theoreti- cally—with painful sensibility or sensa- tion ; from which, however, it is quite distinct. The hysterical patient often ex- hibits true hyperEcsthesia ; she does actu- ally see, hear, smell, and taste what would not be perceptible to those in health, and to herself at other times. The exaggera- tion of hearing power is that which is the most frequently observed ; hysterical girls do sometimes seem to " hear through stone walls:" they detect the minutest change in odor or in taste, and exhibit an exalted keenness of sight. Their sense of touch is also sometimes preternaturally acute. Painful sensation, or dystesthesia, is al- most always present to some degree. One patient cannot bear the light, another is distracted by the slightest sound, to a third all ordinary odors are intolerable, and to others certain tastes, or the contact of sundry innocent articles of clothing, are most highly objectionable. Pain on pres- sure of the skin is very common ; and sometimes the symptom is universal, but more commonly it is limited in its distrir- bution, e.g., to the occiput or the spinal column. It is to be observed that the di- rection of attention to them always makes the painful sensations much more intense; the mere fact of asking a question about them may sometimes develop them. A middle-aged hysteric woman, whom I saw in hospital a few days ago, had been lying for weeks with her hand before her eyes "to keep out the light" of a dull London sky. Bringing a candle before her — the room being so dark from an accidental fog that I could not see the pupils — she shud- dered, knit her brows, and held both hands between her and its feeble light. There was no undue contraction of the pupils, and when her mind was distracted to the condition of her front teeth — the light be- ing still close to her eyes — the brows were relaxed, the hands removed, and there was no expression whatever of uneasiness. This is but one example of a large class of dyssesthesife which may be commonly ob- served in the hysteric. A lady to whom I was speaking lately, in a tone by no means loud, exclaimed in a voice much noisier than mine, and put- ting her hands to her ears at the time, "Not so loud— not so loud;" but, a mo- ment afterwards, she stirred the fire so vehemently, and made so much noise in the process, that it was positively annoy- ing to myself, and this without appearing to give herself the least uncomfortable sensation. Sometimes there is obvious and distinct painfulness of sensation upon impressions of ordinary intensity, and this may be limited to one or another organ. Most commonly, however, the pain is not necessarily associated with the impression, is of variable kind and locality, and inter- mittent in its form. Besides these alterations of sensibility, hysteric patients constantly complain of " pain, " more or less spontaneous in its development. Such pain, wherever it 636 HYSTERIA. may be situated, usually requires several strong adjectives for its description, and the account given of it is sometimes te- diously minute. I have heard one hys- teric lady enumerate and detail nine dif- ferent kinds of pain in her chest ! Of these some were bearable, some " intoler- able, "others "agonizing;" and four or five of them usually appeared together, and were present at the moment of de- scription — and yet the face was calm, and simply conveyed the expression of interest in the description. The localities of pain are very numer- ous, but some are much more frequently complained of than are others. The favorite haunts of hysteric pain are the top of the head, the left mammary re- gion, the hypogastric, and the sacral. Sometimes the coccyx, and often one of the joints of the limbs, is fixed upon ; but I have rarely observed any definite pain in the reproductive organs. When one of the joints is painful, and there is much tenderness of the affected part, it will commonly be found that passive move- ments or even succussion of the limb may be borne without complaint, whereas even gentle pressure of the skin is described as "' agonizing in the extreme." There are other sensations of which much is heard that do not fall into any of the foregoing catagories. The processes of ordinary life, which in health are unfelt, become sensible, and sometimes painfully so, to the hysteric patient. She feels the want of breath, the action of the heart, the intestinal movements, the pro- cesses of micturition and defecation, and those of sexual intercourse to an exag- gerated degree, and in a distressing man- ner. She feels "short of breath," al- though there is no actual acceleration of the respiratory movements; "palpita- tion," although the action of the heart is normal ; rolling and rumbling movements, when such are not perceptible to the phy- sician ; and distress or difficulty in re- lieving either the bladder or the rectum, when there is no physical disturbance of such processes. Sexual intercourse is sometimes quite impossible from some morbid sensitiveness of the vulva or spas- modic action of the sphincter vaginise, neither of which can be detected on ex- amination by the medical attendant. There is, further, the sensation termed "globus hystericus," which is often, but by no means universally present. It is not always of the same character. Some- times it IS the feeUng of a " great lump" in the hypogastric region, rising through the epigastrium and chest, to the throat ; but this is, so far as I have seen, extremely rare, and is more frequently met with in books than in practice. The commonest form of distress is that of a ball or lump in the throat ; a something which the pa- tient cannot swallow, and which she feels will "choke" her. Anything round the neck is intolerable ; she feels as if " some- thing were tight there," although there may be nothing present in the form of dress ; she makes constant attempts to swallow, but the " lump will not move ;" and these discomforts are exaggerated by sobbing efforts which very frequently at- tend them. Sometimes the patient puts her finger in her throat to cause vomiting, that she may "bring it up ;" sometimes she drinks largelj- to "push it down ;" but in spite of both classes of effort the lump remain's. Children when about to cry know what the feeling is, and probably it is of the same nature in the adult. Diminished sensibility, and even actual ansesthesia of certain localities, may also be found. Ansesthesia may exist over the whole or a large portion of the sur- face of the body, and may extend to the deeper tissues, to the muscles,' and even to the nerves of special sense. It most commonly follows an hysteric paroxysm, but it may be met with when no such seizure has taken place. Commonly it is limited to certain parts, such as the back of the hand or foot, but it may be para- plegic or hemiplegic in its distribution, or may be found along the course of one or more intercostal nerves, and in the mu- cous membrane of the nose or mouth. The temperature of anaesthetic limbs is sometimes reduced. It is a rare event in any locality, but it has existed in several cases that I have seen in the mucous membrane of the vulva and vagina ; the anaesthesia in these instances having been absolute, and that in highly hysterical, married women, who had borne and were still bearing children. Probably, anses- thesia is the cause of occasional retention of the urine and of the fseces in hysterical patients, as either bladder or rectum may be found sometimes enormously distended without the patient being aware of any other discomfort than that occasioned by the swelling. Loss of the senses of sight, hearing, smell, and taste also sometimes occur as phases of hysteric ansesthesia. [Following riorry, Macario and Gendrin in France, and Szokalsky in Germany, Briquet, Charcot, Westphal, and others have of late years made an extended study of Hysterical ansesthesia, and es- pecially hemiancesthesia.^ In this, the line of demarcation is usually perfect for the whole length of the body. Briquet a^s- serts that the left side is affected in 70 cases, to 20 of the right. There may be complete ansesthesia, involving the sense of touch, of pain, and of temperature, together ; or it may be incomplete. In ' See article, Muscular Ansesthesia. [2 Charcot, Lectures on the Diseases of the Nervous System, Lecture X.] NATURAL HISTORY: SYMPTOMS. 637 such a case analgesia (insensibility to pain) may exist, and yet lieat and cold may be perceived and discerned ; or, instead, thefrmo-aiidestliesia, insensibility to tem- perature, without perfect analgesia. The anaesthetic side of the body is apt to be pale and cold ; antemic or isehsemic. Sometimes very little blood will flow, even from a wound. Charcot supposes that possibly the stoi-y that, in the " Con- vulsionnaires" of Saint Medard, no blood followed when they were struck with a sword, may meet with a partial explana- tion in this way. Affections of the special senses not un- frequently accompany that of the surface of the anaesthetic side. I remember in my own practice the case of a girl who, for several months, was totally blind in one eye, and then, recovering sight upon that side, the other eye became blind ; this, too, being followed by recovery.' Galezowski has called attention to Hys- terical achromatopsia, color-blindness, as occurring upon one side; especially the left. Charcot points out that hemianeesthesia is commonly attended by ovarian hyper- msthesia of the opposite side. If loss of muscular power, or contraction of the limbs occurs, it is upon the same side as the hemiansesthesia. As a part of the medical history of Hysteria, it is proper to mention in this place some facts in connection with the recent use of metalloscopy and metallo- therapy. Dr. Burq, a French physician, obtained, in 1876, the appointment by the Sooiete de Biologic, of a commission, con- sisting of Drs. Charcot, Luys, and Du- montpallier, to examine into his asserted observations. These were to the effect that, in patients having hysterical anes- thesia, the internal use, and external ap- plication of certain metals, different for different patients, had a remarkable power in restoring sensibility. The commission not only confirmed these statements (at least concerning the external contact of metals), but also discovered that, when, in hemianeesthesia, the sensibility of the affected side was restored, a transfer of anssthesia occurred, to the sound side. Re;^'nard, Magnan, Westphal, and Adam- kiewicz essentially confirmed these re- sults ; and Charcot exhibited, in August, 1878, at the Salpetriere, some of the most remarkable of them, to Profs. Virchow, Grainger Stewart, Liebreich, Kay Lan- kester, Broadbent, and other distinguished medical men.^ Besides simple metals, magnets and galvano-electric spirals have been found to have similar influences. Some of the [' See a paper by Dr. G. C. Harlan, Phila. Med. and Surg. Reporter, August 12, 1876.] [' British Med. Journal, Oct. 12, 1878.] observers are inclined to refer the action in all cases to the effects of galvanic cur- rents ; but no satisfactory explanation has yet been agreed upon. In reading such accounts at a distance, the most na- tural suggestion would seem to be, that, as the events described take place in hys- terical patients, the elements of imagina- tion and simulation may play a large part in their production. Yet the evidence of those who have witnessed, and in great degree, confirmed them, entitles them to attentive study and record, while await- ing the final decision of science in regard to them. Farther reference to some of the same facts will be made in the article on Hystero-epilepsy in tliis volume. — H.] Motorial Condition. — In health there are different kinds of movements which the muscular system exhibits ; some are voluntary, others depend upon idea, a third group upon emotion, a fourth upon sensation, and a fifth upon impressions which are not felt. There is, moreover, a certain relation between these which is characteristic of health, but either of them may be so altered as to disturb the balance of well-being, and constitute or exhibit either derangement or disease. In Hysteria the normal relation is per- verted, and there is an excess of the in- voluntary motility, and a diminution of the volitional ; the former overrides the latter : and not only so, but the particular elements of the former display their powers in an altered ratio ; sensational movements are not in due relation to emotional, nor are the latter to those of idea. Generally speaking, the lower ac- ' quires the ascendency, and exhibits the ! most marked phenomena. Involuntary muscular activity may be increased in regard of either the readiness with which it is called into exercise, or the force and persistence of its display. If these involuntary movements be placed in the following order — ideational, emo- tional, sensational, reflective, and organic — it will be found generally true that the increased readiness of action is found at its maximum in the first, whereas aug- mented force and persistence of action are observed most distinctly in the last ; and that the two kinds of alteration di- minish in passing from either one of these extremes towards the other. Voluntary movements are sluggish, the patient often lying about on sofas, or in bed, and saying that she is quite incapable of doing this or that. Irrational move- ments are in excess ; and, under the influ- ence of morbid "notions," gestures may be assumed, and sundry physical efforts performed which transcend the powers of health. All the emotional movements are exaggerated ; the individual laughs, cries, and makes grimaces of the most distressing kind, and manages often to do 6£8 HYSTERTA, that which she could not do under ordi- nary circumstances. Sensational movements are in excess : the brows are knit and the eyelids con- tracted upon the approach of light ; there is starting and tremor upon the occurrence of an}- sudden sound or jar ; there is vio- lent spasm upon the production of any pain ; and this often without any real exaggeration or sensibility. Reflex mo- tility is greatly increased and perverted, so that spasms arise from ''irritations" which in health would be passed by unno- ticed ; and numberless movements, of momentary duration and varied locality, occur in relation to impressions which are quite inadequate to produce them in the normal state. Other muscular actions, tonic or persistent, exist in various parts of the body, which differ from the reflex in the fact of their permanence, and must be referred to some induced change in the nervous centres. Of these, histrionic spasm, cramps, and long-continued spasms in the limbs or elsewhere, afford the most frequent examples. These tonic spasms are not confined to the muscles of the limbs, they may affect the pharynx, the oesophagus, the stomach, or the intestines; causing difficulty of swallowing or breath- ing, vomiting movements, strange noises, eructations, hiccup, borborygmi, and grip- ing pains. But besides the alterations mentioned, there is another kind which is less com- mon, but of more serious character, viz., paralysis. Loss of power usually occurs as the seque lof an hysteric paroxysm, but it may sometimes take place spontaneously M. Landouzy' states that, in 47 cases of hysteric paralysis, the distribution of the symptoms was as follows : — General paralysis of motion and sensation 3 " " of sensation .... 2 Complete left hemiplegia 8 Complete hemiplegia, side being doubtful 6 Paraplegia 9 Partial paralysis 19 Usually only one extremity is involved, sometimes only a part of the limb ; but in many instances there may be what is roughly termed "hemiplegia." In the latter case the face and tongue are rarely affected, and the paralysis is incomplete; and the motion of the partlv paralyzed leg is not like that of an ordinary hemiplegic individual. Dr. Toddsnys that the patient " drags the palsied limb after her, as if it were a piece of inanimate matter, and vises no act of circumduction, nor effort of any kind to lift it from the ground ; the foot sweeps the ground as she walks."" This is true of many cases. And there is a yet further condition which may be ' Traiti complet de l'Hyst(Srie, p. 106. " Clinical Lectures, p. 620. noticed, viz., the absence of any special paralysis of the extensor muscles of the toes. If an ordinary hemiplegic patient be made to walk, it is seen that on at- tempting to raise the foot from the ground the toes droop and the leg is circumducted; but the hysteric patient does what the healthy person cannot help doing, except by a strong effort of the will, — when mak- ing the attempt to walk, she causes an elevation of the great toe at the time of endeavoring to move the foot forwards. The paralytic patient looks at his feet, the hysteric patient looks at her observers. The electric irritability persists in the palsied limb, and its nutrition does not become affected ; but there is sometimes diminished sensibility to the electric cur- rent ; it is at other times normal, and in some cases notably increased. Occasion- ally the electric contractility and sensi- bility are both diminished or abolished. Paraplegia is a form of malady sometimes witnessed, and patients suffering in such manner may keep their beds, or leave them only to exhibit a most curious mode of progression, or a series of falls which are quite unlike those arising from organic lesion of the spinal cord. At this time I have under my care two cases of hysterical paraplegia, in which the symptoms are almost precisely similar. The limbs are well nourished, there is perfect electric contractility and sensibility ; the patients when lying in bed can elevate their limbs, separately or together, to any height that is required ; they can move all the toes, and cutaneous sensibility is intact : but if they attempt to walk, their legs appear to be no stronger than pieces of"wet paper, and they tumble down and bruise themselves in various quarters. What, however, is peculiar in the attempt at walking is this, that no amount of help, such as a "strong arm on either side, pre- vents the staggering and falling, but the patients tumble down to within a few inches of the ground, and then recover themselves without help. An ataxic pa- tient would walk, comparatively speaking, well with such assistance ; a really para- plegic patient' could not so recover the upright position. Where paraplegia has been due to hysteria, I have not found loss of power over the expulsors or the sphinc- ters of either rectum or bladder ; although it often happens that the latter exists with- out the former. General paralysis is ex- tremely rare, and is only imperfect in degree. 'Vaso-Motor Condition i.— Sometimes hys- teric patients, after a shght rigor, exhibit a certain amount of fever, with headache, and mild delirium, which speedily pa_ss away, or give place to paralysis of the kind described. An irregular distribution of temperature, or the fitful occurrence of sweating, of salivation, or of increase in NATURAL HISTORY: SYMPTOMS. 639 some other secretion, afford further illus- trations of disturbance in that portion of the nervous system which is related to the control of blood-supply. The Oeneral symptoms in Hysteria, or those outside the nervous system, are not distinctive in their character. Usually the patient is not in robust health ; there is some pallor, and failure of nutrition ; or there may be a great tendency to de- posit of adipose tissue. Sometimes there is a condition of habitual ill-health, or delicacy ; digestion is impaired, or the uterine functions are irregular, or there is some constant, but more or less indefinite, grievance in the head, thorax, or abdo- men. On the other hand, there are many cases of Hysteria in which the general health is good ; the patient eats, drinks, sleeps, feels, and is " well." Numbers complain of nausea, and eruc- tations, or vomiting ; but in many cases these symptoms have been entirely due to errors, and even absurdities of diet, and in not a few to excess of stimulants. It is by no means rare for hysterical people to "take to drinking." Alcohol relieves them for a time ; is often recommended by medical advisers ; the patients know its power to diminish their passing dis- comforts, and push, beyond all reasonable bojnds, their recourse to its aid. Flatu- lence and borborygmi of the intestines are common enough ; and so are palpita- tion of the heart, syncopal feelings, and dyspnoea — the last, however, without any notable change in the ratio of respiration to pulse. Large quantities of pale, lim- pid urine, of low specific gravity, are passed ; but this is also true of epilepsy and of many other diseases of the nervous system. With regard to affections of the generative organs, there is great discrep- ancy of opinion. Landouzy states that in twenty-six, of twenty-seven cases, there was some abnormal condition ;' and, fur- ther, that of sixty-seven cases of Hyste- ria, the symptoms coincided with material alterations of the generative apparatus in fifty-eight, and that in nineteen cases the Hysteria was cured after th£ removal of the genital affection :^ bu«l is, so far as my experience extends, the exception and not the rule to find any definite malady, or indeed definite complaint, in this direc- tion ; while in a vast number of cases there has been absolute health in all particulars relating to the reproductive organs.' ' Traits, p. 171. ! Op. cit. p. 174. ' Niemeyer says; "Unterden Krankheiten des Uterus sind es ausser dem Infarct nament- lich die Greschwflre des Miittermundes und Tor Allem die Knickungen der Gebarmutter, welohe am Hiiufigsten zu H. fUhren, wahrend liei bosartigen Neubildungen und bei destruct- iven Prozessen hysterische Zuf iille weit selt- ener smi."—Handbuch, 2er Band, p. 356. When men have presented hysterical symptoms, there have always been, in my practice, considerable deterioration of the general health, an impaired nutrition, and a feeble circulation, with exhausted brain. (6) Pakoxysmal Syjiptoms.— The at- tacks of hysteric convulsion do not pass through stages that can be defined, like those of epilepsy, to which they some- times bear a rude resemblance. They differ widely in degree of intensity, but have a general similitude inter se, and can rarely be mistaken in either their shghter or severer form. When slight, they are but an exaggeration of the interparox- ysmal state ; when severe, they have been confounded with certain grave diseases. The following may be regarded as the description of a severe attack : A patient is talking vehemently, often unreason- ably, and is agitated in manner ; she is crying or laughing, or both, and perhaps apologizing for or lamenting her weak- ness ; friends are either scolding or con- doling, and sometimes there is a combina- tion of both modes of domestic treatment ; some real or imaginary grievance is upper- most in the mind and the conversation, and is not " met" or removed by the en- deavors of the friends. Suddenly the patient gives a scream, or makes a splut- tering noise, appears to lose voluntary power and self-control ; she falls down with snorting breathing, and a quasi- tonic contraction of the muscles of the extremities and the trunk. She makes hideous grimaces and outrageous noises, throws her limbs about in a disorderly manner, utters incoherent sentences, adopts histrionic attitudes ; complains or her throat and stomach, and breathing ; appears exhausted, or faint, and some- times stupefied ; occasionally she seems to lose her consciousness, and then, after a fit of "crying," to be "herself again." The whole paro:5ysm may last for afew moments only, but more commonly it is of much longer duration ; a number of absurd gesticulations and irregular con- vulsive movements lasting from a few minutes to three or four hours, after which the patient seems worn out, and falls asleep. These points maybe observed during the attack : There is rarely absolute or sudden loss of consciousness ; the patient does not fall in such manner as to hurt herself, or tear her clothes ; there is some- body near who shall see the phenomenon ; hysteric paroxysms do not occur during sleep, or when the patient is alone ; there is something artistic in the mode of their approach —"the hysteric patient gathers her robe around her, and falls gracefully ; she appears to the casual observer to be unconscious, but there is not real or ab- 640 EYSTEKIA. solute loss of sense or of perception ; there is not the hideous distortion of feature observed in epilepsy, nor is there the dilatation of the pupil ; the eyelids may quiver, and the eyeballs may be turned up, but there is no divergent strabismus, nor is there the wide-open eye. Ex- amined carefully, the physician may ob- serve that the patient not only sees, but looks ; the eyes are often definitely turned towards objects or persons standing near, and then rolled up again towards the forehead : there is no bitten tongue, al- though there may be much foaming and spluttering with the mouth : the breath- ing is tumultuous and noisy, but there is no such absolute arrest of respiration as to cause asphyxia ; and the irregular movements and noises that accompany the labored breathing may often be seen to be occasioned by the lips. The attacks last for an indefinite time, are followed by much apparent exliaustion, but not by real stupor. "Wherever the attacks pass beyond the description here given, it is probable that something more than mere Hysteria ex- ists, and that the case borders upon the much more severe ailment known as epi- lepsy. In a few patients the two diseases coexist, and then the attacks bear some of the characters common to the two ele- ments ; but in the vast majority of cases it is comparatively easy to distinguish be- tween them. Mr. K. B. Carter, in an interesting book,' has described the hysteric paroxysm under three phases, giving to them the terms "primary," "secondary," and " tertiary ;" implying that in the first in- stance the attack is quite involuntary, and is the product of violent emotion ; that in the second it is reproduced by association of ideas ; and that in the third it is deliberately "got up" by the patient. There does not, however, appear to me to be sufficient reason for adopting these phrases, as I am sure that in many in- stances all that can be said of any of the tertiary paroxysms may be affirmed with equal accuracy of the very first attack. Hysterical Mania sometimes appears after an attack, and its features resolve themselves into an exaggeration of the condition already described as the "hys- teric state." The patient is unmanage- able, sometimes mischievous, and very often highly abusive ; but generally is merely loquacious, unreasonable, and de- monstrative in regard of emotion, and the attack speedily subsides under judicious treatment. It, however, exhibits a great tendency to recur ; and hysteric patients sometimes become, for a time, maniacal without going through a paroxysm of convulsion. ' On the Pathology and Treatment of Hys- teria, p. 43. Hypochondrtacnl sj-mptoms are met with, and are by no means rare, in cases of Hysteria ; but it is quite easy to sepa- rate the two diseases. Pathology. — Anatomical investiga- tion has failed to show the presence of any organic lesion which is either so con- stant or so prevalent in Hysteria, that it may be justly regarded as its cause. Pathological examination has been equal- ly unsuccessful in its attempts to explain the disease by a reference to the disturbed function of any one set of organs. It is common to find some derangement of the digestive, the assimilative, or of the re- productive systems ; but these may exist without Hysteria ; and vice versd, that disease may be present when those bodily functions are healthily performed. There is, however, one thing common to all cases of Hysteria, and that is a perturbed con- dition of the nervous system. The essen- tial character of this morbid state is an exaggeration of involuntary motility, and a diminution of the power of the will ; the emotional, sensational, and reflex move- ments are in excess, while the voluntary are defective. The outcome of such a condition is seen in the mode of life of the hysteric patient. The will is determined by anything rather than by judgment, while ideas, feelings, and fancies exert an undue influence. Sensations are often morbidly acute, are uncorrected by any careful discrimination, and thus they in- crease the evil. Keflex movements, which in health are under some control, are not only exaggerated in their individual in- tensity, as a part of the hysteric state, but, from the weakness of volition, are allowed to run such riot that they pass beyond all bounds of healthy iniiuence. It has already been shown that the hysteric condition is somewhat analogous to that of the earliest period of decay, whether that be the result of age or of degeneration from disease. Hysterical symptoms are common enough in soften- ing of the brain, and also during the course of, or convalescence from, exhaust- ing diseases. They may break out sud- denly, from a loss of blood, of food, or of rest, and they may occur as the immedi- ate sequel of some violent shock, mental, moral, or corporeal. Whatever weakens the individual generally may bring about this state of nervous disturbance, may alter the relations of the several nervous functions ; and this is, I believe, the true pathology of Hysteria, a disease which is more closely associated with affections of the nervous system than with those of the generative organs, although it is well known that the latter may and do exert a marked influence upon the former. The hysteric state is essentially one of mental perturbation ; and it is brought P.^THOLOGY. 641 into existence, if not inlierited, \>\ those conditions whicli are tlie most aetive in producing disorder of tlie mind : in tlie male sex by worry, anxiety, over-work, late hours, accidental injuries, and dissi- pation ; in the female sex by vexatious emotions, v^ant of sympathy or success, disappointed and concealed affection, ■vvaiit of occupation, fear, and morbid con- ditions, or supposed morbid conditions, of the reproductive system. The latter are sometimes the coincidents, but I believe much more commonly the effects of Hys- teria than its cause. Their relation is by no means constant in existence, and is most variable in kind. It would appear that the nutrition of the whole nervous system is changed, but that the change is of such kind that it passes beyond our power of recognition, except in its physiological or pathological effects. We cannot see degeneration of tissue here, or too rapid a metamorphosis there ; but we can witness the effects of such morbid processes, in movement, in secretion, and nutrition, and we can ob- serve some of the ulterior results of such changes, in emotion and sensation. The influences exerted by emotion upon secretion and nutrition have been well shown, in their relation to Hysteria, b}^ Mr. Carter,' and the inter-relations of physical, mental, and moral life have been very ably treated by Mr. Hovell in a more recent publication ;2 but the primary fact in that condition which we term Hysteria, would seem to lie behind all that is refer- red to in these considerations, and to con- sist in that special morbid change of the nervous centres, which either gives to emotion an undue influence, or removes the limitations of its action. There are divers links in the chain of causes and effects, but there is one link at which, in fixing upon the pathology of Hysteria, we must stop and say — all behind this is cause, all beyond it is symptom or effect ; here is the one point which determines ' Op. cit. p. 5 et seq. 2 Medicine and Psychology, p. 56, &c. The gist of Mr. Hovell's argument lies in the fol- lowing sentence : " The nutrition of the body is not affected, mental power is not impaired, although it may be suspended, innervation is deranged, for the generation of nerve power is feeble, and its distribution is irregular ; but it is the sympathetic, the vaso-motory system, the moral power, that is at fault: either from exhaustion of the physical strength of the sensori-motor centres, or be- cause, perhaps most frequently, the purposes of life are in some respects disappointed, and tlie paresis of disappointment not only saps the strength, hut, at the same time that it brings low the nervous system, also renders it peculiarly liable to irritable excitability from opposing and aggravating causes." P. "0, op. cit. VOL. I.— 41 the hysteric result. Up to this link we find the caui^cs of chorea, of epilepsy, and of insanity, together with and identical with those of Hysteria ; beyond it we And neither chorea, epilepsy, nor insanity, but what we term Hysteria : in that link, therefore, we must seek for and find, it we can, the essential fact of the disease. I do not say that we have found it ; still we are much nearer its discovery than we were fifty years ago : but I think it better to state, in general terms, wherein this morbid condition lies, than to lose sight of that point, by regarding some outlying facts, and attaching undue importance to certain frequent lines of apparent causa- tion and effect. There is nothing to prove that the vaso-motor or sympathetic system of nerve-fibres is primarily at fault ; on the contrary, it often appears that the secretions and the general nutri- tion are late in suffering ; and that the earliest departure from health is to be found in the disturbed balance of mental and emotional operations. If it be held that every change in every organ and every function is, more or less directly, determined by a change in the vaso-motor nerves. Hysteria may be driven theoreti- cally into this "sympathetic" corner; but, when it is made to go there, it will find itself -in company with almost every ill to which flesh is heir — with tubercle and corns, with cancer and ataxy. If the ' ' vaso-motor system " furnishes the agency by which all departures from health find their expression, we have yet to discover the nature and cause of those special changes in its action which lead to these particular results. The most general expression that we can give to the pathology of the hysteric state is, perhaps, this, that it is a malnu- trition of the nervous system, so distri- l)uted that its higher functions are rela- tively impaired and subordinated to the lower — that there is diminished power of the former and increased activity of the latter. Every one knows that, in health, there are numberless processes which are quite familiar to the mind, but which appear very strange when described in technical language. A physiological or pathological discovery is sometimes nothing more than the translation into scientific terms of a "well-known saw ;" and what may now be said upon the pathology of Hysteria is little more than such translation. Slight emotional excitement, such as shyness, trifling vexation, or moderate pleasure, may flush the face, quiver the lip, and make the breathing "panting;" strong emotion, such as terror, intense anger, or disgust, may blanch the cheek, fix the jaw, parch the mouth, and hold the breath. Moderate distress may "find relief in tears ;" but when grief is deepest the eyes 642 HYSTERIA. are dry. The postures of the various emotions are kuowu, and have bci-n studies for tlie artist in marble or on can- vas, and for the actor on tlie stage. If we express this pliysiologically, we say that emotions lead through certain nerve- tracks to the contraction or elongation of some muscular fibres ; that the vessels are dilated in the one instance, so that more blood than usual passes tlirough the or- gans ; and are diminished in the other, so that the circulation is arrested ; in the former, occasioning an excess of secretion, in the latter, a defect : that the muscles are spasmodically fixed in one condition, and in another are relaxed ; but what we want to know is the primary fact leading to such changes, when they are unusual in degree or persistence, and morbid in kind. Some individuals, we say, have more " control over themselves," or more "pre- sence of mind, ' ' than others ; that A never shows what he feels, while B never hides, and never can hide, anything ; and if we translate this into technical phraseology, it is but to say that the one is of " phleg- matic," and the other of "nervous tem- perament ;" that A is a stolid, resolute individual, and thatB is somewhat "hys- teric ;" but here again we do but throw the question one step backward. There is an old proverb to the effect that " it is the last straw that breaks the camel's back ;" and if we put this into other terms, it often means but this — that an individual has for a long time gone on bearing what was too much to bear heal- thily, that he has struggled against it, and by forced effort has made everything appear quite tolerable or even easy ; but at last he "breaks down" from some "shock," and then all the "wear and tear" comes out, and friends see that he had done or borne far too much before. Sometimes what is held to be " shock" is a mere trifle compared with the rough handling that had been previously en- dured without complaint ; it is simply be- cause it, a mere "straw," fell upon the already overburdened soul that the great crash came, and that then — all power of resistance being gone, the "back broken," as it were — the brave sufferer was pros- trate, crushed, gave way, and the pent-up tide he had kept back so sternly broke through destructively. In some there is weakness at the out- set, congenital, or acquired ; in others there is weakness, but it is induced by long patience, vexation, care, or trouble, that have at last done their work, and a work which it may take years to undo. But here, again, we have yet to learn why, out of a hundred individuals simi- larly exposed, one becomes hysteric, an- other epileptic, and a third maniacal. If we refer to the etiology of Hysteria, we shall see that all the facts point in one direction ; if we look to the symptoms, we shall see that they are partially explained. In the female sex, at certain ages and under certain conditions. Hysteria is most common, for it is but an exaggeration of that which constitutes the normal cha- racteristics of that sex ; in the male sex it is met with when circumstances have gradually converted males into the con- dition of the other sex; i. e.,when emotions have been so played upon that they have, at last, broken through the force of resist- ance, which held out for a long time bravely, but at length gave way. The essential fact of Hysteria, then, is the distorted balance between voluntai'y and involuntary power ; volition is defec- tive ; emotional, sensational, and reflex activity are in excess ; and this distortion may be brought about by the many and divers circumstances of age, sex, position, employment, and the like which have been enumerated in the section on etiol- ogy ; but the precise nature of the change which is the efficient cause of such distor- tion — i. e., the primary physical fact in the pathology of Hysteria — has yet to be dis- covered. Diagnosis. — If the symptoms already described be borne in mind, and the his- tory of each case be carefully considered, there is not much difficulty in the diag- nosis. A physician called in on an emer- gency may have, however, to distinguish Hysteria from several diseases which it simulates. From Epilepsy it may be separated by negative characters. There is neither the suddenness of attack, the absolute loss of consciousness, the dilated pupils, the complete asphyxia, the bitten tongue, nor the reckless injury of either the person or the clothes. The patient "looks about," the attack lasts longer, there is much sobbing and crying, much exhaustion, but no perfect stupor. The interparoxysmal state of the hysteric patient exhibits fea- tures not met with in epilepsy, and vice versA. [See Hystero-epilepsy, in this vol- ume. — H.] From various inflammatory affections, such as Peritonitis^ Laryngitis, and Arth- ritis, hysterical symptoms may be distin- guished by a careful use of the ther- mometer, which fails to show any rise of temperature. Again, the tenderness of ]iarts complained of may be seen to be ideal rather than real, and to bear rela- tion to the skin quite as much as, and often more obviously than, to the deeper tissues. When there is loss of voice, this has the characters already described ; there is no attempt made to whisper loudly ; the failure is evidently not in the apparatus of voice, as a mechanical pro- duction, but in the will to put that ma- PROGNOSIS. 643 cliincry into play. A laryngoscopic ex- amination will sliow tliat tlie tliroat is liealtliy, or is simply relaxed — the vocal cords being widely separated, and slight effort being made for their approximation. The pulse-respiration ratio will further show that although the breathing may be tumultuous, there is no real dyspnosa. Phantom tumors may be removed by the inhalation of chloroform, v/hile palpation and percussion usually reveal the nature of their constituents. Organic diseases of the nervous centres^ which are sometimes simulated by hys- teric paralyses and antesthesife, may be excluded by the conditions already de- scribed, when detailing, in the section on symptoms, the mode of their development. Usually the phenomena presented are in- consistent with the idea of any definite disease of either the cerebrum or the spine ; the paralyses are imperfect in de- velopment, vague in their distribution, and changing in their locality ; they are not accompanied by the alterations of nutrition, or of electric contractility or sensibility which are proper to other af- fections ; and the history of the case will usually reveal their true nature. The walk in hysteric paralysis has already been described ; but it is further to be observed that the patient does not look at her feet, as those who are ataxic do, but looks around about her to observe the effect of her performance. The ataxic or paraplegic patient tries to walk ; the hys- teric girl tries to show that slie cannot use her limbs : if the former forgets him- self, he falls ; if the latter forgets herself, she walks. Neuralgia, when of hysteric origin, has not the real intensity of the genuine dis- ease, as may be proved by withdrawal of attention. There is also an absence of those "painful spots," which are present when Hysteria does not complicate the case. The distribution of pain described by hysteric patients is, moreover, often so wide of all relation to anatomy and physiology, that its true nature may be recognized. Prognosis. — "When once established. Hysteria is very difficult to cure, and this is true under all the conditions of causa- tion. The most difficult cases are those in which it is but an exaggeration of a constitutional defect, inasmuch as it is impossible to cure the malady without changing the individual, and this is by no means an easy task. If the hysteric habit be natural, or have become a ' ' sec- ond nature" by long existence, the prog- nosis is pro tanto bad : if it be something quite unlike "the former self," or if it have been only recently developed, there is much room for hope. If the cause ex- ist in the patient, i. e., in the essential features of the individual character, com- paratively little can be done ; if it lie in external circumstances, much may be done, provided that those circumstances can be changed. If there be definite or- ganic disease, and this be of such a cha- racter that it is amenable to treatment, prognosis is so far favorable ; but if there be no such disease, and a fortiori if the general health be good, the prognosis is unfavorable. llj'steric symptoms, such as paralysis, aphonia, and the like, are often easily re- moved when they are of recent origin ; but when they have existed for many months, the prognosis with regard to them is uni'avorable. It is not, however, hopeless ; for in some cases, of even many years' duration, there has been amend- ment, and— but more rarely — cure. The prognosis in Hysteria depends, therefore, mainly upon these two things — the nature of the "cause," and the freedom with which treatment may be employed. Xo human being can cure, the physician can do but little for, one who is born hysteric ; i. e. , for one whose disease is but an exaggeration, and some- times only a slight exaggeration, of her habitual, constitutional state. Education might have accomplished much in child- hood, but often when the physician is called in, the grooves of life are worn so deeply that he cannot change them, and all that is possible is to soften their sharp edges, or to retard the movement which, he can neither stop nor guide. In such cases the prognosis is unfavorable. When Hysteria is an accident, is unlike the ear- lier promise of the individual, or when it is brought about by long, and at last un- endurable pressure from without, then there is much room for hope. "When the treatment of the hysteric patient is cramped by the anxieties of friends— hmited, in this direction, and in that, by fri::,ditened, too sympathetic, or unwise relatives— the prognosis is unfavorable; but when the circumstances are such that the physician can control them all, much hope may be entertained. Upon these points, rather than upon the special cha- racter of the symptoms, the prognosis turns. "When Hysteria is a disease, and the physician has given to him a carte hianclie to treat it as he deems best, the patient may be cured : but when it is a constitutional pecuharity, and the phy- sician is checked at every turn by anxious friends, the case is hopeless, and might as w^ell be left alone. In regard to all special symptoms, the prognosis is more favorable than it is in those diseases which Hysteria simulates ; but even here the general principles just stated arc the most trustworthy guides m our attempts to forecast the future. 644 HYSTERIA. TebAtmekt. — The old cop^'-book max- im, "Prevention is better than cure," expresses but a small portion of the truth in regard to the management of Hysteria: prevention might be easy ; cure is often almost impossible. It is not within the scope of this work to describe generally the processes of a healthy education, but some things that are special must be said with regard to prophylaxis. Bearing in mind the pathology of the disease, it is highly important that its earliest indications should be recognized and combated. When there is a tendency to Hysteria in early life, these things are necessary : — 1st. A strenuous effort to draw the per- son " out of himself, " or " herself, " and to develop the faculty of self-control. This should be done, not as an occasional or spasmodic effort, but as the business and prevailing arrangement of daily life ; and while it is done, and in order that it may be done, the predisposed person should be unconscious of the process. A child who is "peculiar," disposed to be taciturn, loquacious, "excited," or unduly gay ; or wlio is very readily "upset," and is "so sensitive" that parents and others are "afraid to tell her" this or that, "for fear that it should make her ill ;" — one who is " impulsive," and disposed to find fault with herself without just ground ; one who is "shy," and hides herself; one who is morose, and who thinks herself " misunderstood ;" or one who is retiring, and shuts herself out from the sympathy she craves for ; — should be carefully watched, tended, and unconsciously guid- ed away from self, and into some line of feeling, thought, and action, which may interest the mind without fatiguing the body. The worst thing that can be done is that which makes the patient know and feel that she is thought to be "peculiar." Sometimes such treatment is gratifying to her and she likes it— it is easy, and it "seems kind" to give it— but it is radi- cally wrong. Anything that looks like harshness, rigid discipline with a view to improvement, or want of sympathy from want of " understanding her feelings," is shrunk from, or resented by, the patient, and is worse than useless. At the same time, all exhibitions of a want of self-con- trol should be checked, and much of this kind may be done in the nursery, and long before Hysteria is dreamt of. ' Kindness, firmness, and obvious recognition of "ten- der points," with judicious, sympathetic, and wise regard to them, may do much to avoid future evil ; and sometimes the qualities of mind which will produce such treatment may be met with in a parent, a sister, or a governess. The physician should guide, in Uttle details of daily life, those who have the management of such a child. The object is to make her feel that she is understood and cared for ; and the best mode of attaining this object is often indirect in its operation. The mind and the heart should be engaged in some healthy pursuit ; interest should be awa- kened, and exercised in anything — it mat- ters not what — outside the individual ; self should be lost sight of, and life made useful. 2d. The bodily health should be most carefully regarded, and this witliout any admission or appearance of anxiety on the part of others. The points that re- quire attention are the following : — (a) J)iet, which should be sufficient, whole- some, and easj"- of digestion, avoiding too long an interval between meals, and ob- serving an especial regularity in the times at which they are taken. (6) Beat. The hours of sleep should be long, and those of rest or lying down not too long. Hys- teric girls, or those who are dif-posed to become such, are in the habit of reading at night and of lying in bed in the morn- ing. Such habits should be broken, — not roughly, for the sake of breaking them, and of "doing something disagreeable," but^by supplying a reason and motive for a different mode of life, (c) Exercise should be taken regularly, and in the open air, as much as possible without fatigue ; and here, again, the exercise should have some other apparent object than a mere piece of tedious hj-giene. {d) Becreation should be ample and merry ; but all such things as precocious or preternatural ex- citements should be avoided, (e) Study should be systematic and disciplinary, but varied and interesting, and made to sub- serve some purpose which lies, obviously, outside of mere personal accomplishment or pleasure. (/) The various functions of secretion, excretion, and (if they have commenced) of menstruation, should be regulated ; and this, again, should be done, as far as possible, without any particular notice being taken of the fact that they may be unhealthy. 3d. Some motive or purpose should be supplied which may give foixe, persistence, unity, and success to the endeavors of the patient. This is sometimes very difficult to manage ; but it is less difficult in early life and in predisposed persons than it is in those who are older and have already shown definite symptoms of the malady. Still, much may be done by those who have a little ingenuity in detecting cha- racter, and a great deal of perseverance and determination in carrying out their wishes. The patient should be led to feel that the object is in itself desirable ; she should never think that it is suggested for her own treatment or benefit. If she is urged on the former ground, she may do much ; if on the latter, she fails entirely. The hysteric patient is often most thank- ful for and happy in the idea that she is TREATMENT. 645 doing good to others, and she will take great pains to make her eftbrts successful and pleasing ; but she hates the notion of doing anything of such kind as a mere means of self-cure, thinks that the doctor who recommends them is grossly ignorant of her real wants, and that the friends who urge her onwards are singularly stu- pid or unkind in their advice. To "make an effort," simply because told to do so for her own sake, is sheerly detestable to the hysteric patient, and is sometimes as impossible as it is distasteful ; but to exert herself, almost unconsciously, because a motive is supplied, is scarcely felt to be an effort. The patient does what she herself is surprised and pleased with, and derives great benefit from the process. When the symptoms of Hysteria are developed, the treatment should be con- ducted upon the principles already laid down with regard to prevention. There is, so far as I know, not one single drug which exerts any specific action on the disease ; but there are many medicines which may be used with advantage for the relief of associated disorders. These do not require any special notice here, further than to say that if the patient be anaemic, iron is useful ; if deficient in gen- eral nervous tone, quinine, strychnia, and vegetable bitters may do good ; if there be indigestion with much flatulence, bismuth, charcoal, and alkalies, or mineral acids with light bitter infusions, may give relief; if there be constipation, mild aperients may overcome the difficulty ; if there be menstrual derangements, they should be treated upon general principles. The whole list of anti-hysteric remedies —such as musk, castor, valerian, asafce- tida, and the like — appear to have this one property in common, that they do no good, and delay the real treatment of the case, which is not one of "nauseous gums," but of mental, moral, and social management. Painstaking appreciation of the patient's own feelings ; determinate assurance that the disease is a real thing, and no idle fancy; strenuous effort to help the patient in weakness, and to set her right when wrong ; fertility of resource in little things; a cheerful but not boastful, a sympathetic and calm, but neither condoling nor anx- ious, manner ; and a strong will, with pa- tient work and tact, may do very much, and may often cure. But the physician should see that he manages his patient, and that all that he has attempted to effect is not undone by frightened relatives or anxious friends. There are some drugs which are useful under special circumstances ; and these are opium, or morphia, where there is loss of sleep, or persistent pain ; and the diffusible stimulants, where there is a great tendency to recurrent sjjasm. Mor- phia may be administered most effeetually, for the relief of pain, by hypodermic injec- tion ; it may be given by the mouth, with light food, when there is want of sleep. Chloric ether, ammonia, and musk, often relieve the tendency to spasm ; and in some eases Indian hemp has proved of service when other medicines have failed : in the large majority of cases, however, I have found Indian hemp of but little use. Asafoetida, in doses of thirty grains, three or four times daily, is of service in some cases. Bromide of potassium has appear- ed to me to be singularly useless in Hys- teria, faihng to reUeve either the attacks or the symptoms which exist between the periods of their recurrence. The attacks of hysteric convulsion may be arrested by a plan suggested by Dr. Hare — viz., that of forcibly preventing the patient from breathing" for a certain time, by holding the nose and mouth. The effect of such constraint is to make the patient, when allowed to do so, "draw a long breath," this vigorous inspiration being usually followed by a relaxation of all spasm, and a disappearance of the fit. Some attacks are of such short duration, that there is neither occasion nor time for this mode of treatment ; but when they are prolonged, I have seen it notably useful. Dashing cold water on the face and neck may sometimes succeed in doing im- perfectly that which Dr. Hare's treatment accomplishes efiectually ; but even cold water is not always at hand, and when it is — in addition to its other inconveniences in regard to carpets and dress — it often fails to do any good. A calm manner, the absence of all ap- pearance of alarm, and of either scolding or distressing sympathy, — all of which things the apparently unconscious patient observes much more accurately than do her frightened friends, — will sometimes bring a fit to a speedy end. Some special symptoms of Hysteria re- quire special treatment. Aphonia ma}^ often be cured by electricity ; and the mode of application which has appeared to be the most useful is that of giving sparks to, or taking them from, the larynx. An ordinary plafe or cylinder machine may be used for the purpose, and either the patient or the physician may be insu- lated, and the sparks taken from or given respectively by a brass knob. The inter- rupted current from a magneto-electric or volta-dynamic apparatus may be used so as to pass the shocks through the throat, or a shock may be administered from a charged Leyden phial. Under all these circu'mstanees, the voice is sometimes in- stantaneously restored. But when Apho- nia has been of very long duration, and such measures fail to affect it, good may be done by directly galvanizing the vocal cords, in the manner proposed by Dr. 646 ECSTASY. Morell Mackenzie. Further, I have known a strip of blister round the tliroat recall the voice when all means of eleotri- fj'ing have failed. Paralyses are treated very successfully by Faradization, and by passive move- ments and frictions, employed by a well- instructed nurse. The electricity should be applied to the muscles afiected, and also to the skin which covers them. I have, however, found no mode of treat- ing hysterical paralyses comparable in etficjency with that of placing narrow strips of blister completely round the af- fected limbs. This method of treatment has succeeded perfectly and rapidly, after all other plans have failed. Bhjid Contractions may be relieved by the continuous galvanic current, but much more successfully by the inhalation of chloroform, and the adaptation of some apparatus to maintain extension when the eftect of chloroform has subsided. Passive movements are also of much ser- vice in such cases. Drugs may be taken in almost poisonous doses without reliev- ing the tonic spasm. The treatment of other symptoms must be conducted upon the general principles already laid down, and may be assi^ted by those local sedative measures to which allusion has been made. ECSTASY. By Thomas King Chambers, M.D., F.R.C.P. By intense concentration on one object, engaging only a few of the intellectual faculties, the mind is liable to lose tempo- rarily its sensitive and controlling power in respect to its other relations. In minor degrees this state is a matter of daily ex- perience with us all, and in minds of ave- rage strength it does not seem to go be- yond minor degrees. They do not wish or practise such intense concentration ; they are able to do and feel all they want to do and feel without overtasking them- selves. But there are some, either natu- rally weaker, and so incapable of full feel- ing without concentration, or else desirous of a higher degree of emotion than they are healthily capable of; and in these a condition may be adduced allied in some respects to catalepsy, and in some to hys- teria — a condition certainly morbid, for it renders the patient unequal to the func- tions of social life, and is excited by causes which affect some and not others. Sometimes the patient falls into a state of immobility, in which there is a passive reception of ideas, like that of the Mid- ianite prophet "falling into a trance, but having his eyes open," a state he evi- dently considered rarer than that of a mere dreamer of dreams. Hoffman' de- scribes an ignorant peasant woman of twenty-four, after a fortnight's course of exciting sermons, remaining motionless for more than an hour ; after which she gave a few sighs and returned to herself, ' Medicina Ratioiialis, vol. iii. p. 50. having seen or heard nothing of what was going on about her, but having had ex- quisite revelations of the love of Christ. During forty days she had a hundred re- turns of the same state, which would al- ways be induced by a recitation of a few verses of the Scriptures concerning the love of God. During the fits the pulse re., mained quite natural. They were finally removed by a change of air and scene, after bleeding and stimulants had failed. The followers of St. Francis, in' the days of faith, were often brought into these ecstasies by fasting, meditation, and ab- stinence from varied intellectual exertion. Nowhere is it so strikingly depicted as by the Tuscan artist Cigoli — a man of by no means lively fancy, for, except an Ecce Homo, he painted nothing well but ecstatic and starving Franciscans. So he is probably truthful. After visiting each Florentine gallery it is difficult to expel from one's memory these strange figures, of marble paleness, kneeling, but sunk on one side from exhaiistion, the eyes open, the pupils fixed, the arms extended to embrace the beloved vision, the hvid lips parted in smiles, showing the parched dark mouth, the breast heaving with de- light. It is necessary to add only one medical fact, derived from M. Sagar's ob- servation' of a Capuchin in this state; namely, that the pulse was pretty strong. One main psychical difference between ' auoted by M. Tissot, (Euvres, vol. xiii. p. 4. ECSTASY. 647 this and catalepsy lies in the visions \Yliiuh are recollected afterwards with all the force of reality. In true catalepsy all memory of what is done during the tits is completely wiped away — a phenomenon which may assist in the detection of im- postors. A more common development of Ecs- tasy is where the sufferer feels '' home in upon him," a desire to communicate to others the feelings he is sensible of him- self, instead of reserving the experience till afterwards. The simplest instances of this are the scenes which take place from time to time in the Primitive Metho- dists' or "Banters' " chapels. The con- gregation groan and respond to the feel- ings of the preacher, second his words with their own experience, and various members work themselves up into a state of excitement, repeating the last words of the sentence, ''Salvation ! salvation !" or whatever else it may be, with continually increasing earnestness, till they end in shouting and sobbing. The next stage or form of Ecstasy is where the enthusiasm tries to express and exhaust itself in bodily movements. One of the most famous instances of this is the spasm of the Conmdsionnaires de Saint Medard, a disease which was by neglect allowed to attain most formidable proportions in the last century. It owed its origin to the discussion of dogmas whose character one would never have expected to have stimulated feeling ; namely, those which were in dispute be- tween the Galileans and Ultramontanists on the occasion of the bull ''Unigenitus." A popular Galilean deacon, named Paris, died in 1727, and was buried at St. Me- dard •, and on his grave people began to fall into convulsions, be affected with clairvoyance, preach, jump, spin round with incredible rapidity, run their heads against the walls, &c. &c. Of no avail was Louis the Fifteenth's proclamation, which some one parodied — " De part le Rol! Defense Ji Dieu De laire miracles dans ce lieu." In spite of it Convulsionism grew into a sect, and was at last only smothered by the French Revolution. A transition between this form and the last is exhibited in Revivalism ; and its reduction to a certain system and order is shown in the ceremonies of the Jumpers of New York and the Dancing Dervishes of Cairo. Sporadic cases of this Ecstasy not in- frequently occur in the experience of the promulgators of new or arousing doc- trine ; but judicious discouragement has usually prevented its becoming historical. We meet with it in the biographies of such men as Samuel Wesley and Edward Irving; and a valuable lesson is to be learnt from their wise mode of dealing with it, especially the former. The mention made of this disease being used by dishonest or foolish people as a bond of union for religious sects, leads to a point in its history which constitutes the main interest it possesses forpraulical consideration. It is eminently communi- cable, especially in its more active, noisy, and ridiculous forms. There is not much worth reading in the Pastorals of Longus ; but one expression of his — >j tCjv 6^fla>./»iui/ aXioaif ' ' the conta- gion of the eyes" — is so picturesque and truthful that he deserves the credit of it. Through the eye instinctive imitation, or sympathy, directs the first intellectual and corporeal efforts of the infant, and makes him grow up in the image of his kind ; and, as Longus felt, it is by such means that two adult souls get bound into one. So also through the eye flashes in that morbid state in which a nervous malady fetters the normal powers of con- trol, binding them up as with an electric spasm, and allowing the lowest animal emotions to exhibit themselves. An initi- ative compliance, a voluntary surrender of the gates of the soul, is doubtless neces- sary at first : but with each yielding the energy is weaker, and this natural and healthy sympathy may pass into an actual disease, of the mind, in which the power of the will is quite in abeyance. In this way, from the accidental eccen- tricity, convulsion, or insanity of often a single person, the strange spasmodic epi- demics of the Middle Ages arose. We can easily understand the disorganization which they produced among the lower orders, when we read that a few months after a new appearance of the " dancing mania" at Aix-la-Chapelle, on St. John's Day, 1374, there were as many as eleven thousand dancers in the streets of Metz. In this instance, at least, the outbreak took its rise in the scandalous midsum- mer revels, which had been handed over from paganism to the ascetic Baptist's festival, "in spite of the protests of the Church from St. Augustine to Pope Boni- face. The origin was a disreputable one, so the dancers hastened to avoid the in- ference by placing themselves under the protection of St. Vitus, one of the four- teen "Helpers in need.'" For full 150 years it was in Germany a most serious plaa-ue, of which a full history is given in Hecker's "Epidemics of the Middle ■ Most travellers in Flanders and Germany are probably familiar with the shrines of the fourteen "Nothhelfer" or "Apotheker" saints, spiritual specialists, of whom one cures tooth- ache, another stone, another cancer. It is a curious fact that the regularly educated phy- sicians, St. Luke, St. Cosmo, and St. Damian, are not among them. 648 ECSTASY. Ages." As a translation of that graphic description is published by the Sydenham Society, it is unnecessary to do more than refer to it those who are anxious to trace to its most disgusting results an extreme indulgence in uncontrolled sympathj'. Spasmodic epidemics seem to have ap- peared in Italy about the same time as in Germany, but to have been for some time confined to Apulia. At the end of the fifteenth century they spread further, and coincident with the spread there seems to have been observed an increase in the numbers of the tarantula or ground-spi- der. The two facts became associated together, and a panic flashed like light- ning through the country that this crea- ture was communicating the disease by its bite. Of "tarantism" in Italy, pure fright was as potent an exciting cause as superstitious fanaticism had been of the "St. John's" or "St. Vitus's dance" in Germany. And for this reason it affected a higher and better educated class of society. Even a sceptical prelate did not find his freethinking a protection. Quin- zato, Bishop of Foligno, having allowed himself in joke to be bitten by a taran- tula, fell into the disease, and could only be cured in the undignified method adopt- ed by vulgar laymen. (Hecker. ) He was obliged to kick off his shoes (such at least is the necessary prelude nowadays) and dance the tarantella. As an epidemic, tarantism has long dis- appeared, but sporadic cases are said still to occur, and hysterical women will per- suade their gossips that they have been bitten by the tarantula, and that they can- not get rid of their mental fidgets without an immoderate indulgence in the tradi- tional cure by dancing. Of the exciting causes of Ecstasy, and its allied spasmodic epidemics, the most common is perverted religious feeling, of which elaborate examples are given in the "iNew America" and other works of Mr. Hepworth Dixon. The reason is that, since the diffusion of Christianity, religion has a more powerful hold upon the emo- tions than anything else. But all histo- rians agree in attributing much influence also to venereal excitement ; and in pre- Christian times, when in default of revela- tion men worshipped their incarnate pas- sions, we have from the pen of Sappho a description of a purely erotic ecstasy, which can never be paralleled again. In the case of tarantism it seems to have been cowardice which was the exciting cause. The history of the treatment of exag- gerated instances of this disease is instruc- tive to us. not from the likelihood that any of this volume's readers will be called upon to undertake it, but as a suggestive guide for the management of allied states, semi- mental, semi-corporeal, which are as com- monly, as it is rarely, under mcdicrJ charge. Allusion is especially intended to two — dwrea, the heir to the name, and in a diluted degree to the nature, of the mediseval mad dancers who put them- selves under the protection of St. Vitus ; and to hysteria, which being more usual among women than among men, has ac- quired a name derived from a part oi their bodies anciently supposed to produce the symptoms— a nomenclature often leading to bad practice. 1. If taken in time, ecstatic and emo- tional exhibitions are capable of being for- cibly repressed. For example, in Unst, the most northerly of the Shetlands, an epidemic of convulsive fits occurring in sermon time began to prevail in several parish churches. At one of these, Xorth- maven, the disease was cut short by a rough fellow of a kirk officer, who carried out a troublesome patient and " tossed her into a wet ditch." Nobody else caught it.' From what scandalous scenes Europe might have been saved had the first dancers on St. John's eve been " tossed into a wet ditch !" 2. A strict quarantine prevents infec- tion. In 1796 an epidemic convulsion spread to twenty-four persons in Angle- sea. Their landlord. Lord Uxbridge, consulted Dr. Haygarth, and by his ad- vice all communication with the afflicted persons was prevented, and the plague was stayed, as he records.' I have often had chorea and hysteria arrested in hospital wards on separating the patients thus diseased, who had been keeping up one another's malady by sym- pathy. 3. Order, rhythm, designed consecutive- ness, and in short anything implying voluntary control, has a beneficial effect in this class of complaints. Doubtless when once Sappho had grown particular in winding up with a dactyle and spondee the pretty stanzas named after her, when Madam Guyon had learnt to be careful of her rhymes, and Saint Theresa had com- mitted her devotions to paper, all danger of contagious enthusiasm was past. But it is only an intellect of above the average capacity that can undertake to reduce it- self to order in this way. Those afflicted in Germany with the epidemic convul- sions before alluded to, took to dancing, evidently with an instinctive feeling that rhythmical movement was a relief to their morbid sensations ; but in that country the appUcation of it as a mode of cure does not appear to have been turned to such good account by art as in Italy. The ' Edinburgh Med. and Surg. Journal, voL iii. p. 4.39. ' Haygarth, "On the Imagination as a Cause and Cure of the Disorders of the Body. " Bath , 1801. HYSTERO- EPILEPSY, 049 tarantellas I have seen performed in South Italy are verj' complicated figures, accom- panied by an amount of arm-waving, fin- ger-snapping, simultaneous wriggling, slapping of hands, bumping of backs, and crossing one another's footsteps, that can only be accomplished by a strict adherence to time. And the time is marked by a tambourine or drum. These dances are probably nmch older than tarantism ; but for the cure of it they became popu- lar, and from it they got their name. It is impossible to doubt that they had a real influence, even over those who undertook them unwillingly, as in the case of the sceptical bishop above alluded to. The peculiar features of them, to which I should attribute their usefulness, are the marked time and intricate figure, by which they are honorably distinguished from the senseless rotatory embrace now called dancing. I am sure I have seen decided benefit in hysteria from dancing reels, and there would proljably be much more, if time were better marked and kept. In chorea, marching in timed stc]) is ex- cehent practice for regaining the directing po^ycr over the limbs. In stuttering, which is a sort of chorea, spouting poetry before a looking-glass contributes much to the cure. [HYSTEEO-EPILEPST. By Henry Hartshornb, M.D. It has long been a familiar fact to most practitioners, that some cases of Hysteria simulate or approach Epilepsy so closely that their diagnosis requires a very care- ful estimation of the whole history of each case. Latterly, Briquet,' and more espe- cially Charcot^ and Bourneville,' have elaborately described and analyzed cases which are regarded by some pathologists as a combination of the two maladies ; al- though Villermay, Briquet, Tissot, Char- cot, and others, consider them rather as examples of exaggerated Hysteria. Lan- douzy, Saunders, Anderson,* McLane Hamilton,^ and others, also, have record- ed cases having more or less resemblance to those of the SalpStriere. It appears probable that the two diseases may some- times be actually combined. In some cases Epilepsy is then the primary disor- der. Hysteria being engrafted upon it, generally by some powerfully disturbing emotional cause. In other instances. Hys- teria having previously existed. Epilepsy has been added, as it were, to it. Mar- riage, in some cases, seemed to be the immediately exciting cause. In others, the attacks (as in a case mentioned by [' Traits Clinique et Th^rapeutique de I'Hyst^rie, Paris, 1859.] [' Le9ons sur les Maladies du Systfeme Ner- veux, Paris, 1872.] [' Iconographie Photographique de la Sal- pMri^re (service de M. Charcot) . Par Bourne- ville et P. Regnard, Paris, 1878.] [' Brit. Med. Journal, Feb. 8, 1879.] [' Nervous Diseases, &c., Philada., 1878.] Hamilton) coincided with the menstrual period. A personal history of a kind likely to predispose to psychical as well as corporeal functional disorders, is stated to have oc- curred in connection with each of the most typical cases. Some were prostitutes ; others had suffered extreme fright (e. g., during the terrors of the Commune in Paris); or had been the victims of domes- tic tragedies. Preliminary symptoms of the attack are nasbfly always observable, through one, two, or three days. These are, palpita- tion of the heart, the "globus hystericus," noises in the ears, visual disturbances, and (ascertained by palpation) ovarian hijpercesthesia. Strong pressure upon the aflected ovary will sometimes arrest the attack. Charcot asserts' that ovarialgia is an important part of these seizures ; and calls attention to the not uncommon empirical resort to pressure upon the ab- domen, in convulsive affections of women, as long ago as the 16th century. Mercado, in 1513, advised abdominal frictions, and about the same time Monartes placed a large stone on the patient's belly during the seizure. Willits,^ in the 17th century, made a similar recommendation, which was, later, reviewed by Eecamier and ISTegrier. But most remarkable was the semurs afforded to the "Convulsionnaires de St. Medard," in the ISth century, dur- ing their paroxysms. Several m'etbods [I Op. cit., Lecture XI ] [2 De Morbis Convulsivis, t. ii. p 34.] 650 HYSTERO-EPILEPSY. were employed : 1st, striking the abdomen repeatedly with a heavy andiron, or a large wooden pestle ; 2d, the two fists of a man being thrust, with all his might, against the abdomen ; 3d, three, four, or five persons together getting upon the body of the " convulsionnaire ;" 4th, long bands being passed around the body, so as to compress it when they were drawn right and left. Charcot ascribes the ben- efit of all these measures to pressure upon hypercesthetic ovaries. For an account of the hystero-epileptic paroxysm itself, we cannot do better than to have recourse to a description, by an eye-witness, of one of Charcot's patients at the Salpgtriere. Dr. Arthur Gamgee, of Owen's College, Manchester, thus nar- rates' what took place in one of the demon- strations occurring during a visit in Au- gust, 1878, to Prof. Charcot's wards, made by himself, in company with Drs. Vir- chow, G. Stewart Turner, 0. Liebreich, E. Hart, and others : — '■• Hystero-Epilepsy; Absolute Hemiances- thesia with Bight-sided Orarinn Hyperces- thesia; IndiKtion of the Hystcro-Epileptic Seizure by Peripheral Irritation ; its Arrest by Compression in the Sight Ovarian Se- gion; Inhibition of Fits by contiguous Ap- plication of Pressure. — The patient, a young woman of considerable vigor and intelligence, is apparently about twenty- two years of age, and is vei-y frequently subject to the most characteristic hystero- epileptic attacks. These attacks had been exceedingly frequent on the day pre- ceding our visit, but had been inhibited by the systematic application of pressure to the right ovarian region, as will be more particularly mentioned in the sequel. They still continued to recur. "Professor Charcot pointed out that the hystero-epileptic seizure, besides occurring spontaneously, can usually be induced with ease by some modes of peripheral irritation. In the present case, for in- stance, by suddenly "gripping" the skin of the breast on both sides, about on a level with the fifth rib, and midway be- tween the anterior and posterior bounda- ries of the axilla, the patient instantly fell into the hystero-epileptic convulsion. The constancy with which the effect fol- lowed the cause was demonstrated over and over again to be absolute. "Although the various phenomena of the hystero-epileptic seizure are known to many readers through the writings of M. Charcot, it may be not uninteresting to describe them with all minuteness as they were presented before us by this patient. The attack may be conveniently divided into three or four stages. "■^ The first stage followed the appUcation of the peripheral irritation without the intervention of any perceptible latent pe- riod ; its features were the following : The head was thrown violently back- wards, the limbs and body became rigid, the respirations infrequent and stertorous; in a few seconds, the tonic spasms were succeeded by clonic spasms affecting the muscular system. A slight remission, Fig. 35. Hystero-Epilepsy, Stiiye of Rigidity. (Bournevilla.) lasting for a very few seconds, occurred, which was spoken of as a kind of entr'acte, and then commenced the second stage. The first may be termed the epileptiform, stage. " Tlie second stage was characterized by extraordinary movements affecting the whole trunk. The back being somewhat [' British Medical Journal, Oct. 12, 1878.] opisthotonically arched, the body was thrown with great violence and astound- ing rapidity alternately on to the occiput and heels. This stage, which, like the first, is of very brief duration, is denomi- nated the phase des grands mouvements; during its continuance occur the first hal- lucinations, to be afterwards referred to. The violent movements cease almost in- stantaneously, and then follows HYSTERO-EPILEPSY. 651 Fig. 36. Eystero-Epilepsy. Stage of "granda mouvements." (BonrneTlUe.) " The third stage, or stage of emotional attitudes [phase des attiticdes passionelles). During this stage, the patient assumes successively the expression of face, the attitudes, and the gestures which portray varied emotions — intense and vivid. The varied emotional states will he distin- guished in the order in which they oc- curred by letters. "a. No sooner had the great movements FiET. 37. Hystero-Epilepsy, Period of Contortion. (Charcot.) ceased, than, raising herself into a sitting I expression, the patient presented the posture, with clenched fists and menacing | most startling picture of one threatenmg. 652 CATALEPSY. but almost instantlj' the picture changed to "6. The whole exprtssiou and attitude portrayed cowering, abject fear. Of no longer duration than a, b was followed by stage "c. The patient now assumed an ex- pression of absolute beatitude. It is im- possible to describe the look of saintly happiness, as of one who realized the blcbsedness of heaven, which the patient presented. It was the expression which some of the old masters ha^e impressed upon their saints and martyrs. "But now occurred a cliange no less striking than the preceding. "c?. The expression of saintly happi- ness was succeeded by one of intense joy; the patient sees one whom she loves ; s-he beckons to him to come, to come quickly; he has come. . . . Then succeed ges- tures which stamp this as the phase of luhrkitij or the stage of the emotional atti- tudes. ' ' e. Again fear takes possession of the patient ; at first it is rats which she sees, and which she appears to fear the attack of, which evoke passionate exclamations of dread and disgust ; then it is obviously the fear of some human being which op- presses her, and causes her to beg for mercy. "/. There is no longer fear. The pa- tient hears the strains of music ; she is pleased ; she herself begins to hum the tune, but only for an instant, for " g. Pier singing is followed by weeping, which is broken by reproaches addressed to her parents as the causes of her misery. This last phase ((/) in the stage of passion- ate attitudes may be made to constitute a fourth stage, or a stage of recovery, in which halliicinations persist for a time." Other cases present difierent features. Sometimes .the clonic stage is followed, as described by Bourneville, by throwing out the arms at right angles from the body, as in the position of crucifixion. Induction of "mesmeric" sleep, with insensibility to pain, and artificial som- nambulism, is readily effected in some Hystero-epileptic patients. In them, also, the extraordinary action of metals, mag- nets, and galvano-electric spirals has been observed and recorded, by Charcot, Bourneville, Westphal, Dumontpallier, Luys, and others, to which allusion was made on a previous page of this volume.' It is, as befAre said, the eminence of those who have witnessed these phenome- na, and brought them before the attention of the profession, that entitles them to re- spectful attention. Much care has been evidently taken to eliminate as far as pos- sible the element of deception. The transfer of hemi-anwsthesia from one side of the body to the other, under the influence (however explained) of metals, magnetic or otherwise, appears to have been clearly established. It remains, however, yet to be placed beyond doubt how much of this and the connected phe- nomena is due to physical, and how much to psychical impressions and communica- tions. In any case, the study of Hystero- Epilepsy is of great interest, as furnishing a comparatively new chapter in the an- nais of Hysteria, to which, chiefly, its characteristics must be referred.] CATALEPSY. By Thomas King Chambers, M.D., F.K.C.P. !!S^A:^^E. — This word Catalepsy is derived from the Greek xaza.%rj^ii, a "seizure" or " arrest." Definition. — Catalepsy is the name given to intermittent attacks of a suspen- sion, more or less complete, of sensation and voluntary power, without convul- sions, accompanied by a stiftening, gene- ral or partial, of the muscular system ; so that the parts affected retain for a period of variable duration the position in which they happen to be at the invasion of the fit. DesceiptiOjST. — This is one of those pathological phenomena of whose anatom- ical cause we are entirely ignorant, and therefore it is best defined by its symp- toms, instead of committing ourselves to any vague theory of its nature. It is best to call " Catalepsy" any attack which ful- fils the conditions above named, and then we shall at once avoid all those discus- sions with which writings on the subject are laden about "true" Catalepsy and [■ See article on Hysteria.^ DESCRIPTION. 653 "false" Catalepsy, and the separation into symptomatic and idiopathic, ■which we have no warrant for malting at all. It is as much Catalepsy, and the ultimate morbid state is essentially the same, whether it is followed by a disease with another name, or whether it is followed by restored health. The following account of a well-marked case by Dr. John Jebb describes the de- tails of Catalepsy more graphically and fully than any I have yet read. He says :' — "In the latter end of last year (viz., 1781), I was desired to visit a young lady who for nine months had been afflicted with that singular disorder termed a Cata- lepsy. Although she was prepared for my visit, she was seized with the disorder as soon as my arrival was announced. She was employed in netting, and was passing the needle through the mesh, in which position she immediately became rigid, exhibiting in a very pleasing form a figure of death-like sleep, beyond the power of art to imitate, or the imagination to conceive. Her forehead was serene, her features perfectly composed. The pale- ness of her color, her breathing at a dis- tance being also scarcely perceptible, ope- rated in rendering the similitude to marble more exact and striking. The positions of her fingers, hands, and arms, were al- tered with difficulty, but they preserved every form of flexure they acquired ; nor were the muscles of the neck exempted from this law, her head maintaining every situation in which the hand could place it as firmly as her limbs. "Upon gently raising the eyelids, they immediately closed, with a degree of spasm. The iris contracted upon the ap- proach of a candle, as if in a state of vigi- lance ; the eyeball was slightly agitated with a tremulous motion, discernible when the eyehd had descended. "About half an hour after my arrival, the rigidity in her limbs and statue-like appearance being yet unaltered, she sang three plaintive songs, in a tone of voice so elegantly expressive, and with such affecting modulation, as evidently pointed out how much the most powerful passion of the mind was concerned in the produc- tion of her disorder, as indeed her history confirmed. In a few minutes afterwards she sighed deeply, and the spasm in her limbs was immediately relaxed. She complained that she could not open her eyes, her hands grew cold, a general tre- mor followed ; but, in a few seconds, re- covering entirely her recollection and powers of motion, she entered into a de- ' Appendix to Select Cases of the Disorder commonly called the Paralysis of the Lower Extremities, by John Jebb, M.D., F.R.S. Lon- don, 1782. tail of her symptoms and a history of her complaints. ' ' She informed me that she had no re- collection whatever of what passed in the fits ; that upon coming out of them she felt fatigued, in proportion to the time of their continuance ; and that they some- times lasted for five hours, though gene- rally for a much shorter period. "She further related, that the fits re- turned once or twice a day, sometimes more frequently ; but that she was never troubled with them in the night. She sometimes lost her sight and speech, the power over her limbs and her intellectual faculties remaining unimpaired. The fits frequently attacked her without any pre- vious warning ; at other times, a fiutter- ing at her stomach, and a fixed pain at the top of her head, occupying a part she could cover with her finger, announced their approach. "Hysterical risings in her throat, ap- pearance of fire, pains in her eyes, and not infrequently in her teeth, flatulence, a sense of weight in her stomach after eating, with convulsive motions in the region of that organ, were superadded symptoms of which she much complained. "Her disorder was evidently exaspe- rated at the approach of the catamenia, which were constantly present at the reg- ular period. She was always much agi- tated previously to a storm of thunder, and every material alteration of the weather produced a sensible effect. "After she had discoursed for some time with apparent calmness, the univer- sal spasm suddenly returned. Her fea- tures now assumed a different form, de- noting a mind strongly impressed with anxiety and apprehension. At times she uttered short and vehement exclamations, in a piercing tone of voice, expressive of the passions that agitated her mind, her hands being strongly locked in each other, and all her muscles, those subservient to speech excepted, being aftected with the same rigidity as before. "During the time of my attendance similar appearances were frequently ex- hibited. " I was informed by the family of many particularities in the access of the dis- order, all denoting its instantaneous effect upon the nervous system. She once was seized in my presence while drinkmg tea, and became universally rigid at the m- stant she was advancing the tea-cup to her mouth. Her tears sometimes flowed copiously, while every internal, as well as external, sense seemed entirely locked up in sleep. "I will now proceed to describe the pron-ress of the disorder, and the mode ol treatment, before she was entrusted to my Ccirc, " it appears that for many years before 654 CATALEPSY. the access of the c.ataloptical sj'mptonis, she had suH'ered much from violent head- aches, particulaLiy that species of head- ache termed clavus I13 stericus. Her spirits were easily discomposed. Her flagers, upon touching cold substances, would frequently lose their natural heat and feeling. Her habit of body had been uncommonly costive, but of late her bowels were much disturbed by every kind of laxative. Her nervous complaints were always particularly troublesome at the approach of rain and after a sleepless night. ^' Her disorder commenced with hys- teric fits ; to these succeeded a delirium of several days' continuance, attended with slight shiverings, but no other sign of fever"; the Catalepsy followed next in order, which at first aftected her with only single fits, at a week or fortnight's interval ; these gradually advanced in strength and frequency until by her own sutferings, and her sensibility on account of the anxiety of her friends, she was re- duced to the most pitiable distress." Then follow details of the treatment advised by Dr. Jebb, which was judicious and successful. An opium plaster to the epigastrium did good, but the last and longest continued prescription consisted of bark, gentian, and tincture of lavender, which she went on with till quite well. This exceedingly well-drawn-up de- scription makes one regret that the ac- complished author had not continued to apply his pen to depicting the eternal truths of nature, instead of wasting it upon theological and political advocacy. It renders needless the repetition of stock cases which usually illustrate the subject. Causes. — The most common exciting cause of Catalepsy seems to be strong mental emotion. When Covent Garden Theatre was last burnt down, tlje blaze flashed in at the uncurtained windows of St. Mary's Hospital. One of my patients, a girl of twenty, recovering from low fever, was woke up by it, and exclaimed that the day of judgment was come. She remained in an excited state all night, and the next morning grew gradually stiff, like a corpse, whispering before she became quite insensible that she was dead. If her arm was raised, it remained extended in the position in which it was placed for several minutes, and then slowly subsided. The inelastic kind of way in which it retained its position for a time, and then gradually yielded to the force of gravity, reminded one more of a was figure than of the marble, to which Dr. Jebb compares it. A strange effect was produced by opening the eyelid of one eye ; the other eye remained closed, and the raised lid after a time fell very slowly, like the arm. A better superficial 1 representation of death it is difficult to conceive. The pupils, however, contracted sluggishly under the infiuence of light ; and the pulse could be felt beating softly at both heart and wrist. She came round again by degrees in the course of the morning, and had no relapse ; nor had she any manifestations of ordinary hys- teria during her stay in the hospital, I believe. Less acute but more long-continued mental emotion will sometimes cause it. Tlie same year as that in which the last case occurred, I was attending for men- orrhagia from relaxed fibre a young wo- man, aged twenty-two or twenty-three, who had been a governess in a family I was acquainted with. She was of an affectionate disposition, and had been rather coldly treated — "misunderstood," as it is called. The menorrhagia, too, had pulled her down a good deal, and forced her into involuntary idleness. One morn- ing when 1 called to see her, she was in bed, unable to move, and scarcely capable of articulating. She said she was just recovering consciousness, but all the limbs were partially stiff, and the neck and back quite so, as appeared by raising her up with the hand at the back of the neck, when the body remained straight, resting on the heels. This state soon passed oft^ even while I was in the room. But the next morning I found her partially affected in the same way ; the left side was rigid, and especially the left arm, which re- mained stretched out at an angle when so placed. ' I observed that when I bent the arm, the deltoid contracted as it does when flexion is made by voluntary effort. She then told me that, though quite in- capable of moving the limb of her own unassisted will, she thought she could do so if I bade her very strongly. And such proved to be the fact ; for, on my rating her soundly and ordering her to get up, she at last obeyed. I explained to her what I believed to be the nature of the disorder, namely, a broken connection (to speak metaphorically) between the will and the nervous system ; and that she must rejoin this broken link by painful exertion and violent determination. She had no further relapse. In both these cases I convinced myself carefully that there was no deception. C'atalepsy is sometimes very brief and sudden. I have a young lady now under my care, for non-assimilative indigestion, of whom I received the following accounts from a mother of more than ordinary in- telligence and powers of observation. She said that her daughter was fond of read- ing aloud, and that sometimes in the mid- ' M. Tissot mentions a similar case of par- tial Catalepsy affecting tlie arms in a man. (CEuvres, torn. xiii. p. 56.) CAUSES. 655 die of a sentence the voice would sud- denly stop, a peculiar stiffiiess of the whole body would come on and fix the limbs immovably for several minutes. Then it would relax, and the reading would be continued at the very word it stopped at, the patient being quite un- conscious that a parenthesis had been snipped out of her existence, or that aught strange had happened. She grew much better under tonic and restorative treat- ment, and gradually ceastd to have these singular attacks ; but after about a month's interval, as she was one evening engaged in playing a round game of cards, she suddenly went oif into a regular epi- leptic fit, which was followed by sleep, and she did not recover consciousness till the next morning. This fit could be ac- counted for by certain errors in digestion, and she has had no recurrence of it, or of the Catalepsy, though four months have passed over. So I hope it was epilepsy of an intercurrent or curable sort. But sometimes the epilepsy preceded by Catalepsy is of a more serious sort. I re- member a much-respected lecturer in this metropolis, in whom the petit nial of epi- lepsy assumed this form. He used to be attacked sometimes in the middle of a sentence, with his hand wielded in de- monstration before his class. He would remain perfectly stiff for a minute or so, with mouth open and arm extended, and then resume his sentence just where he had dropped it, quite unconscious that anything had happened. After a time the seizures assumed the more usual and more fatal form. This sort of short attack is not, how- ever, always the precursor of anything so serious. Nor, if traceable to a material cause, is that cause necessarily in the brain. Van Swieten tells a story of a woman, forty years of age, who was roast- ing chestnuts in the frying-pan, and kept continually stirring them lest they should be too much scorched ; in doing which, she was seized with a true Catalepsy. As Van Swieten lived hard by, he was im- mediately called in ; in his presence she suddenly vomited two live worms, and forthwith proceeded with her cookery, quite unconscious of what had happened. She had no relapse.' Other cases are of much longer dura- tion. The death-like state may last for days. It may be mistaken for real death, and treated as such. In the old pre- Christian times we do not hear of this, though it was a sort of thing that would appeal strongly to the feelings and me- mory. No Sadducee seems to have sug- gested Catalepsy to discredit the real re- ' Van Swieten's Commentary on Boerhaave, § 1040, vol. X. p. 170. surrections recorded in the Gospels,' and the fear of being accidentally buried aUve is never alludcil to by the classic writers, though so picturesque and so capable of poetical treatment. Any cases of appa- rent death that did occur weve burnt, or buried, or otherwise put out of the way, and were never more heard of. But after the establishment of Christianity, tender- ness, sometimes excessive, for the remains of departed friends took the place of the hard heathen selfishness. The dead were kept closer to the congregations of the living, as if to represent iu material form the dogma of the communion of saints. This led to the discovery that some per- sons, indeed some persons of note (amongst others, Duns Scotus the theologian, at Cologne), had got out of their coffins, and died in a vain attempt to open the doors of their vaults. Others were more fortunate. Those who have visited the Lutheran cathedral at Magdeburg, have probably not failed to notice a quaint monument to the Frau von Asseburg. There is her effigy on it in stone, kneeling with her husband, and, in the style of the period, a goodly line of sons on one side and daughters on the other support the pair. The inscription relates how that this noble lady was, after her marriage, supposed to be dead, and placed in the family vault. Luckily the entrance was left unclosed that night, for she rose up, returned to her home and husband, and bore all this fair family aftei her strange experience of the tomb. Such events caused no slight panic at the time, and probably led to the custom, still kept up in many parts of Germany, of fastening a bell-pull to the hand of a corpse when laid in the public mortuary. Some cases of resuscitated cataleptics have even occurred in modern times, ac- cording to the statement made by Arch- bishop Donnet to the French Senate last spring. Catalepsy may be a premonitory symp- tom of other diseases. Epilepsy has al- ready been mentioned. De Haen relates, in a clinical lecture, a case he saw of a child of twelve, who began by being cata- leptic, and ended by reciting the metrical Protestant version of David's Psalms, say- ing her catechism with proof texts, and 1 Had he done so, it would have been a telling argument for the Council and the Scribes ; but it would have small weight with an experienced physician now, nor would it make the miracle any the less in his eyes. He would know that it is quite as supernatu- ral to detect a cataleptic in a funeral-train accidentally met at the city gate, or in one who had lain three days in a tomb completely rolled up in mummy cloth, as it is to raise the dead. 656 CATALEPSY. preaching a sermon on adultery.' And in several other stock cases, somnambu- lism seems to have been a complication. Marx saw a girl who became cataleptic from being frightened at a fire (like my patient at St. Mary's), and afterwards went out of her mind.^ In Goebel's case of a young soldier, Catalepsy complicated the invasion of melancholia.'' Sauvages says he saw an old man in the hospital at Alais, in whom Catalepsy alternated with quartan fever. '' Catalepsy seems to be sometimes volun- tary, or at least capable of being brought on by very little external aid. Of this, St. Augustine gives an instance within his own knowledge : — "There was a certain presbyter of the name of Kestitutus in a parish of the dio- cese of Calami, who, when he pleased (and he was often asked to do it bj' those who wished to have ocular demonstration of the strange fact), just by having a noise made like as of somebody crying, used to convey himself out of the influence of sen- sation, and he like a corpse. So that not onlj- was he insensible to people pinching and pricking him, but sometimes fire had been brought and he burnt with it, with- out any sense of pain, except from the wound afterwards. The body seemed to be motionless, not in consequence of any voluntary eflbrt, but from want of sensa- tion, as was made the more probable by the absence of any appearance of respira- tion, as in a dead body : yet people's voices, if they spoke out very clear, he said afterwards he could hear as if they were a long way off. "' Persons "liable to this form in various degrees lose, by yielding to it more and more, their power of voluntary control, so that exhibitions of it are easily brought on by others who assume an influence over them. They are told in a positive manner that they cannot raise their limbs, cannot open their eyes, cannot feel, and they really seem to lose temporarily mo- tion, sight, sensation. Mesmer turned this artiflcial production of disease to profit (his own), and it has been largely experimented upon of late years. But the unfortunate subjects of it have brought to their masters so much "gain by their soothsaying," that deception has largely adulterated the real phenomena, and it is difficult to find a genuine patient. For this reason I thought it preferable to 1 De Haen, Ratio Medendi, vol. i. cap. xxsiii. 2 Marx, De Spasmis, § 61. " De Catalepsi, aiitore Theophilo Goebel. (A Berlin inaugural thesis, 1818.) * Memoires de I'Academie Royale des Sci- ences, &c., 1742, last page. ^ Augustine, De Civitate Dei, lib. xiv. cap. xxiv. quote a case from a writer of unimpeach- able shrewdness and honesty, and far from credulous, though destitute of the light of modern science, than to detail the experience of our own generation. In the artificial disease and in the natu- ral, somnambulism {clairvoyance) is a fre- quent complication, as appears from sev- eral cases cited by Tissot. (CEuvres, toui. xiii.) It was not a groundless idea to suggest that, as we employ counter-irritants to re- lieve an internal unmanageable inflam- mation by one which is under our control and less injurious, so hysteria might be cured by inducing in its place an allied malady more subject to our will. But harm seems to be done bv it, and probably only a limited number of the English race have a suitable diathesis. ' Both in the natural and artificial dis- ease there is exerted a very diflerent in- fluence over the patient by different indi- viduals. The sight of l)r. Jeljb's face seems to have acted like the Gorgon's head in reducing his patient to instanta- neous marble. Mj- own experience is quite the reverse. Strange nervous phe- nomena ah^'ays seem to be frightened away or subside into conmionplace at my presence, and so perhaps my report of them is printed in less bright colors than the subject admits of. Natural Catalepsy seems to become less frequent, or, at all events, the symptoms less marked and strange, as the world grows older. Some are even getting scep- tical about its existence, and doubt the propriety of retaining it on our list of dis- eases. But even if it should be as extinct as the dodo or the great auk, this insult is uncalled for. The circumstances which surround the human race, especiallj' when sick, are so altered, that it would be won- derful if some of the phenomena exhibited in pathological conditions were not altered too. Read the treatment adopted in many of the cases of Catalepsy quoted by the systematic writers. Take, for in- stance, that which M. Sauvages commu- nicated to the Academic des Sciences,^ where intermittent attacks of the disease occurred from time to time during several years. Though the patient was pale with a weak pulse, and though the blood could scarce be got to flow from the veins, yet she was bled, once from the arms, many times from the feet, and seven times from the neck. She had five or six repetitions of purgative medicine, not to mention ' Those who wish to pursue the subject of mesmerism will find it treated of with the broad views of a non-specialist by Feuchter- sleben in his Medical Psychology, translated by the Sydenham Society. 2 Memoires de I'AcadiJmie Eoyale des Sci- ences, Annee 1742, p. 409. CAUSES. 657 houillons aperitives, stomachic opiates, and twenty tepid batlis, before they tliou,i;ht of giving her iron, whicli wrouglit a cure sooner than one could have expected. I lighted accidentally on another case com- municated to the same scientitic body by M. Imbert, in 1713.' It is that of the driver of the Rouen diligence, aged 45, who fell into a kind of soporific Catalepsy on hearing of the sudden death of a man he had quarrelled with. It appears that "M. Burette, under whose care he was at La Charite, made use of the most powerful assistances of art — bleeding in the arm, the foot, the neck, emetics, pur- gatives, blisters, leeches," &c. At last somebody "threw him naked into cold water to surprise him." The effect sur- prised the doctors as much as the patient; it is related with evident wonder how that "he opened his eyes, looked stead- fastly, but did not speak." His wife seems to have been a prudent woman, for a week afterwards she " carried him home, where he is at present : they give him no medicine ; he speaks sensibly enough, and mends every day." Again, the "damede FesoMt," whom M. Tissot justly calls " la cataleptiqiie par ex- cellence," so characteristic were the phe- nomena, was attacked during Lent, when she had been starving herself in order to give alms to the poor, and was also wor- ried by a lawsuit which had brought her to Besan9on. Yet she was bled in the foot. Fortunately, after three days, her friends took her home to Vesoul. What happened then the reporter says was quite as wonderful as her illness,^ namely, that she had no more medical treatment, and yet got well without a relapse. I cannot feel the same wonder, for I feel sure that the "powerful assistances of art" — bleeding, blistering, starving, purg- ing, coddling, sympathizing, and admir- ing—would have converted any of the cases under my charge into equally mag- nificent specimens of a long-continued in- termittent disease. But the fact of its being partly pro- duced by art does not make Catalepsy a bit less of a reality, for the same may be said of all preventible diseases. _ Besides the effect of treatment, it is likely that the unrestrained manners and want of mental control peculiar to the barbarous ages of all nations, would ren- der mediaeval Europe liable to exaggerated exhibitions of all physical defects. And, as physical defects are indubitably hered- itary, the national temperament would be thereby afiected. As an example of ' Martin's Memoirs of the Academy of Sci- ences at Paris, vol. iv. p. 360. ' "Ce qui ne surprendra pent-etre pas moins que sa maladie." (Tissot, ffiuvres, torn. xiii. p. 16.) TOL. I. — 42 what is alluded to, take one scene from early English history, and conceive it happening in the present day. Eancy four members of the Queen's Privy Coun- cil calling after lunch on a refractorv archbishop who had voted against tlie Ministry that had appointed him, with the intention of showing him the error of his ways. Fancy them scolding and blas- pheming " by God's wounds," giving him the he, "jumping up and leaping about," " throwing about their arras," "twisting their gloves," "raving hke madmen." Fancy him, red in the face, defying them, rushing after them to the door, calling one his lackey, and another "a pimp." Yet this is only a part of the want of re- straint shown by both parties when Regi- nald Fitzurse, William de Tracy, Hugh de Morville, and Richard Brito called on Archbishop Becket on the afternoon of December 29th, 1170.' The mere fact of the murder, with the nauseous details of how Tracy picked out the brains with his sword, is not half so strange as such a scene. How many generations does it take to produce descendants of such men free from nervous disorders ? The deficient vitality of which Catalep- sy is a manifestation occupies that puz- ling part of the circle of hfe which lies between spirit and matter. We know so little about the chain which connects the two, that its links are reckoned by us as few and short, and we have no names for them. Yet when we see the varied phe- nomena produced by breaches in the con- nection, we are led to feel our ignorance of the subject, and to conjecture that these abysses of incertitude veil a long list of vital functions. In default of names for even the normal functions of this department of life, we must not expect an accurate nomenclature for their aberrations from health ; and the most we can do in attempting to classify them, is to observe how near their origin lies to one or the other extremity of the series of vital acts which are interfered with — what relations their phenomena bear on the one hand to mind, and on the other to body. We shall thus have a natural order with pure insanity at the one end, and epilepsy traceable to organic lesion at the other. In the middle will lie ecstasy. Catalepsy, and hysteria, with many a blank between for the anonymous transitional forms. I do not think we can spare any of these names, and instead of clubbing them together, as some would fain do, under the common head of "hys- teria," it would appear more useful to divide that disease, according as its emo- tional, anesthetic, hyperajsthetic, or con- vulsive phenomena are most prominent. ' Hook's Archbishops of Canterbury, vol. li. p. 497. G58 SO.MNAMBULISJI AND ALLIED STATES. I say it would be u:-eful to make a main P'lint in each individual case wliether the malady is most related to deviation from mental or bodily health ; for I feel con- vinced it is only by this observation that we can avoid such disappointment as leads many to look upon hysteria, for example, as an opprobrium niedicinm which makes them feel the same sort of anger against it as is roused by moral guiltiness, and disposes them rather to punish than to cure the patient who has thwarted them. Treatmekt. — As to the treatment of Catalepsy, it is probable that valerian and ammonia, administered in draught or enema, whichever is most convenient, together with a modification of what cured the Rouenese stage-coachman, namely shower-baths, will accomplish all that is wanted in the way of medicine for the slighter cases likely to come under treat- ment in the present day. In longer con- tinued cases Dr. Jebb's prescription of an opium plaster to the epigastrium, with tonics to the mucous membranes, is ra- tional practice ; for Catalepsy seems to depend much on the mucous membrane of the stomach, as is the case with its sister malady, hysteria. But I would strongly urge upon all who have the charge of these and similar mental, serai- corporeal manifestations, to take the hint given me by the second patient, and try to acquire (surely it is to be acquired by trying) tlie habit of command. Let them exercise it in the direction of sup- plying the deficient will, not of paralyzing it, of demesraerizing instead of mesmer- izing their patients, and it is astonishing how much pharmacopoeial medication will be saved to both parties. Catalepsy may be sometimes feigned. For its detection the most cruel means appear sometimes to have been adopted by our forefathers, such as burning, pinch- ing, cutting, putting into coffins, and otherwise frightening the supposed im- postors. A caution is therefore needed, that the trial of the^^e methods would in England very properly subject the experi- menter to legal proceedings, the more so as they are quite useless, and prove no- thing. Ko malingerer could successfully feign the peculiar wax-like yielding re- sistance of a cataleptic muscle, and ought to be immediately detected by a medical man. If a doubt is felt, some expedient may be tried like that of Dr. Marx. Ob- serving that really cataleptic limbs finally, though slowly, yield to the force of gravity and fall by their own weight, he attached a heavy body to the extended hand of a suspected imposter. She bore it up with- out moving ; the intention of the experi- ment was explained, and she confessed her fraud.' The points intended to be made con- cerning Catalepsy are these : — 1. That it is a rare pathological condition of mind and body, allied in its causes to hysteria, but not so apt to become chronic. 2. That it is not dangerous in itself, though it may be the precursor of danger- ous disease. 3. That it may be artificially produced, but is not easy to feign. 4. That the treatment, moral and phy- sical, should be conducted on the same principles as the treatment of hysteria. kSOMj^ambulism a:n"d allied states. By Thomas Kinq Chambees, M.D., F.R.C.P. SojixAMBTJLiSM is a slumber so mor- bidly profound that resisting spontaneity is loit, and the obscure images, known as ordinary dreams, are able to exert a mo- tor power. " Sleep-walking," where even tlie intricate concatenated motions neces- sary to preserve the Ijody's balance are performed, is the most striking and dan- gerous exhibition of this state, and there- fore has given a name to the disease ; but it differs in degree only from sleep-talking, sleep-eating, and a form of noc'turnal in- continence of urine and of spermator- rhcea. That it is not a partial waking is shown by the difficulty always found in fully waking a somnambulist, and also by the bewilderment and slow return of consciousness afterwards. This be^^'ilder- ment, moreover, is often followed by head- ache and a clamminess of the mouth, jutt like that of the condition known as " the intoxication of sleep" in those who have slumbered too heavily and too long. Again, decided somnambulists are en- tirely ignorant of what they have been doing during sleep : whereas dreams which ' Marx, De Spasmis. Halae, 1765, § 19. SOMNAMBULISM AND ALLIED STATES. 659 occur (Juriug a partial waking are always remembered more or less. Again, ttie automatic acts done during partial waking are very short, have no continuity, and quickly end in a decided condition ; whereas the acts of the somnambulist are consecutive one upon another. It seems impossible, therefore, to a^ree with Drs. Symonds, Hartmann, and others, who have regarded it as an incomplete sleep. Still less can we agree with the super- stitious awe which would represent it as an exalted state, in which the soul is freed from the trammels of the corruptible car- case. It is in truth a lower life, in which " the sceptre of reason is surrendered to a physically-directed fancy." (Feuchter- sleben.) Instead of nearing the angels, man thus approaches temporarily the na- ture of ill-bred horses who refuse to lie down in their stalls, birds who roost stand- ing on one leg, and gorged dogs who — "Weary with the chase, Lie stretch'd upon the rushy floor, And urge, in dreams, the forest race From Teviotstone to Eskdale Moor." This morbid sleep usually arises in the first instance from eating too much. Per- haps the overloaded stomach presses on the solar plexus, and produces a partial paralysis in the coats of the arteries, and so in the cerebral circulation. The ex- planation is the more probable, because sleeping with the head too low is another predisposing cause, whose action would be on the brain. Strong mental emotion, excessive exer- tion of the intellect, violent grief, love, &c., probably act in the same way ; namely, by arresting digestion and causing a weight at the stomach. When, however, the habit is once estab- lished, it is persisted in even after the gluttony or emotion has been discon- tinued. In this it follows the rule of all morbid states of the nervous system, ■which are peculiarly apt to be retained in spite of the removal of their causes. It is most common in j'outh, and at about the age of puberty. Then the sexes are equally subject to it ; but later in life it seldomer attacks men than women. Somnambulism is sometimes heredi- tary. A young lad}^, about whom I have been consulted a few times this summer, will often (sometimes two or three days a week) go off in the evening into a pecu- liar dreamy state. She talks and answers questions, though after an interval, walks about the house, goes to bed, remains quiet at night, and sometimes recovers her ordinary condition on waking : but sometimes her mother will go into her room and find her dressing in a vague, dreamy way. After a while she will stare, stretch herself like a person waking from sleep, and resume her natural lively manner. Her memory is always quite blank as to anything said, seen, or done during this condition. iShe has never had any hysteric or epileptic fits. Such are the symptoms, and her father asked me what name I should give to the disease. I hesitated at first, and then said that some might call it perhaps catalepsy, but that the more proper name was Somnam- bvilism. That Avas curious, he observed, for his mother had been afflicted with what was called both catalcps}' and Som- nambulism, and he had heard it was in the family. I have also recently under- stood that a younger sister of mjf patient is falling into the same state, but I have not seen her. This lady had occasionally got out of bed when in her unconscious state, but it happened so seldom that no alarm on that score was expressed by the family. Somnambulism is inconvenient to other people from the fright it causes, and dan- gerous to the patient from the awkward positions it puts him in when unprotected by reason. But it is by no means incon- sistent with a fair condition of general health. It is, for instance, not unfrequent amongst boys and girls at school who bodily and mentally are quite equal to their companions. At schools accidental accesses of it are liable to be fostered into a habit by the patients' room-fellows talking to them, and otherwise " drawing them out," when in this state. Like epilepsy, and indeed all diseases of the nervous system, it is apt to become peri- odical. Some persons will walk or talk, or wet their beds, &c. , once a fortnight, week, or month, and so on with great regularity. That does not arise from an accumula- tion of secretion or excitability ; for at first, and while the original cause is pre- dominant, several attacks occur often close together in succession, and then cease. It is rather an evidence of the weakness becoming constitutional, after the original cause has been removed. Somnambulism has in some rare cases alternated with catalepsy, of which M. Sauvages has recorded an instance. {See Catalepsy. ) ISIore generally, it alternates with a normal state. There are cases recorded where the somnambulistic sopors have been so fre- quent and so long, that there is as much of a sleeping as there is of a waking condi- tion, and thus has arisen the singular phe- nomenon called "double consciousness." Trains of thought are carried on from one attack to the next, though in the normal interval the mind is quite unconscioiis of them. A remarkable instance of this is recorded by Dr. Dewar, in the "Transact tions of the Royal Society of Edinburgh," vol. ix. p. 365. A servant maid began by 660 SOMNAMBULISM AND ALLIED STATES. being subject to attacks of extreme sleepi- ness : then in tiiese sleeps she began to be talkative. Soon there appeared more method in what she said : slie personated an episcopal clergyman, went through the baptismal service for three children, and delivered an extempore prayer. Another time she was a jockey at Epsom, and rode round the kitchen on a stool. On awaking, all these pranks were quite for- gotten, but in the succeeding fit she re- membered all that occurred. Thus, one night a villain indecently assaulted her when somnambulistic. On the morrow the insult was forgotten, but shortly after- wards she had a fresh attack and told her mother of it. She got well after an emetic and the return of the catamenia, which had been absent. Dr. Abercrombie adds two more cases related to him by non-medical persons, and for that reason (probably) accompa- nied by more wonderful phenomena. (On the Intellectual Powers, Pt. III., sect. iv. ? 2, n.) In principle these phenomena are quite in analogy with healtliy dreams, which scarcely ever take cognizance of re- cent facts of the waking state. For ex- ample, in my own dreams, though I had the misfortune to lose a leg two years ago, I always seem to walk about as in youth. And I certainly remember a room-fellow at school who used to talk in his sleep on a class of subjects he never mentioned by day, and who seemed to recollect when in the same state next night that he had spoken of them before. But that an edu- cation should be carried on, and languages acquired, during somnambulism, as some strange stories record, is hard to credit. Possibly some confusion existed in the minds of the observers, and they mistook the waking for the sleeping state. Somnambulistic phenomena have some- times accompanied the artificial catalepsy of the mesmeric trance. They are called "cZairro/zaiice," not that the patients see particularly clearly, but that the common sensorium is very receptive of those slight suggestions which it would neglect at other times, when its attention is occupied with the external world ; and so they ap- pear to careless observers to see with the tips of their fingers, the epigastrium, &c., when their eyes are closed. Singular ex- hibitions are thus produced. i3ut with practice this rapid obedience to slight suggestion is soon acquired by even stupid people ; so that jugglers have no difficulty in obtaining sham cases for shows, by no means easy of detection. This prevents the investigation of the subject by scienti- fic persons. Trbatmekt.— 1. The patient must be removed from the company of those who would be disposed to foster into a habit by experiment the recent establishment of the disease. This applies particularly to young persons at school, and those brought under the dominion of mesmerizers. 2. The patient must be prevented from falling into that morbidly deep sleep in whicli the special phenomena of the case are produced. This can be accomplished by wakinw them up once or twice in the night, before they begin to walk, talk, or do other unseemly acts. It may be done with great advantage during the second hour of sleep in cases of simple sleep- walking and of bed-wetting. A young lady under my care who used to rise and make water on the floor with- out being aware of it, was relieved by this means. M. Trousseau' knew a wealthy and beautiful girl, from whose feet wooers had been driven away by an incontinence of urine occurring nightly. At last the im- pediment to marriage was overcome by a hero. M. Trousseau cynically calls him " un individu sans fortune," implying that the girl's purse was her only attraction ; but poetic justice requires a better motive for an act so richly rewarded ; for, like the knight of whom the "Wif of Bath" tells, he found her " bothe faire and good," when expecting, like him, the latter only; the disgusting affliction vanished straight away — " And thus they live unto hir lives ende In parfit joye" — at least they have the chance of doing so. Doubtless it was the prevention of over- profound sleep which cured her. Some years ago a foolish young man from the country brought for my opinion an instrument which he had purchased of an advertising quack, designed to cure spermatorrhcta by compression of the ure- thra and prostate. The disease in his case, being purely imaginary, was of course incurable ; but I should not won- der if the plan had been found useful, act- ing as an obstacle to morbid sleep. How- ever, it would require careful medical superintendence. A clergyman (who corresponded with me anonymously, and therefore I can say nothing of his general health) took by my aclvice, unsuccessfully, several remedies for spermatorrhoea, till he suspected that he abused himself during sleep ; he tied his hands by a string to the bedpost, was awakened several times a night, and cured. Another patient, troubled with really involuntary emissions, cured himself by having an alarum which he set so as to wake him occasionally in the night. Other attacks of spermatorrhoea I have found to take place durinj^ the abnormally heavy morning doze which lazy people ' Clinique M^dicale. Le9on LX. sunstroke: history. 661 indulge in after tliey have really had enough rest — the intoxication of i-epose. These patients should be told to get up and dress immediately after their first waking. It soon cures them. 3. Care should be taken that the head lie high in the bed, and that the body be not covered with too great a weight of clothes. The son of an old and intimate friend of mine used to suffer when a child from in- continence of urine. Soon after puberty this inconvenience ceased, and has not returned. But at eighteen he has come to me complaining of seminal emissions, which have occurred on a few occasions more than once in a night. On inquiry, he said that on waking up after a defile- ment he had often found his head right under the bolster. He was advised to be careful in keepin"; a good hard pillow well down under the shoulders, and he has not suffered since. 4. Though prevention by means of keeping off too profound sleep is desirable, yet patients should not be wakened when walking, or in any other unnatural pos- ture. They should be led back quietly to bed "Donee discussis redeant erroribus ad se." Otherwise the fright is dangerous, espe- cially to hysterical persons. 5. Light meals and digestible food are essential, and special expedients should not be trusted in till the general health has been brought up to the average. SU^STEOKE. By W. C. Maclean, M.D. Definition. — A disease of the nervous system, excited by heat, sometimes fol- lowing exposure to the direct rays of the sun, particularly when to heat is added the pressure of tight and unsuitable cloth- ing and accoutrements, or both ; more frequently occurring when the above con- ditions combine with exhaustion, induced by great fatigue in hot weather, or from the effects of high temperature, night and day, on men breathing the vitiated air of crowded barracks or ships. The affection is generally preceded by premonitory symptoms, such as thirst, heat, and dryness of skin, vertigo, conges- tion of the eyes, frequent desire to mictu- rate, followed by syncope, often instantly fatal (the cardiac variety of Morehead), or by insensibility and stertorous breath- ing, with or without convulsions (the cerebro-spinal variety of the same author). In both varieties the mortality is high, and unexampled congestion of the lungs is the most common morbid appearance observed after death. Synonyms. — Insolation ; Sun-fever ; Coup de Soleil ; Calenture ; Heat-apo- plexy ; Ictus soils ; Erythismus tropicus. _ The first is the name by which the affec- tion is designated in the official classifica- tion of diseases in use in the British army. History. — Sunstroke has been known and recognized as a dangerous disease from early times. Fatal examples of it are recorded by the sacred writers, and these have been referred to by most mo- dern authors who have written on the subject. It is worthy of note that one of the blessings promised to those who shall be partakers of the better life that is to come, is, "that the sun shall not light upon them, nor any heat," — a promise full of meaning to the inhabitants of the "dry and thirsty land" to whom it was first made. Men of European birth who become sojourners in Hindostan are hardly more solicitous to protect their heads from the direct rays of the sun than are the various races who are children of the soil. In China, on the other hand, the inhabitants expose their closely shaven heads to the hottest sun with apparent impunity.' But when so doing they generally make vigorous use of their fans, as if they at- tached more importance to having a free current of air about their faces, than to protecting their heads from the sun's rays. Sportsmen in India constantly ex- pose themselves in the hottest weather when in pursuit of game. Those who use ' I have recently, however, seen an account of an epidemic of insolation, whicli attacked one of our trading ports in China, after many days and nights of unusually high tempera- ture. The mortality was high, and by no means confined to the European community. 662 SUNSTROKE. reasonable precautions, who protect the head and spine by a liead-dress adapted for the purpose, wear loose clothing of a suitable material, and abstain from stim- ulants, rarely suffer from Sunstroke.' [The same is true of those who play cricket and base-ball in the United States ; where the temperature in July and August is sometimes very nearly as high as in India. — H.] On the other hand, as will be shown further on, men who are made to undergo fatigue under a hot sun, dressed as British soldiers used to be in such circumstances, in tight-fitting clothes, and encumbered with heavy and badly-adjusted accoutre- ments, wearing a head-dress wnich not only gave no protection, but concentrated the sun's rays on their heads, suffered from insolation in great numbers in a most fatal form. Sunstroke, if we are to judge from the older medical returns of the Indian army, was not a frequent or a fatal disease. Even in the eight years ending 1853-4, as appears from Dr. Hugh Macpherson's in- structive analysis of later Bengal medical returns, only thirty-eight cases are record- ed. This would be very puzzling if we did not know that a great many cases, which would now be entered without hesi- tation under the head of imolatio, were in those days " returned" under the heads of continued or remittent fevers ; while those proving quickly fatal, with insensi- bility, convulsions, stertorous breathing, and such-like symptoms, were considered to be cases of cerebral apoplexy, and reg- istered accordingly. For example, in the case of the two wings of H. M. 13th Regiment, referred to by Martin, which marched, after some very ill-judged exposure and drilling in the sun, from Kuddea to Berampore in the midst of the hot weather, the men suffered terribly. As the result of one march, " the day closed with a sick-list of sixty-three, and eighteen deaths," all of which appear to have been registered as cases of apoplexy. It is certain from the description left by the medical officers, that the cases would in the present day be considered to have no pathological re- lation to apoplexy, yet Dr. Henderson ' Staff-surgeon Becker informs me that ■wliile on active service in China, a sudden order was given for a movement in the heat of the day. One commanding officer opened the canteen before the men marched ; by way of precaution they partook freely of spirits. The effects of this injudicious measure were soon apparent : the men who thus indulged suffered twice as much from Sunstroke as those who did not. On this occasion also it was noted that a large proportion of the vic- tims had heart disease, in one or other of tlie forms I have elsewhere shown to be so com- mon in the army. was at a loss " whether to consider them cases of remittent fe 'er or apoplexy." (Martin.) The symptoms were clearly those of insolation. Many other examples of a like kind could be given. The following are some of the best his- torical instances of insolation occurring in the field and in barracks ; they have been brought forward in more or less detail by nearly all recent authors on the subject, and for the last five 3ears I have used them in my lectures in illustration of the different forms of this affection. In May, 1834, the 68th Regiment, quartered in Fort St. George, Madras, at- tended the funeral of a general officer. The regiment paraded in full dress at an early hour in the afternoon in one of the hottest months in the year, their tight- fitting coats buttoned up, their leather stocks, as stiff and unj'ielding as liorse- collars, round their necks, heavy cross- belts so contrived as to interfere with every movement of the chest, heavy sha- koes on their heads, made of black felt, mounted with brass ornaments with wide flat circular tops, ingeniously contrived to concentrate the sun's rays on the crown of the head, and without protection in the way of a depending flap for the nape of the neck. So dressed, the men marched for several miles. Before the funeral pa- rade was over, the soldiers began to fall senseless— one died on the spot, two more in less than two hours. Men suffering from insolation in various degrees were brought into hospital all that night and part of next day. The cases that did not prove fatal, although their real nature was correctly understood by Dr. Russell, acting surgeon of the regiment, were all registered as cases either of continued or ephemeral fever. The symptoms in the fatal cases were thirst, excessive heat of skin, extreme prostration, immediately followed by gasping respiration, coma, stertor, lividity of the face, and death. After death no morbid appearance was found in the brain, but in the lungs of all there was extreme congestion. There lingers a tradition of this parade in Ma- dras to this day. The 63d Regiment suffered in the same way, at the same place, and under cir- cumstances precisely alike. (Martin : Influence of Tropical Climates.) Of the next example the writer of this article was an eye-witness. The 98th Regiment joined the expeditionary force under Lord Gough in China in 1842. The regiment came from England in the BeUeisle, an old 74-gun ship, and suffered from overcrowding. On the 21st of July, the 98th took part in the attack on Chin- Kiang-Foo, the final military operation of the war. The men were dressed precisely as already described in the case of the 68th Regiment. In this condition they HISTORY. 6G3 had to take possession of a steep hill ex- posed to the fierce rays of the sun shining out of an unclouded sky. A great many men were struck down by the heat, about fifteen died on the spot, falling on their faces, as Dr. Parkes, on the authority of another eye-witness, has correctly de- scribed (Practical Hygiene) ; they gave a few con\ailsive gasps, and died before anything could be done for their relief. The best history of an outbreak of inso- lation with which the writer is acquainted is that given by Dr. Barclay, of the 40d Light Infantry, and published in the sec- ond number of the Madras Quarterly Journal of Iledical Science. The 43d Regi- ment performed one of the most extra- ordinary marches on record, having marched from Bangalore, in the Deccan, to Calpee, in Central India, a distance by the route taken considerably exceeding eleven hundred miles. The exigencies of the public service at that time (1857-58, memorable as the years of the mutiny in Bengal) were such, that this march, with the exception of a few brief halts at sta- tions by the way, was made continuously, and a great portion of it was accomplished during tlie hottest season of the year. The men were exposed to a very high temperature by night as well as by day. Dr. Barclay, while in a valley at the foot of the Bisramgunge Ghat, observed the thermometer at 118° Pahr. in the largest tents during the day, V27° in the smallest, and on one occasion he observed it at 105° at midnight. This prolonged exertion and continuous exposure to ex- cessive heat by night as well as by day, exceeded the limits of human endurance. When they reached Nagode, " the indi- cations of exhaustion in the altered looks of the men, their loss of flesh, and their evidently failing strength, were so obvious that they forced themselves on the obser- vation of every one. " But further on, on the march from Humeerpore to Calpee, Dr. Barclay records, "There was scarcely a man in the regiment whose strength was not reduced to a level with that of a child." It is remarkable that no case of insola- tion occurred until the 2Sth of April, i. e., until the 43d had marched 909 miles — until, in fact, the signs of exhaustion, first noted by Dr. Barclay, were apparent. From that date they increased in fre- quency. When at the foot of the pass, named above, cases " were brought to the hospital tents at every hour of the day and night, and although a large propor- tion of them recovered, two officers and eleven men were buried under one tree in tlie neighborhood of the camp." (Dr. Barclay on the M'atural History of Inso- lation.) Boudin relates a terrible example of the ellests of heat on a body of Belgian sol- diers on the line of march, which may be fairly taken as a striking instance of the evil consequences of tiglit clothing and accoutrements under exertion in a high temperature. On the 8th of July, 18u3, a body of men, 1200 strong, marched from Beverloo to Hassclt. They started at eight o'clock in the morning. Only 500 reached Ilasselt in the evening. Nine- teen perished en route, and a great num- ber in a state of furious delirium were taken to hospital. I do not tliink that anything so disastrous as this occurred during the unavoidable exposure of Brit- ish soldiers to the fierce heat of the sun in Central India, in the years of the Mutiny, 1857-58. It is remarkable that the tem- perature on this occasion did not exceed 33° or 35° Centigrade. M. Boudin adds, that two well-known Eg3-ptian astrono- mers, MM. Mahmoud and Ismael, who were in Brussels on that day, assured M. Quetelet that they sufiered as much from a temperature of 30 '7° C. in that city as in Cairo under a temperature of nearly 50° C. : " JSTouvelle preuve de la necessite de tenir compte de la qualite de la temperature." But, as has been said, insolation occurs in barracks as well as in the field. The two best and most carefully observed ex- amples of this form of the affection are those recorded by Dr. Butler, of the 3d Light Cavalry, at Meean Meer, and by Itlr. Longmore, then surgeon of the 19th Regiment, stationed at Barrackpore, in Lower Bengal, and both published in the Indian Annals of Medicine. Dr. Butler records that his men had not been overworked or fatigued, but at a time when the heat was excessive (lO^o in the shade) they were overcrowded. "Assuredly," says Dr. Butler, "those barracks most crowded, least ventilated, and worst provided with punkahs and other appliances to moderate excessive heat, furnished the greatest number of fatal cases." Mr. Longmore 's evidence on the same point is most important. Out of sixteen cases thirteen occurred in barracks or in hospital, and Mr. Longmore notes that one-third of his cases, and nearly half the deaths, " occurred in one company of tlie regiment quartered in the barrack which was manifestly the worst conditioned as to ventilation, and, indeed, in every sani- tary requirement." Mr. Longmore remarked also that " the patients seized in hospital were lying in two wards on the leeward side, and from circumstances of situation the warmest and most confined." Insolation has frequently been observed on board ship, but almost always under conditions similar to those in barracks ; that is, where overcrowding and impure air are added to the influence of excessive heat. Insolation is not uncommon on 6G4 SUNSTROKE. board the mail steamers in the Red Sea in the hot montlis of August and September; it has been observed that most of tlie cases occur while tlie sufferers are in tlie hori- zontal position in iU-ventilated cabins. M. Bassier, Surgeon in the French Navy, reports (Dissertation sur la Calen- ture) that in the month of August, 1823, the man-of-war brig Le Lynx, cruising off Cadiz, had eighteen cases oi insolation, out of a crew of seventy-eight men. The heat was excessive (" 33 d 35 deyres Cent.") and much aggravated by calms. In this case the ship was overcrowded : " ie hdti- ment, tres 2xtit, offrait peu d'espace pour le covcher de V equipage. M. Boudin (Statistiques Medicales) quotes from the same author the case of the French man-of-war Duqwsne. This ship, while at Eio Janeiro, had a hundred cases of insolation, out of a crew of six hundred men. Most of the men were attacked, not when exposed to the direct heat of the sun, but at night when in the recumbent position — that is, when breathing not only a hot and suffocating, but also an impure air. [An important fact is, that heat-stroke is very much more common in cities than in the open country. Tokio has had 100 cases in a single day ; New York, 60 ; Philadelphia, 20. By the statistics of tlie New York Board of Health it has been shown that, when the thermometer is over 90° Fahr. the number of cases of heat-stroke is not exactly proportional to the maximum or average of daily temper- ature. The existence of another factor may be here suspected ; probably, the condition of the atmospere in regard to humidity, electricity, or pressure. — H.] Etiology. — I have already remarked, that men will bear a high temperature in the open air with comparative impunity, provided (a) that it is not too long contin- ued, (&)that the dress be reasonably adapted to the temperature, (c) that the free move- ment of the chest be not interfered with. As already remarked, British sportsmen in India often pursue their exciting amusement in the hottest weather ; but as they are careful to dress suitably, they seldom suffer from insolation. It will be remarked, that in all the ex- amples of insolation in the direct rays of the sun given above, the sufferers were soldiers dressed and accoutred precisely as men ought not to be in the circum- stances in which they were placed. Dress and accoutrements, then, are powerful aids to high temperature. The case of the 43d Light Infantry, as related by Dr. Barclay, brings out an- other predisposing cause, which appears to exercise a powerful influence, viz. ex- haustion, the result of prolonged exertion. This appears to act in various ways. First, there is a great waste of tissue, for a time, — that is, so long as the functions of the skin, lungs, bowels, and kidneys continue in tolerable activity, the blood is maintained in a state probably not far from its normal condition. But as exer- tion continues under a temperature sel- dom falling below 90° or 92° Fahr., and often reaching, as we have seen, 100°, 107°, and sometimes 118°, in a well-made tent, the function of the skin ceases, and the result of this must be not only the loss of the cooling effect of evaporation, but also blood impurity. Again, all observers note that under such circumstances, ob- stinate constipation of the bowels is a constant condition, still further promoting this impure condition of the blood. But not only may we reasonably suppose that the blood must be in an abnormal condi- tion from the above causes ; it is very im- perfectly replenished by healthy, well- digested food. "The appetite," says Dr. Barclay, " gradually failed, and a feeling of nausea was generally complained o^ the sight of food often exciting loathing." In other instances there was nearly complete anorexia. It may be supposed that the activity of the kidneys may, to some extent, compensate for the lost func- tion of the skin and the impaired eliminat- ing action of other organs. But not to dilate on the fact that frequent micturi--. tion, although a common, is by no means an invariable sj'mptom in the premonitory stage of insolation, is it not possible that the inability to retain urine in the blad- der is quite as much due to its quality as its quantity ? "I cannot hold my water," was the almost invariable com- plaint of Dr. Barclay's men ; and Mr. Longmore carefully noted the same thing in his cases. Dr. Obernier is of opinion that although the secretion of urine is in excess at the beginning of a march, the quantity is les- sened by prolonged exertion, doubtless because the blood has lost much of its water through profuse perspiration ; and he states that suppression of urine often precedes Sunstroke. "Now, suppression of urine means retention of urea in the blood," and accordingly in two cases of Sunstroke Dr. Obernier found urea in ex- cess of the normal quantity in the blood. Yet the same author declares that in liis experiments on animals subjected to the effects of heat until they exhibited signs of Sunstroke, he " could not discover a trace of urea in their blood. " If we look again to the cases quoted as occurring in barracks and ships, it will be seen that another cause besides heat was in operation. In all the examples giv^u of insolation in barracks, the observers have noted the ill-ventilated, overcrowded condition of the places where the majority of the cases occurred. Many of the small ETIOLOGY. 665 bungalows occupied by officers in military stations in India, are quite as hot as any barrack-room, yet nothing is more rare than to see officers aifected with this form of insolation. In the Trench ships, over- crowding and imperfect ventilation, with their necessary consequence, impure air, were noted by the surgeons who reported the cases. It is then evident, from the above facts, and from many more of the same kind that might be adduced, that the pressure of tight and unsuitable clothes and accou- trements, excessive fatigue, with all its consequences, and the impure air of ill- ventilated barracks and ships, are power- ful predisposing causes of insolation. [Another obviously predisposing cause, in the cities of the United States, is intem- perance. A large proportion of the victims of insolation are those who drink freely, whether actually drunkards or not. In 1878, when a considerable number of deaths from Sunstroke occurred, a sort of panic in regard to the agency of alcohol and over-exertion in its promotion was started by the public press. "Whether this had a beneficial effect or not, it happened that on the hottest day (16th) of July, 1879, with the thermometer lOQO in the shade in some places in Philadelphia, no cases of heat-stroke were there reported. -H.] But it cannot be doubted that heat, and, speaking generally, heat long continued, is the true exciting cause of this formida- ble affection. The recently published ob- servations of Dr. Obernier, of Bonn, put this opinion beyond doubt. Pick, a Ger- man physiologist of reputation, maintains that under the controlling influence of radiation and evaporation through the lungs and skin, the temperature of the blood in man is always the same. ' But Obemier's experiments confirm the opinion urged in this article, viz. that, if through any cause the cooling effect of the above processes be interrupted, " as ly warm and tight clothing, by an elevated ' My friend Staff-surgeon Becker will short- ly publish a series of most interesting obser- vations on his own temperature on a voyage to India. Dr. Becker lived as much as pos- sible on a uniform diet, which he weighed exactly, and ascertained the amount of urine excreted daily. He took his temperature with unfailing regularity eleven times in twenty-four hours. Every tenth day he fasted, and took his temperature every hour. The temperature in the external air was also carefully registered. The chart shows that the temperature of the observer rose or fell one degree with every twenty degrees of rise or fall of that of the external air. The dis- turbance on the days of fasting was very marked, the temperature invariably falling, and not recovering for many hours after food was resumed. temperature of the outer air, by exposure to direct suushine, or the overheated at- mosphere of the engine-room, or even the forced deprivation of cold water : the effect is an accumulation of heat in the body, and an injurious if not fatal action of this heated blood on the nervous system and through it on the heart." The observations of physiologists have shown that the human ijody produces four times as much heat under considerable muscular exertion as during sleep. Ober- nier's exact experiments prove that the temperature of a man walking for half an hour increased by i° Cent, or 0'9^ Fahr. After two hours' walking in sunshine, his temperature rose 3 '6° Fahr. If exertion be continued in a hot atmosphere, or with the clothing so often adverted to in this article, or without the use of cold water, until the cooling processes of radiation and evaporation fail, " then the action of the heart grows weaker and weaker, the lesser circuit of the blood becomes overcharged, the venous vessels of the head grow tur- gid and sensibly expand ; these symptoms develop gradually, but the resulting dis- ease — Sunstroke — makes its appearance suddenly. ' ' Obernier offers no opinion on the question whether or not nerve tissue undergoes any change of structure under heat. At this point the observations and experiments of Kiiline, recorded in the second edition of Ludwig's Physiology, are full of interest.' This physiologist found that after exposing frogs to a high temperature, an electric current could with difficulty be transmitted along thoir nerves ; at first it was lessened, and finally stopped altogether. Other experiments by the same ob- server demonstrate that if the heat in any vertebrate animal exceeds 113° of Fahr. , coagulation of the albuminous principle in the muscular system at once takes place. [Similar investigations, by H. C. "Wood and others, have added nothing of much importance to the above results. It appears certain that when a tempera- ture a few degrees above 100° Fahr. is reached in the human body, the normal conditions of the muscular and nervous tissues and of the blood are all in danger of alteration. This becomes more or less serious according to the extremity of heat attained, and also according to the vital energy of the system at the time. Fa- tigue, intemperance, perhaps the depress- ing influence of humidity, and certainly that of the foul atmosphere of ships, bar- racks, or large cities, by lowering vital resistance, may promote the production, by heat, of disorganization of nerve-cor- puscles, sarcous elements, or of the blood. Either of these, if carried to a consider- ' Ludwig's Physiologie, vol. ii. p. 732. 666 SUNSTROKE. able extent, may cause death. The capa- city of the body to endure with safety ex- posure to an external temperature much above 100° Pahr. is due to the protective etfect of cutaneous transpiration and evaporation. The sun temperature of New York and Pliiladelphia is often as high as 132°. I found it on one occasion in Maryland, 135°. Livingstone, in African deserts, found it VHP. But the hot-air bath is often taken as high as 1.50° — 250° ; andChabert, the " Pire-king," is reported to have gone, specially protected, into an oven heated to 600° Pahr.— H.] There is no agreement among observers as to the effects of extreme dryness or moisture in increasing or diminishing the effects of heat. Insolation has been ob- served m both conditions. In the case of the 43d Regiment, the hot, dry land winds ■were blowing. !Mr. Longmore also notes the extreme dryness of the air at Bar- rackpore during the outbreak there ; and in all the examples given, the disease dis- appeared with the first heavy fall of rain, attended with a rapid fall in tempera- ture. On the other hand, Dr. Baxter, of the 93d Highlanders, v^^ho gives four cases of Sunstroke observed at Sealkote, con- siders that Sunstroke is much more likely to occur when the atmosphere " is largely impregnated with watery vapor." (Dub- lin Quart. Journal of Med. Science, No. 81, Peb. 180G.) Mr. Xaylor also is of opinion that cloudy days, with "a moist condition of the atmosphere," favor the occurrence of insolation (Morehcad's Clinical Re- searches). Exact observations on this point, with the wet and dry bulb, are much required. It would appear that a hot and moist condition of tlie air is most favor.able to the production of insolation in barracks, because not only does such a condition diminish the cooling effect of the evapora- tion from the skin, but interferes with the artificial means used to reduce the tem- perature of the overheated rooms. Duration. — The disease may prove fatal, as we have seen, in a few minutes, or the symptoms may last from one to forty-six or forty-eight hours. Termination. — The disease terminates either in death or recovery, which may be complete or partial, certain sequels in a considerable number of cases appearing. These are persisting headache, the pam being either fixed or shifting ; a chorea- like affection of the muscles, generally those of the forearm and hands ; epilepsy, particularly in those who have suffered from tliis disease in youth, or who have a hereditary tendency to it. In some cases mental weakness, wdiich may prove per- manent, follows Sunstroke. In one ex- ample, thnt of an officer of distinction, who lost his hunting-cap while pursuing a wild hog at speed, and in the eagerness of the chase rode for miles bare-headed, Sunstroke was the result ; from that hour his mind was affected, and complete recovery never took place. Symptoms. — Dr. Morehead has divided Insolation into three varieties — the Car- diac, the Cerebro-spinal, and the Mixed. In the present state of knowledge this classification is useful, and it certainly appears to be founded on correct pa- thology. In the Cardiac variety, although it is probable that the sufl'erer is himself con- scious of some premonitory symptoms, there is seldom time for their full develop- ment so as to attract the attention of liy- standers before the patient falls, gasps, and in some severe cases expires before there is time to do much, or anything, for his recovery, death taking place by syn- cope. This is the form most frequently seen in men exerting themselves in the heat of the sun when dressed and accou- tred as were the soldiers of the 98th Regi- ment at Chin-Kiang-Foo, or at the funeral parades at Madras above described. In the so-called Cerebro-spinal cases, premonitory symptoms generally give no- tice of the coming danger. These are heat of skin— tliis is never absent ; the heat is attended with extreme dryness, and is remarkably ardent and stinging, exceeding that of the worst form of re- mittent fever, which is sometimes as high as 107° Pahr.— giddiness, congestion of the eyes, extreme debility, nausea, and frequent desire to micturate. This last symptom is much insisted on by Long- more, and Dr. Barclay says that " 1 can- not hold my water" was often the first complaint made by many of his patients. It is a notable thing that headache is by no means a common symptom ; it does not appear to have been complained of in a single instance in Dr. Barclay's cases. Again, a wild shout of laughter, or an attempt to escape in terror from some imaginary enemj', sometimes precedes the more serious symptoms, to be presently described. M. Bassier, in the case already referred to of the French man-of-war at Rio Janeiro, mentions that the utmost diffl- culty was experienced in preventing the men from throwing themselves into the sea: ''^ lis devcnaient incoMrents dans leitr discours, poussaient des curis, nena^aient de geste et de regard, entraient en furetir, et sembhdent niettre tons Icurs soins adecoiiirir tine issue qui lew permit de s''elancer a la, mer."' On one occasion I saw a man in ' Frenchmen under the influence of insola- tion seem strongly impelled to self-destruc- tion . Boudin relates that in 1836, "pendant una DIAGNOSIS — PATHOLOGY. CG7 this condition suddenly possess himself of the 'arms of a sentry to defend himself from an imaginary enemy. It is not by any means always that we have an opportunity of seeing the above premonitory symptoms. Where men in barracks are sensible of the approach of any of them, they generally assume the recumbent position, and in that state pass into a state of coma, the attention of their comrades being first called to their con- dition by their stertorous breathing. After a longer or shorter continuance of the above symptoms, the patient be- comes insensible ; the heat and dryness of the skin augment ; the respiration be- comes hurried, noisy, labored ; the pupils contract, and are quite insensible to light ; the coiijunctivfe become more congested, " pinky" (Barclay) ; the heart acts tumul- tuously ; the pulse in men in asthenic condition being at first rapid, but distinct, but as the case progresses unfavorably, becoming compressible, feeble, and irregu- lar ; convulsions are frequent, but not in- variable : sometimes they appear early, in other cases they immediately precede death. Dr. Barclay expressly says, that "in a large proportion of cases, from the com- mencement of the attack to its termina- tion in death, the patient never moved a Umb or even an eyelid." In the Mixed form of Morehead, the symptoms partake of both varieties, and the fatal event is brought about partly by coma, partly by syncope. Diagnosis. — The diseases with which this affection appears to have been con- founded are cerebral apoplexy, and various forms of fever, such as ardent continued fever, and even some of the graver forms of remittent. With the first named it has no pathological relations at all, and it is to be regretted that the term " apoplexy" continues to be appended to any of the names in use to distinguish this disease. In both apoplexy and the cerebro-spinal variety of Sunstroke, there is coma ; but the pulse in apoplexy is slow, generally full, sometimes intermitting. In Sun- stroke it is quick and sharp. In apoplexy the breathing is slow, irregular, and ex- plosive in expiration ; in Sunstroke it is rapid, noisy, but not explosive. In apo- plexy the pupils are usually dilated, or one is more so than the other ; in Sun- stroke both are contracted, and the con- junctivse are deeply congested. The skin in apoplexy is not hot, and is often cold expedition du G^n^ral Bugeaud dans la pro- viuce d'Oran, on a pu compter en quelques lieures, 11 suicides et 200 hommes atteints de congestion cerred as representing tlie earlier stages of a great constitutional malady. (a) Sy^nvtoms of Clironic Alcoholism.— It is upon the motor nervous system that the influence of chronic excess is first dis- cernible in the largest number of cases. Of an extremely large number of patients who present themselves at the out-patient department of AVestminster Hospital suf- fering from this disease, certainly more than two-thirds, upon careful analysis of their complaints, state that a muscular inquietude, which might or might not amount to actual tremor, was the first disagreeable symptom wliich they noticed. In cases of gradual access the affection at first may amount to no more than an in- ability to keep the limbs of the body still without a special effort of attention — the exercise of the will being sufficient to render the muscles perfectly steady. The degree of motor disturbance is distinct from and independent of the peculiar mental restlessness to be presently no- ticed as arising somewhat later, although the occurrence of the mental affection very much aggravates the tendency to in- voluntary movement. This distinction is noticeable in relation to the nocturnal state of the patients. Long before the occurrence of terrifying dreams, of noc- turnal delirium, or of hallucination — even before there is conscious nocturnal dis- turbance of the mind at all— the patient feels an inability to sleep which appears to depend on the condition of the motor nervous system. Ecpeatodly I have been assured by persons suffering from the slighter degrees of Alcoholism that they go to bed with a sense of at least average drowsiness, but an invincible disposition to turn restlessly from side to side ip the bed entirely prevents them from getting any sleep. It is not very often that a patient asks for advice at the early stage of the dis- ease, which is represented by the pres- 676 ALCOHOLISM. ence of the above symptoms only. More commonly he does not come under medi- cal notice till the motor disorder has reached a further stage ; and his com- plaint is now, probably, that he suffers from persistent muscular tremor. This S3mptom develops itself first in the ex- tremities. Magnus Huss declares that it always appears earliest in the hands ; but it is probable that this is a mistake, for in a majority of the cases which have come under my care the lower extremi- ties were first affected ; while it is less easy to detect tremor of the lower than of the upper extremities, and the former often escapes notice for some time after its commencement. Huss notes correctly the fact that even in the stage of persistent alcoholic tremor the patients can at first, by a strong effort of the will, restrain their movements for a time, but on the cessation of the effort the tremulousness is ordinarily worse than ever. A very old and general observation is to the effect that the tremor of Alcoholism is almost invariably worse in the nwrning, and it has been usual to assign as the reason for this, that the accustomed stimulus of al- cohol has been withheld for some hours. The statement is plausible, because it is the fact that a glass of beer, or wine, or brandy, taken under these circumstances, will at once diminish the unsteadiness of the muscles : but another fact may be mentioned which strongly opposes the theory — viz. that common foods, such as bread and milk, or broth (if the stomach be not too much irritated to digest them), will answer precisely the same purpose. In truth, the excessive morning tremor of the chronic toper is due chiefly to ex- haustion from failure to get sleep. What sleep he has had has been of an unre- freshing kind, and a complete condition of nervous prostration naturally results, from which he can only be rallied lay food or drink. Coincidently with the establishment of persistent muscular tremor, and some- times earlier than this, certain cerebral symptoms present themselves. One of the commonest of these is a buzzing or a rushing sound in the ears, which is fre- quently, though not always, accompanied with dull diffused headache. Vision is also affected, with varying degrees of severity, the most trifling symptoms being the appearance of muscce volitantes, or of "clouds" before the eyes. Flashes of light are a more serious phenomenon, and their occurrence at night, just before the patient drops into his first uneasy half-slumber, is frequently the immediate precursor of the more definite visual hal- lucinations. Momentary attacks of ver- tigo are common. By this time the pecu- liar alcoholic insomnia is fully developed in the great majority of cases : the patient tosses from side to side during nearly the whole night, getting only broken snatches of sleep, and these almost always at- tended with disturbing, ana often with frightful, dreams. The mental condition is now usually such as to distress the patient and to im- press the medical observer who sees the case for the first time. Its chief feature is the uncertainty of purpose which the sufferer displays : independently of any fixed delusion, or even of a distinct feeling of terror, there is a mental inquietude which makes it impossible for him to set- tle to any ordinary occupation, or to com- plete the tasks which he begins. To this is added either violent temper or a feeling of dread which may be vague and unac- countable, or (in bad cases) may arise from actual delusions, such as the belief that an enemy is constantly lying in wait to inflict an injury, &c. This sort of de- lusion is not to be confounded with another kind, which consists in a vivid apprehen- sion by the patient that he is in danger of falling down a precipice even when he is walking on firm ground in broad daylight, and which seems to me to be connected with rapidly progressing impairment of muscular co-ordination. Cases which dis- play the latter feature are commonly of a dangerous type, and, unless energetically treated, pass rapidly to a hopeless condi- tion as to recovery. The sensation as described to me is not like that of ordi- nary vertigo, or of fainting ; it resembles the disagreeable nightmare which every one has experienced on first falling asleep after an indigestible supper, or, still more closely, the hideous feelings which some persons (myself among the number) suffer from under the action of a large dose of Indian hemp. But it is not usually found among the earlier symptoms of Alcohol- ism. The above is a fair description of the nervous symptoms under which the pa- tient commonly suffers when he first ap- plies for relief. The disorders of common sensation which are frequently produced by alcoholic excess are, in my experience, usually later in their advent. When the patient comes under notice, he may pre- sent either of several conditions as regards his outward appearance. There is not often, at this early stage, any very great emaciation, even in the case of habitual spirit-drinkers ; but there may be eveiT degree of fatness, from the unwieldy bulk of the country publican, who chiefly fud- dles himself with beer, to the slight frame of the London hairdresser, who too often makes away with two or three quarterns of gin or rum daily. It is a great mistake, however, to push so far, as is often done in descriptive works, the contrast between the respective influences of spirit-drinking and beer-drinking. The haggard wretches SYMPTOMS. 677 whose portraits Hogarth has drawn in his picture of "Gin Lane" are emaciated to that degree quite as much from utter want of all the comforts of life as from the direct influence of spirit-drinking ; and, in fact, one sees, in the classes whose circumstances are a shade more easy, plenty of gin-drinkers who (living chiefly on gin) have a good allowance of fat, if not of muscle. The countenance of the drinker (whether of spirits or beer) usually presents two remarkable features iu con- junction, viz., great flahbiness of the mus- cles of expression, and red, watery eyes ; the conjunctivEC are also very generally more or less jaundiced. To this" is often added redness of the nose and cheeks, and an eruption, resembling acne rosacea, around the nose and the mouth. On in- quiry we learn that, besides the already- described nervous symptoms, the patient suffers from morning vomiting, or at least nausea. This is nearly alwaj's the ease, but there may be any amount — or no amount — of general symptoms of gastric or intestinal irritation, except this one symptom ; and the tongue, in correspond- ence with these variations, may be in nearly any state, from perfect cleanness and moistaess to dry red glaziness or thick yellow furring: the latter is its more com- mon condition, especially at the back part. The morning vomiting is in my opinion not a mere dyspeptic disorder, but a true part of the nervous phenomena of receding narcosis. One symptom, which it is not easy to explain, but which nearly always exists, even where there are no signs of dyspepsia, is a peculiar foul breath-smell, which it is impossible to describe, or to mistake when once it has been smelt. It is quite unlike the odor of the alcoholic liquor itself, and may be separately dis- tinguished even when the latter is also present. Considering the enormous quantities of spirituous liquors which are drunk by many of the patients who apply for relief from the consequences of chronic Alcohol- ism, it would be natural for the reader who holds the usual opinion as to the ori- gin of cirrhosis of the liver to expect that serious symptoms, produced by the latter disorder, must often comijhcate cases of the former. The case, however, is far otherwise, in my own experience. Of an immense number of patients in whom the nervous disorder has been clearly identi- fied, I have only seen thirteen cases in which the symptoms of cirrhotic disease called for any special treatment, although a certain degree of cirrhosis was doubtless present in many of the others ; and I can- not avoid the conclusion that some very powerful element, over and above the in- fluence of alcohohc excess, is needed to produce the severe type of that disease. J-O a less, but still a remarkable extent, the same observation holds good for kid- ney disease of the degenerative kind. With regard to these disorders, I am con- vinced that other depressing influences must bear a large share of the blame or- dinarily attributed to alcohol. How is it possible to form any other opinion, when of the multitudes of drinkers whose kid- neys must be daily traversed by blood containing large quantities of alcohol, so few present any characteristic change of the urine, or other recognizable symptoms of renal mischief? Be this as it may, it is certain that renal, and still more he- patic, complications are very rarely the source of serious embarrassment in the treatment of chronic Alcoholism of the ordinary type which is indicated by such a group of nervous symptoms as is above described. Not to anticipate unduly what will have to be said under the head of Prog- nosis, it may be stated here that the form of the disease which we have so far con- sidered, is decidedly curable, tending in fact to right itself on the simple adoption of a plan of complete abstinence from the exciting cause of the mischief, combined with a nourishing and supporting diet, unless in the rare instances where sundry complications, which may fairly be called accidental, happen to receive a dangerous development. These complications arise out of the local irritant action of the more concentrated alcoholic liquors on the gas- tro-intestinal mucous membrane or on the air-passages, and will now be described. The irritant effects of alcohol on the alimentary canal are chiefly seen in the case of spirit-drinkers, and more particu- larly in those who drink spirits neat, or highly concentrated. Beer-drinkers do, indeed, often suffer from a simple form of dyspepsia, and there is httle doubt that slow degenerative changes are usually set up in the stomachs of these patients ; but, except in the case of enormous habitual excesses, the dyspepsia is a transient phe- nomenon which rapidly disappears on the adoption of a rigid plan of abstinence to- gether with a simple medicinal treatment. The more concentrated alcohols, however, when used for any length of time, may set up a formidable irritation which produces intense congestion of the stomach or the intestines, or both : in short, a greater or less portion of the tract in which the radi- cles of the portal veins take their rise is subject to severe engorgement. Perhaps the most serious consequence of such an action is the occurrence, which we now and then witness, of profuse hemorrhage from the stomach or bowels. According to what I have seen, this is rare. I have not met with a dozen cases of this kind altogether : two of these— one a case ot hffiinatemesis, and the other of intestmal hemorrhage— occurred in the same weeK, 678 ALCOHOLISM. in the practice of Westminster Hospital, quite lately. It is a frequent thing, how- ever, for drinkers to be affected with hem- orrhoids, from which more or less bleeding takes place. Great numbers even of the heaviest drinkers never develop any further specific symptoms of Alcoholism than those which have been already described, and their vicious habit, if it shortens their lives, does so chiefly by impairing their general nu- tiition, and thus rendering them less able to resist the attacks of intercurrent acute disease, and at the same time more pre- disposed to constitutional maladies, such as gout for instance, to which they may chance to ha\'e a hereditary bias. Others suffer from attacks of delirium tremens (to be presently described), once and again. But in many other drinkers the nervous symptoms, still preserving a more or less chronic type, assume a far more serious development ; and we have now to speak of these more extreme develop- ments of chronic Alcoholism. Of the earliest symptoms which indi- cate a dangerous degree of nervous de- generation, the occurrence of marked sen- sory paralysis is one of the most frequent. Unlike the corresponding affection of the motor nerves, sensory paralysis is most commonly exhibited in a slight degree in the upper extremities before it appears in the lower. The occurrence of any con- siderable degree of sensory palsy in the lower limbs is a sign of grave import : the patient so affected, unless he be induced at once to adopt a proper abstinence, and an appropriate medical treatment, is al- most certain very quickly to experience some serious organic lesion of the brain. Simultaneously with the occurrence of a considerable degree of sensory paralysis, there is usually a great development of the muscular tremor, which, in several cases which I have seen, approached closely to the type of paralysis agitans. The mental powers are by this time usu- ally affected in a marked degree — the most common mental condition being one of general intellectual enfecblement and moral degradation, marked by cowardice and untruthfulness. At this point the progress of the case ma}' diverp-e in either of several directions. In patients whose family liistorj^ is stronf;ly marked with the taint of insanity, a tendency to suicide is often developed, or else the sufferer sinks rapidly into a state of confirmed and incurable dementia. In others the func- tion of muscular co-ordination is inter- fered with to a degree which makes the case resemble, at first siijlit, the affection known as Locomotor Ataxy. In others there occurs a sudden break-down of ner- vous fibres in the corpora striata, or optic thalami, which produces a stroke of hemi- plegic x^aralj-sis. In others, along with some symptoms of mental alienation, a general motor palsy is so distinctly ob- served as strongly to suggest the idea of commencing general paralysis of the in- sane. In others the rupture of a cerebral artery leads to an effusion of blood and the sudden occurrence of an attack resem- bling ordinary apoplexy. In others, again (but this is a very small class), the patient suffers attacks of convulsions indistin- guishable from those of simple epilepsy. Epileptic attacks, occurring in this way, as a symptom of a very advanced stage of the nervous degeneration developed by chronic Alcoholism, are broadly distin- guished, in a clinical and prognostic point of view, from the much commoner attacks of epilepsy in a subject known to be pre- disposed to or actually affected with that disease, as a mere consequence of a some- what unusual alcoholic excess : the latter are of comparatively slight consequence, while the former indicate an altogether hopeless phase of alcoholic degeneration of the nervous centres. They are almost always accompanied by an advanced de- gree of dementia. (b) Symptoms of Acute Alcoholism. — If we set aside the case of common drunken- ness, as being rather an instance of nar- cotic poisoning, to be dealt with by toxi- cologists, than a morbid affection coming under the definition which we have placed at the head of this article, we may de- scribe the symptoms of acute Alcohol- ism as presenting themselves under four principal forms — namely. Delirium Tre- mens, Acute Mania from drink. Acute Melancholia from drink, and Oinomania. 1. Delirium Tremens. — The clinical his- tory of this disease was much misunder- stood in former times. It used to be be- lieved that in the majority of cases the delirious affection was produced, not by the direct poisonous action of alcohol upon the nervous system, but by the circum- stance of an habitually intemperate per- son's leaving off the use of his accustomed potations. As a matter of fact it had fre- quently been observed that a sufferer from delirium tremens had ceased to drink for one, two, or three days before the access of his more acute symptoms, and the ex- haustion caused by the loss of his ordi- nary stimulant was supposed to produce those symptoms. Dr. Ware, of Boston (1831), 'was one of the first writers who pointed out that this statement includes a fallacy of observation. From an analysis of 100 cases, he proved that the cessation of drinking, where this occurs, is in fact produced by a feeling of revulsion to strong liquors, which is a part of the early symptoms of the acute disease in many cases ; and, on the other hand, that very many patients do not leave off' drinking at all, but the delirious attack supervenes in the midst of a debauch. This observation SYMPTOMS. 679 has been confirmed by Dr. Gairdner, and many other excellent writers, and at present the classical theory o± exhaus- tion from withdrawal of an accustomed stimulus has but few upholders. [Sur- geons are familiar with the occurrence of delirium tremens in intemperate per- sons who have suffered severe injuries, or have undergone amputation or other severe operations. It is reasonable to suppose that this may be due to the con- tributive or exciting causative action of surgical shock, and not to the withdrawal, under treatment, of their accustomed ex- cessive stimulation. Yet it is hard not to think, that in these, and some other cases of suddenly enforced abstinence, this with- drawal does have something to do with bringing on the attack. — H.] The first warning of the approach of delirium tremens is ordinarily given by the occurrence of complete insomnia. The patient may have long indulged to excess in drink, or he may be quite a novice in intemperance, but in any case a greater debauch than usual has commonly been perpetrated ; and the sufferer finds himself quite unable to obtain any sleep, or at most can only gain short snatches of ■slumber, disturbed by horrifying dreams and visions : and during his waking mo- ments, even in broad daylight, he suffers from hallucinations of sight which com- monly take the form of disgusting or ter- rifying objects, such as snakes, insects, monsters, or of armed men pursuing him with threatening gestures. More rarely he hears voices denouncing threats, or mocking him : occasionally he experiences delusive sensations of disgusting smells. Often the occurrence of distinct visual hallucinations while the jjationt is awake is the first sign of the passage from chronic Alcoholism (which may have lasted for months or years, with a vary- ing degree of insomnia, and perhaps with habitually distressing dreams) to the acute affection. During the first day or two days the patient is in an extraordi- narily depressed state, with slow and feeble pulse, cold extremities, and a pro- fuse sweating. The mental state is one of great anxiety, but there are usually no real delusions : even where visual halluci- nations are present, the patient can by an effort of the will recognize tliem as such, and momentarily banish them from his sight. During all this time there is so complete an absence of appetite, in the great majority of cases, that no food, or scarcely any, is taken, and this circum- stance probably mainly conduces to pre- cipitate the onset of the second stage. In this the mere anxiety and nervousness is exchanged for incoherence of speech and wild excitability of manner, which sometimes takes the shape of causeless anger (though even then nearly always mixed with cowardice), and sometimes of great terror, which the sufferer often accounts for by pointing to imaginary terrific shapes which seem to people the room, and which he is constantly seeking to push aside with a restless motion of his hands. He talks incessantly, in a ram- bling fashion. Even when his terror or his anger is at its height he can generally be momentarily restrained by the influ- ence of any onlooker who addresses him in a firm and determined manner, and may even be reasoned temporarily out of his hallucinatory imaginations. The pulse has now become quick (from 100 to 130 or 140 a minute) : it is sometimes small and thready, sometimes soft and voluminous : but in every case which I have examined it gives a tracing, by the use of Marey's sphygmograph, in which the form of the pulse-waves closely resembles that which is observed in fevers and inflammations of a typhoid type, and is especially re- markable for the prominence of the phe- nomenon called "dicrotism." The an- nexed tracings will give a more accurate idea of the quality of the pulse than any description of the sensations which it communicates to the finger : — Muscular tretnor, which, from its strik- ing prominence in many eases, has given the disease its name of delirium tremens, is by no means universally present. According to Craigie, whose observations on this point I believe to be correct, they are usually observed in the cases of con- firmed dram-drinkers ; and in many in- stances I have found on inquiry that they were only an exaggeration of a tremu- 680 ALCOHOLISM. lousness of the extremities -which had ah-eadj' existed for moutlis or for years. But even wlien the characteristic tremu- lous movement of the arms and hands is not present there is a constant restless- nrss ; the patient shifts constantly in the hed, and Avill get out of it twenty times in an hour if he be permitted to do so. The eyes are in almost constant movement ; the pupils are usually, though by no means always, dilated. The temporal and carotid arteries throb violently in most cases ; very often the face is flushed, but sometimes it remains deadly pale ; nearly always there is much sweating, which is obviously due, in great part, to the constant muscular movements. The tongue is protruded, on the request of the physician, with an almost choreic jerk. It almost always trembles ; usually it is covered with a yellowish fur, but it may be clean, red, and glassy on the one hand, or brown, dry, and cracked on the other. It is usual to assign a limit to the second stage (which may last one, two, or several days) at the period when the patient first falls into continuous slumber ; and no doubt the classical descriptions which assign this as the critical event to which convalescence may be expected to succeed, find a considerable superficial justification in clinical facts. But, in common with some of the most careful observers, I believe that to be a very erro- neous and mischievous opinion which ascribes to a few hours' sleep anything hke a distinctly curative power. It is true that in man 3-, perhaps most, instances, the patient awakes, after his first sleep of considerable duration, in a condition of comparative convalescence. But, on the other hand, nvunerous cases have been observed in which the patient has sunk into profound slumber for many hours, and has awakened as delirious as ever, or in a state of complete prostration, which has rapidly terminated in death. Inter- esting considerations will he brought for- ward on tliis point, under the head of Prognosis, particularly with regard to the condition of the pulse, and the amount of success which has attended the efforts of the attendants to get the patient to take nourishment. In fact, the occurrence of sleep, even of considerable duration, marks with accuracy the commencement of convalescence only where we find the patient, on waking, clear in his intellect, free (or nearly so) from hallucinations, and with a pulse greatly reduced in fre- quency and yielding a sphygmographic trace such as will be presently described. The stage of convalescence, once estab- lished, presents nothing particularly worthy of description. But instead of sleep occurring at all, the patient may pass from mere delirium into a comatose condition, -with muttering dehrium, eyes open, staring, and fixed, restless move- ments of the limbs more marked than ever, picking at the bed-clothes, or po.~ji- bly profound stertorous coma, or violent convulsions, these symptoms being fol- lowed speedily by death. In other cases the patient, in the midst of violent deli- rium, with great excitability, suddenly collapses, as it were ; the pulse becomes hurried, intermittent, and thready ; the features pinched and ghastly, the breath- ing gasping, and death ensues in a minute or two, sometimes even in a few moments. 2. Acute Mania from drink presents symptoms which, though s( mctimes puz- zlingly like those of simple delirium tre- mens, can usually be discriminated from the latter. The patient, who (invariably, as far as my experience goes) possesses some hereditary predisposition to in- sanity, is seized, in the midst of a drink- ing bout most commonly, with active maniacal delirium of a violent kind, and frequently displays a marked tendency to homicidal acts. In most of the cases which I have seen the whole aspect of the countenance and manner of the pa- tient is different from that of delirium tremens, and there is comparatively little of the busy tremulousness of the hands so often seen in the latter disease. I believe that cases which are attended with posi- tive intellectual delusion are nearly always of this, or else of the melancholic kind. The pulse, whatever its degree of appa- rent strength or weakness, as tested by the finger, is seldom so markedly di'crotows as in delirium tremens. [A modification of this kind of attack occurs in rare in- stances, to which the name of alcoholia phrenitis or injiamtnatory deJirhmi may be applied. I have seen but one case of it ; but the same man had been two or three times similarly affected, as I learned from his previous medical attendant. After a hard drinking spell, he became delirious ; with verj' little tremor, a hot head, skin generally of a high temperature, pulse rather rapid, full, and strong. Acting upon information received of his other attacks, I took several ounces of blood from Ms arm. ' This, with a saline cathartic, was followed b}- improvement in all his symp- toms, and recovery within a week. Alto- gether exceptional as such cases are, it is well to be aware that they are possible. — H.] 3. Acute Melancholia from drink pre- sents the usual characteristics of melan- cholia from any other cause, but is marked by a special tendency to suicidal acts. The influence of a sound, pro- tracted slumber, which in mania from [1 It is proper to say, that, agreeing with tlie general principles of Dr. Anstie's article, I have never taken blood in any other case of delirium from alcoholism. — H.] DIAGNOSIS. 681 drink is usually very beneficial, is far less so in mclcmcholia from the same cause, as far as my limited experience goes. 4. Oinomunia. — The fourth variety of acute Alcoholism is that curious affection ■which Eoesch was the first to describe witli precision, and which is now com- monly called oinomania. It is, in truth, rather a variety of constitutional insanity than of alcoholic disease ; but as the out- breaks owe many of their characteristic symptoms to the influence of drink, the disorder requires notice in a treatise on Alcoholism. The sufferers from oinoma- nia are, I believe, usually descended of families in which insanity (and often in- sanity of the same type) is hereditary. Patients of this class very commonly, though not always, display their tenden- cies early in life ; sometimes, indeed, on the very first occasion on which the op- portunity for the free use of strong drink presents itself It should be clearly un- derstood that the term "monomania," whicli is often applied to the disease, very imperfectly describes the condition of the victims. Closer investigation of their mental state will usually discover the fact that they are liable to periodical recur- rences of causeless exultation and bursts of self-confidence on trifling occasions ; they then display great obstinacy, and a marked excitement of the animal passions generally: indeed the commencement of a drinking bout is often accidentally pre- cipitated by the circumstances of tempta- tion in which they are placed by loose company. Under the influence partly of an uncontrollable impulse, and partly of intoxication, they will perform truly in- sane acts ; they take useless and purpose- less journeys to remote places, or they lose their usual sense of decency, and ex- pose themselves to disgrace by public acts of a degrading character. They exhibit symptoms which in many respects resem- ble those of simple delirium tremens, though there is usually a ma,rked absence of that anxious terror which is almost always present in the latter complaint, and also a far less decided incapacity to sleep; indeed, there is sometimes very little insomnia. After lasting for a few days, a week, sometimes even a month or six weeks, the attack seems to wear itself out, as if rhythmically; and the patient generally recovers very rapidly his usual health, though he suffers "horrors" for a day or two. The condition of these pa- tients in the intervals between these at- tacks is very different from that of the ordinary confirmed sot. Very often they live perfectly sober and chaste lives, and are even remarkable for active and intel- ligent management of their affairs. But this condition only lasts for two or three months, or six months, or at most a year, and then the old symptoms recur, and the patient is uncontrollably liurried into ex- cesses of the most violent kind, "^'cry rarely indeed is a suflerer from this dis- ease really cured ; it usually recurs with increasing frequency throughout hfe, and frequently ends in declared and perma- nent insanity. [It seems to be more generally admit- ted by the profession in America than in Great Britain, that uncontrollable intem- perance constitutes a form of insanity in a large number of instances. Opinion is divided, however, here as well as abroad, as to whether the drinking habit alone is to be credited, in most cases, with the production of oinomania (or methomania, a better term) as an affection in which the will is overborne by the morljid im- pulse to drink liquor. Some consider that either insanity or a predisposition to it existed before ; of which the methomania is only a partial manifestation. My own conviction, from observation, is, that long-continued intemperance very often does induce, in persons otherwise sound in mind, a condition, mental and physical, in which, with opportunity and the ab- sence of restraint, it is impossible for them to resist the tendency to take alcohol in excess. This may be most properly called methomania. — H.] DiAQU'OSlS. — The diagnosis of alcoholic diseases of the nervous system is not un- frequently surrounded with difficulties, especially in the case of the chronic forms. Chronic Alcoholism produces ner- vous symptoms which are particularly liable to be confounded with the follow- ing diseases : 1, chiefly with commencing general paralysis ; 2, with paralysis agi- tans ; 3, with lead-poisoning ; 4, with locomotor ataxy ; 5, with hemiplegia or paraplegia from ordinary softening of the brain or spinal cord ; 6, with epilepsy ; 7, with senile dementia ; 8, with hysteria ; 9, with the nervous malaise associated with some forms of dyspepsia. Tlie gen- eral group of leading symptoms whose presence enables us to affirm the diagnosis of chronic Alcoholism rather than that of any of these diseases is as follows : The patient suffers from restlessness of mind (without delusions), insomnia, muscular fidgetiness, or actual tremor, mornmg vomiting ; and presents flabby features, and watery eyes, and slight jaundice of the conjunctiva}. These symptoms make the diagnosis highly probable. If to them is added the occurrence of vertigo, mus- cffi volitantes, and terrifying dreams, it is greatly strengthened ; and it is raised to the point of certainty, in my opinion, if there be also actual visual or auditory hallucinations in the form of visible shapes of men, beasts, &c., or audible voices. Indeed, the concurrence of dis- tinct visual or auditory hallucination ^'-ith 682 ALCOHOLISM, only four other of the above-mentioned sj'mptoms — viz., insomnia, morning vom- iting, muscular tremor, and causeless mental restlessness — would of itself very nearty persuade me of the existence of alcoholic poisoning. Cases of commenc- ing general paralysis (the most embar- rassing counterfeits of the disease) may nearly always be distinguished by the presence of mental exaltation, the condi- tion of the toper being uniformly one of mental depression, on the whole. The very rare cases of general palsy which do not display mental exaltation are wanting in the other features of Alcoholism, unless indeed when drink has been the exciting cause. As far as I have seen, chronic alcoholic poisoning ahcays produces three or four of tlie leading symptoms which I have "mentioned as specially diagnostic ; and where an acne-like eruption of the face is also present, this settles it. The diagnosis of the acute forms of Alcohol- ism is usually far less difficult. "We can generally get at a knowledge of the pa- tient's mode of life in these cases ; whereas tlie chronic toper is very commonly, espe- cially if a woman, most cautiously and skilfully reticent and deceitful, and often conceals her habits even from her nearest relations. A case of considerable diffi- culty may arise in the distinction between dchrium tremens and some forms of acute mania not caused by drink. The exist- ence of delusions, not mere terrors, should bias us in favor of the diagnosis of mania, as should also the tendency to commit jjarticular acts of violence, and especially hi'tful propensities ; while the predomi- nance of hallucination, especially when combined with terror of mind, tremor, and busy delirium, should predispose us to recognize delirium tremens. For the means of diagnosis between the different forms of acute Alcoholism the reader is referred to what has already been said under the heading of symptoms. Prognosis. — The prognosis in chronic Alcoholism, except in its more advanced forms, which are marked by the occur- rence of serious paralytic or convulsive symptoms, or by considerable mental im- pairment, is highly favorable as regards recovery from the immediate symptoms. Mere abstinence, combined with simple but energetic treatment, to be presently described, will suffice in such cases to pro- cure a rapid removal of all the unpleas- ant symptoms. Unfortunately, too many patients are biased by long habit, by hereditary constitution, or by the dis- mally depressing circumstances of their daily life, in a way which renders their return to intemperance indefinitely prob- able. "When once the more serious symp- toms — such as paralysis, or epilepsy, or extreme and persistent muscular tremor — have occurred, cure, even for a time, is far more difficult, and the moral degrada- tion of the patient, especially if a female, is so great as to allow small hope that abstinence will be observed. In delirium tremens the main elements of prognosis are the occurrence or non- occurrence of sleep before the patient is very much exhausted, the condition of the pulse ^s tested by the sphygmograph, and the degree of success which attends the physician's efforts to get nourishment into the system. Sleep, as already re- marked, is not of itself curative. The disease, in proportion to its original viru- lence, has a course of longer or shorter duration to run : this depends in great measure on the quantity of the poison taken, the sufficiency of the assimilative processes, the original strength of the constitution, and the degree in which it can be supported by well-assimilated food. Thus the prognosis is bad in the extreme when the dose of poison has been very large, the patient's constitution feeble, his powers of assimilation weak, and, in addition to this, disease of the glandular organs (especially of the kidneys) exists. Such a case is well-nigh hopeless. Almost equally bad is that in which any severe degree of pneumonia complicates the mal- ady. The test, however, of the patient's chances which more than any other I am inclined to value, is the indications given by Marey's sphygmograph. In propor- tion as the pulse shows a tendency towards the normal form indicated by this tracing are the chances good. On the contrary, such a pulse as the following offers the extreme type of that typhoid form which is of most evil augviry. This latter tracing was taken from a man, aged 40, who, after remaining for nearly a week in the delirious stage, fell into a sound sleep, which lasted for six or seven hours, awoke COMPLICATIONS. 683 apparently so much improved as to his nervous symptoms, tliat a somewhat con- fident opinion was pronounced in favor of his recovery. I augured the worst from the pulse-tracing ; and in fact the patient sank rapidly, about twenty-four hours later. A somewhat extensive experience of this means of prognosis enables me to recommend it with much confidence. Mere rapidity of pulse counts as nothing in gravity, in my opinion, in comparison with the obstinate maintenance of the typhoid form of pulse-wave. It is almost needless to remark that the circumstance of an attack being the first of the kind which the patient has suffered, renders it much less dangerous to life, as a general rule, than a second, a third, or a fourth would be ; but there are import- ant exceptions and qualifications to this law. Thus it may happen that a first at- tack of delirium tremens seizes a patient who has passed the line of middle age, and whose nervous system has been al- ready much enfeebled by chronic disease or bad feeding, but who has never till re- cently indulged to excess in drink. Such an individual runs a great danger of sink- ing under the first acute attack ; and the reason of this may be partly found in the feebleness of his system, and partly in the circumstance that his eliminating or- gans, especially his kidneys, have not become habituated to the irritation sud- denly thrown upon them by blood con- taining large quantities of unchanged alcohol. The same embarrassment of eliminating organs suddenly charged with unaccustomed alcohol is doubtless the cause that a young man's first debauch (such at that of a young sailor, e. g., put on shore after his first voyage) so often causes an attack of delirium tremens ; but here the constitutional strength usually enables the patient to bear up till the natural process of cure has time to be accomplished. The prognosis both of acute mania and of acute melancholia from drink is de- cidedly good, at any rate on the occasion of first attacks, and provided that the affection is promptly treated. The proli- ability of the case passing into one of con- firmed insanity is of course progres'^ivcly increased on the occasion of each succes- sive acute attack. The prognosis of oinomania is in one way very hopeful, in another almost en- tirely hopeless. The attacks of the acute affection may recur any number of times without any serious result : the patient, after a variable number of hours, days, or weeks, returns to his sober senses, and re- sumes his usual course of life. The hope- lessness of the case lies in the taint of in- sanity which almost always lies at the foundation of the complaint, and which makes it almost impossible that the pa- tient can effect a thorough reformation of his habits. However virtuous his inten- tions may be, and however strongly ho may be urged by every consideration of prudence, or affection for those whose in- terests may depend upon his conduct, it appears as if he were impelled by a really irresistible force to yield himself, at cer- tain intervals, to the temptation of drink. When the outbreaks become, as thoy usually do in the end, greatly more numer- ous than at first, there is reason to appre- hend the speedy supervention of confirmed insanity. CoaiPLiCATiONS. —Of the compHcations of chronic Alcoholism it would be impos- sible to speak in detail, on account of their great number and variety. The onlj' point to which I think it necessary to direct attention, is the question of the comparative liability of drinkers and of sober persons to phthisis. It appears cer- tain, from the most careful statistics, and especially from those recently collected by Dr. Sutton, that the liability of drinkers to the ordinary forms of phthisis is con- siderably less than that of temperate people. On the other hand, every phy- sician has now and then observed cases, which may be classed as " galloping con- sumption," which have occurred in per- sons who have been leading drunken lives, and which arrive with great rapidity at a fatal termination. I believe these victims of acute phthisis from drink are always descended of tuberculous fami- lies ; and I think it likely that the start- ing-point of the actual tubercular deposit, is to be found in continuous paralysis orl semi-paralysis of the "nutritive" fibres contained in the pulmonary branches of the pneumogastric nerve, which is kept up by the patient's drinking habits. Of acute Alcoholism, the only compU- cation of which I shah separately speak is that of pneumonia. Nothing is more insidious than the occurrence of pneu- monia in a subject whose nervous system is deeply poisoned with alcohol. A cru- cial instance of this occurred in the per- son of a patient who died in King's Col- lege Hospital many years a^o, without its being suspected that anything more than delirium tremens was amiss, but whose right lung proved, on post-mortem ex- amination, to be hepatized from apex to base. In this ease there was no cough, no expectoration, no pain in the chest, and only so much frequency of breathnig as seemed sufficiently accounted for by the restless muscular movements of the patient. It is most important, in every case of delirium tremens, that the chest should be periodically examined with care. 684 ALCOHOLISM. Pathology. — The pathology of Alco- holism naturally divides itself into three portions. The morbid influence which the poison exerts is of three kinds : in the first place, it acts as a local irritant (when highly concentrated) upon the mucous membrane of the stomach and the ali- mentary canal generally ; and in the sec- ond place, after absorption, it affects tlie rate of movement and the vitality of the blood, and as a consequence of this im- pairs the nutrition of every organ of the body. And tliirdly, it is clear that the nervous centres, independently of the ill effects on their nutrition of the blood- changes, have a certain chemical attrac- tion for alcohol, which accordingly is found to accumulate in their tissues. In the alimentary canal, and particu- larly in the stomach, the local efiects of habitual large doses of concentrated al- cohol are seen in permanent congestion of the bloodvessels, exaggerated or vitiated secretions from the gastric glands, and ultimately a degenerative change in the structure of the submucous tissues, which consists in the disappearance of charac- teristic secreting structures, and the hy- pertrophic exaggeration of fibrous tissue. Absorbed into the blood in large propor- tions, alcohol increases largely the amount of fatty matters in that fluid, and promotes congestion of certain important organs. The congestion of the lungs, liver, kidneys, &c. seems to be partly due to altered chemical relations between the blood and the tissues of those organs, and partly to a paralytic action of the alcohol upon the vaso-motor nervous system. It is by this latter action that I am inclined to account for the abnormal production of sugar in the liver, which has been experimentally observed by Bernard and Harley to follow the introduction of concentrated alcohol into the portal vein, and also for a largely increased excretion of water from the kidneys, which is one of the most in- variable consequences of large doses of alcoholic liquors. It is indeed doubtful whether the degenerative changes which result from prolonged alcoholic poisoning are not in great part due to the direct chemical influence of alcohol upon the nervous tissues. The characteristic changes which have been observed in the brain, medulla oblongata, &c. of confirmed drinkers, consist essentially of a peculiar atrophic modification, by which the true elements of nervous tissue are partially re- moved, the total mass of nervous matter wastes, serous fluid is effused into the ventricles and the arachnoid, while simul- taneously there is a marked development of fibrous tissue, granular fat, and other elements which belong to a low order of vitalized products. Essentially similar changes are observed in the lungs, the liver, the kidneys, the heart, and the larger arteries, which (after the nervous centres) are the most frequently affected. Tlie cranial bones are also thickened by a deposit which is not of the nature of a true hypertrophj', for the bones lose much of their original texture, and become dense, almost porcellanous. There is much in these changes which reminds us forcibly of the efiects on nutrition of tis- sues produced experimentahy by Schiff and Mantegazza by the section of com- pound nerves, such as the fifth cranial, and the sciatic and crural of the lower limb ; and suggests the idea that in al- coholic poisoning the starting-point (or at least one starting-point) of degenerative tissue-changes may consist in paralysis of those nervous branches which preside specially over nutrition, the distinct character of which has been so well pointed out by Brown-Sequard.' It is highly probable, however, that a considerable portion of the degenerative influence of the continued excessive inges- tion of alcohol is due to a chemical inter- ference with the natural course of oxida- tion of the blood and tissues. Notwith- standing all that has been urged in favor of the view that alcohol is not transformed within the body, the balance of evidence is strongly in favor of the belief that a considerable portion of every dose of alco- hol which is ingested does undergo oxida- tion in the system, and that to the diver- sion from its ordinary purposes of the inspired oxygen must be ascribed the diminished activity of elimination of car- bonic acid, of urea, of chlorine, and of the acids and bases of the urine, which un- doubtedly does occur in the subjects of alcoholic poisoning. Treatsient. — 1. The treatment of the chronic form of Alcoholism varies accord- ing to the stage of the disease which has been reached. In that large majority of the cases which come under our notice, in which the patient merely complains of nervousness, of inability to sleep, of mus- cular tremor, and perhaps of the slighter forms of visual hallucination, together with some dyspepsia and with morning vomiting, the treatment required is ex- tremely simple. One has only to insure that the patient practises a proper absti- nence from drink — to insist upon his tak- ing a diet as rich in nitrogenous matters as may be, but at the same time such as his digestive system can appropriate — and to administer certain tonic medicines; and in nearly every case we ma}^ count upon a rapid disappearance of the un- 1 Vide Lancereaux, Archives G6n., Oct, 1865, for a full account of the Morbid Anato- my of Alcoholism. TREATMENT. 685 pleasant symptoms of wliich he has com- plained. "With regard to the first item, the prescription of abstinence from drink, a good deal of ditHculty may arise, and there is room for diflterence of opinion as to the expedient course. I wish to ex- press the decided opinion that complete abstinence may always be carried out without any immediate danger to life or health, if proper care be taken to substi- tute a substantially nourishing diet. The danger of pursuing this course is not a physical but a moral one : all kinds of pledges which, as it were, bind the indi- vidual, have a tendency to lessen the force of such notions of personal responsibility as he may retain ; he is apt to rest his confidence on the oath or formal resolu- tion, which he has taken, instead of teach- ing himself the virtue of self-restraint, as he would have to do if he were to accus- tom himself to the moderate use of alco- holic liquors. This is a question, how- ever, which must be left to the practi- tioner's judgment in each case. The administration of a highly animalized diet is often a matter of difficulty at first, owing to the feebleness of the digestive powers, which renders the use of solid meat impossible, and even that of soups very difficult. Under these circumstances the greatest possible benefit may be de- rived from the administration of some of the better so-called "concentrated" pre- parations of meat, more especially Gillon's beef-juice, and a solid extract from this which is prepared by Messrs. Bell, of Ox- ford Street, as also the better specimens of the extractum carnis of Liebig. [I have found to answer very well, a strong home- made beef soup ; with the fat carefully removed, and a good seasoning of cayenne pepjjer. — H.] Without entering into the vexed question of the exact nutritive value of these preparations, there can be no doubt that they are powerfully reviving to an exhausted nervous system, and that simultaneously with the general improve- ment which they produce, the digestive organs become strengthened to deal with more bulky forms of animal food. The direct medicinal treatment of chronic Alcohohsm in its milder forms is very simple. The presence of dyspeptic symp- toms, unless they are very aggravated, and there is reason to believe that serious organic changes in the abdominal viscera have taken place, ought not to distract our attention from the main object of fortifying the nervous system ; for with the observance of a proper abstinence from their exciting cause they will rapidly Subside. The nervous tonic in which, after a great many trials of different remedies, I have come to repose the greatest confidence, is quinine in one-grain doses two or three times a day. It should be given from the very first, if possible ; and this may be done, even when the stomach is very irritable, by administering the remedy in effervescence, with bicar- bonate of potash and citric acid. The symptoms which most of all distress the patient, in the majority of cases, are the persistent wakefulness and the tendency to visual hallucinations or to appearances of black specks, flashes of fire, &c., before the eyes : the insomnia is also, of course, a great obstacle to that repair of the ner- vous energy without which recovery is impossible. But it would be a mistake to suppose that soporific narcotics, in doses which in a comparatively healthy patient would produce a stupefying effect, are well adapted to relieve this wakefulness : on the contrary, they generally aggra- vate the nocturnal restlessness, besides seriously impairing the general health. Nothing has been more marked, in my experience, than the superior efficacy of direct tonics, and especially of quinine, in producing that nervous tranquillity which makes sleep possible. When these medi- cines prove insufficient, I have found a remedy, which has been recommended by several authors, very useful — namely, sul- phuric ether, either given in half-drachm doses three times a day, or a single dose of one drachm at bedtime. A good addi- tion to such a night-draught is half a drachm of tincture of sumbul. Another remedy, which has proved very successful in the hands of my friend and late colleague. Dr. Marcet, is the oxide of zinc, which, according to that author, has a powerful effect in inducing sleep. He recommends it to be used at first in doses of two grains twice daily, but this quaii- tity may be progressively increased, if necessary, until ten, twenty, thirty grains daily, or even larger quantities, are taken. I have given this medicine very patient trials, both in the smaller and in the larger doses, and I cannot say that I have been so favorably impressed by its action ; and on the whole I am inclined to think that in the majority of cases quinine acts much more satisfactorily. It must also be borne in mind, as Dr. Marcet himself ad- mits, that in certain subjects, especially the anoemic and the chlorotic, the con- tinued administration of zinc is observed to produce a prejudicially depressing effect on the constitution. Nevertheless there is no doubt that oxide of zinc occa- sionally proves a valuable remedy. I think it should not be administered in larger quantities than at most six grains daily ; and I concur with Dr. Marcet m the recommendation that it should be given shortly after a meal, as it otherwise sometimes occasions nausea. A much more effective remedy than zinc appears to be the bromide of potas- sium in ten- or twenty-grain doses three times a day. Although I have not yet 683 ALCOIIOLISil, had the opportunity of trying this medi- cine so extensively as I should wish, the results obtained have been very good. In several instances it has at once re- moved distressing wakefulness, dreams, and visual hallucinations. It is occasion- ally impossible to give this drug, how- ever, from its exciting gastric irritation. Now and then we tind that sleep is not to be obtained by any of the remedies above mentioned, and we are driven to the use of some of the more recognized hypnotics. Of these one of the most effectual is the extract of Indian hemp; it should be given in small doses ; from a quarter to half a grain of a good extract is quite sufficient, and a larger quantity is more likjly to do harm than good to the majority of patients. Opium, if given at all, should be administered in the form of morphia, hypodermically injected; one- tenth to one-quarter of a grain is suffi- cient. But a medicine which is quite as effectual in many cases is good bottled stout given in one single dose of half a pint at bed-time. In the more advanced cases of chronic Alcoholism, wlicre the nervous centres are undergoing serious degenerative changes, as evidenced by the occurrence of para- lysis, epileptiform convulsions, or grave mental deterioration, further remedial measures are required. Of these the two which have yielded me by far the most satisfactory results are cod-liver oil, and phosphorus in the form of the hypophos- phites of soda or lime. Cod-liver oil, to be really of use, must be continued in tolerably full doses over a long period. Employed for so long a time as three or six months without intermission, I have seen it produce striking benefit even in advanced stages ; and in some instances where it failed to produce anything like a cure, it caused great amendment of the most serious symptoms. The hypophos- phites in five- and ten-grain doses, three times a da}', have been particularly valua- ble, in my hands, in the treatment of cases which were distinguished by com- mencing paralysis of sensation. In one case which was marked by epileptic con- vulsions, with much impairment of the mental faculties, the combined use of cod- liver oil and bromide of potassium pro- duced very beneficial effects. Another class of cases, those in which the predo- minant symptom is a very considerable degree of muscular tremor, are often greatly benefited by strychnia. Very small doses only are to be used ; it is well to commence with the ^th of a grain, and increase this to not more than the j'jd of a grain, three times daily. Doses much larger than this have invariably seemed to do decided harm, especially in- creasing the tendency to vertigo, visual hallucinatious, and noises in the ears. 2. The treatment of Acute Alcoholism, (a) Delirium tremens is a malady the treatment of which has experienced seve- ral changes correspondingly with the pro- gress of accurate clinical observation. In former times — indeed a very few years since — the notion universally prevailed that the delirious symptoms were owins to the exhaustion which was chiefly kept up by want of sleep ; and, consequently, that the production of continuous sleep for several hours was the sole and all- important means of cure. It was there- fore the custom to ply the patients with larger and larger successive doses of opium, with a view of drowning the deli- rium in narcotic stupor. Great mischief arose from this wide-spread belief and practice. In the first place, it has often happened that the patient, without ever sleeping at all, has passed first into a con- dition of coma-vigil, next of stertorous breathing, and at last sunk, fairly poisoned with opium. Again, a fact which was disregarded by the earlier authorities was this, that, without exerting any poisonous action upon the centres of consciousness, opium occasionally spends almost the whole of its depressing force upon the vis- ceral nerves. A minor consequence of neglecting this fact was, that the patient's chance of assimilating food was often en- tirely ruined by the paralyzing action ot the drug upon the digestive organs : a much more serious one was the accident which has doubtless often hajipened, and which occurred in cases within my know- ledge — namely, the rapid induction of a cardiac paralysis, the patient (without any cerebral signs of poisoning whatever) suddenly becoming ghastly pale, the pulse fluttering and coming to a standstill within a few moments. One such example was particularly striking, as it immediately followed two large doses of opium, which had been given" in the vain hope of pro- curing sleep; the second dose was equally inefficacious as a soporific with the first, but its deadly effect upon the circulation could not be mistaken. The idea that patients in delirium tre- mens require to be narcotized into a state of repose, may now be said to be aban- doned by those best qualified to speak on the subject. In truth, the condition of the brain requires that sort of treatment which shall fortify and stimulate its functions. I have already argued at length, in an- other work, that every stimulant, when given in such restricted doses as alone de- serve that name, is a promoter, but not an exhauster, of function, and that the idea of any depressive recoil following its action is purely fictitious. There are, accordingly, a great number of remedies of which the larger doses are narcotic, and the smaller stimulant, which in the latter form are capable of giving more or less TREATMENT. 687 relief to the symptoms of delirium tre- mens. It is not worth while to etiunierate all these. The typical member of the group of stimulants is simple, easily di- gested food ; aud the successful treatment of delirium tremens, in nine cases out of ten, depends on the regular and continu- ous supply of suitable nutriment, whereby the functions of the nervous system arc supported during the struggle towards re- covery. The principal kinds of food which are desirable are milk, soup, or strong broth with bread in it (and given very hot), the concentrated meat-foods already recommended under the head of Chronic Alcoholism, and raw eggs beaten up. The necessity for the administration of some nutriment of this kind is impera- tive ; and if the stomach be at first too irritable or the anorexia too complete to allow of feeding by the stomach, it must he given in the form of enemata, so as not to lose a day, nor even a few hours. It should be observed, however, that there are two classes of patients, in one of whom it is, and in the other it is not, de- sirable to employ some preparatory treat- ment of an eliminative kind. The value ofpurgatives has been recognized by many writers. They are eminently suitable to tliose cases in which a young and some- what robust person has brought on deli- rium by drinking a very large quantity of spirits ; in such instances a dose or two of medicine, producing free watery evacua- tions, effects a wonderful improvement (no doubt by ridding the alimentary canal of much of the alcohol which it has taken in). Where the strength of the patient is sufficient to allow of this plan being safely carried out, it will be found that the sub- sequent assimilation of food is rendered more easy and rapid, and that the stage of convalescence is comparatively soon attained. But in debilitated subjects it is far better not to attempt any forced in- crease of the eliminative processes, but to commence at once with the administra- tion of the more easily digested foods in sraaU quantities frequently repeated. The irritation of the stomach may be combated by the administration of ice, and of small quantities of soda-water and other aerated drinks, and one of the best modes of com- mencing the necessary feeding is by ad- ministering milk, mixed with one-third its bulk of lime-water, at frequent intervals. Everything is to he hoped for a patient who has been well supported by food from the early stages of the attack. Of late years an important question has been raised concerning the therapeutic value of digitalis in delirium tremens. The practice, introduced by Mr. Jones of Jersey, of administering very large doses of tincture of digitalis (from half an ounce to an ounce and even more), was a start- ling innovation on the traditional practice in the use of this drug ; such doses having ibrmerly been universally regarded as dangerously poisonous, and calculated to produce fatal depression of the circula- tion.^ It has been proved, beyond doubt, that in a large number of cases these doses are at least harmless, and the testimony of a good many observers has now appa- rently established the flict that the deli- rium may frequently be quieted, and sleep obtained, by the employment of digitalis in this manner. It must be owned, how- ever, that the question still remains in a very unsatisfactory position. The great majority of the cases have been treateit with the tincture, and not with any simple preparation of digitalis : that is to say, the patients have, in fact, received half- ounce or ounce doses of proof spirit over and above the drug intended to act upon the disease. But it is well known that alcohol, in common with all the stimulant class of remedies, has often a beneficial influence in states of low delirium. In the presence of the very conflicting state- ments on the action of digitalis which have been published by different writers, I have endeavored to clear the matter up by employing a strong infusion instead of the tincture ; but it is unfortunately impossi- ble, in many cases, to get the patients to take the remedy in this shape, and I have thus been hindered from effectively carry- ing out the experiment. The powder, given in pills, would be a better form. Prom the observation of a few cases treated with digitalis, in one form or an- other, which have been under my own treatment or that of friends, I have been led to the provisional conclusion that in all probability a large number of the re- ported successful cases have either been instances of a spontaneous favorable ter- mination of the disease, or have been slightly helped towards their happy issue by the alcohol which is contained in the tincture ordinarily employed. This con- sideration leads us naturally to consider the very important question — whether alcoholic liquors should or should not be used in the treatment of delirium tre- mens. I am inclined to think that the moral argument has great weight here. In all cases, and more especially in first attacks, the subjects of which, we may hope, are not irremediably debased by drunken habits, it appears to be incumbent on us to use the time of sickness as an opportu- nity for possible reformation, unless alco- hol were necessary. It would, therefore, seem to be our duty to commence the work by giving the patient's system an entire rest from the action of alcohol during the period for which he is under our authori- tative guidance. In young subjects, there- fore, and in first attacks, it is proper to abstain altogether from the use of alcohol. 688 ALCOHOLISM. It is more difficult to carry out this plfin vith older patients, and with those who Lave been for a long time accustomed to depend upon strong drinks for a large part of their ordinary nutrition. In every case, however, I think it is our duty to abstain as long as possible from the use of alcohol, and before resorting to a treat- ment of such doubtful propriety, we ought to try less harmful narcotic stimu- lants. Opium and Indian hemp fulfil the indications which we require, under these circumstances, better than any others of their class. Opium should never he ad- ministered by the stomach, but always in the form of morphia hypodermically in- jected, in the dose of one-tenth to one- fourth or one half grain. Where there is any reason, from the quality of the pulse, to "believe that the circulation is much en- feebled, Indian hemp, in doses of a quar- ter to half a grain of good extract, is a less objectionable remedy, and I have seen it produce excellent effects. A very important question is the pro- priety or otherwise of employing the in- halation of chloroform, in order to quiet the patient sufficiently to enable him to sleep : on this matter there has been the greatest difference of opinion. My own experience of this remedy may be summed up as follows : — In the first place, I have known from personal friends of two cases (and many others have been recorded) in which the patient died suddenly, from cardiac palsy, while the inhalation was proceeding. Secondly, I do not believe, though I have frequently tried it, that the action of small doses of a weak atmo- sphere of chloroform (such as would be free from the danger of producing cardiac palsy) is sufficient to induce sleep, or even to greatly induce the patient's agitation, in the majority of cases. And lastly, re- membering how few persons possess a high degree of skill in exactly graduating the dose of chloroform-vapor, it appears undesirable that it should come into gen- eral use in delirium tremens. Por it is certain that the evil effects of a narcotic depression of the heart's action are much more serious in the case of this disease than of many other complaints. Given internally, in doses of twenty to thirty minims (or an equivalent amount of chlo- ric ether), chloroform is less dangerous, but, as far as my experience goes, not more successful. Other practitioners, however, have met with more success in its use, and some have pushed it to much larger doses ; but considering that forty- five minims taken internally by a healthy man has been known to produce full aniBs- thesia (though this is usually too little to produce such an effect), it is not advisable to run the risk of larger doses than I have named. In all probability another remedy, which has only lately become the subject of at- tention in respect to delirium tremens, will prove one of the best of all the auxili- ary means for quieting nervous agitation and hastening the advent of convales- cence. I refer to the bromide of potas- sium. In twenty-grain doses repeated every two hours the bromide succeeds, in a large number of cases, in calming the nervous agitation and procuring really refreshing sleep ; it should be pushed till as much as two drachms have been taken in con- secutive doses, if sleep is not procured before ; but very commonly not more than three or lour doses are required. As soon as the patient wakes out of sleep the ad- ministration should be resumed. My own experience is now sufficient to assure me that this treatment is incomparably more effective as well as more safe than the use of opium. It is more especially fitted for young and vigorous patients however, and especially to those who, while preserving considerable muscular power, have so injured their nervous centres by large ex- cesses as to induce epileptiform tendencies. A second remedy has lately been dis- covered, which appears to me to exactly fill the place of an appropriate remedy for those cases for which the bromide is not suitable — I mean the hydrate of chloral. Given in twenty-grain doses repeated at an hour's interval, chloral appears to me to act in a manner superior to that of any drug which has been used in delirium tre- mens. It is rarely that more than three doses are required to produce calm and refreshing sleep. A remedy which has been used with great success in many cases, and with most unfortunate results in others, is tar- tar emetic. The handling of this drug in delirium tremens is an extremely difficult thing, for it requires much judgment to decide whether the constitutional strength of the patient is sufficient to support its undoubtedly depressing effects. I venture to believe that the directions, so often given, to employ antimony in cases which are distinguished by "active" delirium, with a bold and threatening (instead of a timid) expression of countenance, con- gested conjunctivse, &c. are quite worth- less. Such symptoms afford no measure of the patient's real strength, nor are they any warrant for the use of antimony ; for this remedy must be given in considerable doses, if it is to do any real good : from a quarter to half a grain should be given three or four times, at intervals of one or two hours. When a favorable effect is produced, it is always accompanied (and I believe caused) by an increased secretion from the kidneys, or by profuse sweating, by which probably the elimination of al- cohol is favored. Scantiness of either or both these secretions is therefore the true TREATMENT. 683 indication for antimony. But it is neces- sary, even wlicn these indications exist, to form a very accurate judgment of tlie strengtli of tlio circulation, and tliis, if we trust to tlie finger's estimate of tlie radial pulse, is most difficult. Fortunately, the use of Marey's spliygmograph -will enable us to form a far more correct opinion than was formerly possible on this point. The symptoms which indicate a dangerous action of tartar emetic are faintnoss, cold sweating, and intermittence or irregular- ity of the pulse : the latter symptom should be carefully looked for with the help of the spliygmograph, which may de- tect it when the finger could not. If the first dose produces even a slight irregu- larity of cardiac rhythm, the medicine should be at once suspended. I wish to express the decided opinion that bromide of potassium and chloral are practically the only drugs Ave need ever employ in delirium tremens. [It may be believed, however, that some practitioners will not give up their confidence, based on experi- ence, in the value of moderate doses of opium, at least given at night, in average cases. Alcohol, also, in diminishing quan- tities, does seem to aid in the cure of the feebler cases. If a man has been drink- ing a quart of whiskey daily up to the time of his attack, a pint or a quart of ale or porter will be to him only a mild tonic heverage, aiding liis digestion. The popu- lar idea of "tapering off" is not altogether devoid of scientific as well as clinical foundation. The prolonged v-arvi or hot hath will sometimes do a great deal of good in de- lirium tremens. Also, in cases of very obstinate insomnia, the application of a blister to the back of the neck may have the happiest effect.— II.] The treatment of the complications of delirium tremens hardly requires any spe- cial remark, except perhaps as to the complications otpneummviu. It is of course necessary, as a general rule, to be specially careful to avoid unnecessarily depressing treatment of affections the original cause of which is the action of a depressing narcotic poison such as alcohol : but this rule is of twofold importance in the case of pneumonia supervening in acute Alco- holism. I am satisfied that I have seen the life of a patient sacrificed by the ad- ministration of two or three consecutive quarter-grain doses of tartar emetic, under the idea that this treatment was specific- ally indicated by the affection of the lung. Tartar emetic, blood-letting, both general and local, purgatives, and every other depressing treatment, are to be utterly proscribed in alcoholic pneumonia, an affection which is attended with much greater debility, especially of the heart, than its superficial symptoms would ap- pear to indicate. The sphj'gmograph is VOL. I. — 44 very useful as a test of the real condition of things. One important branch of the treatment remains to be briefly noticed. It is in all cases most highly desirable that a skilled attendant should be procured, and in cases where the patient is at once violent and of considerable strength, two trained per- sons, with experience of the treatment of lunatics, should be placed in constant at- tendance. It is scarcely necessary to say that the utmost violence of a patient should never induce us to employ bandages or the strait-waistcoat, if it be anyhow possible to secure sufficient nursing assistance. (b) The treatment of acute mania from drink is a subject which belongs properly to the department of mental disease, and (c) The treatment of alcoholic melan- cholia is in the same position, as is also {d) The treatment of oinomania. [On the last subject, however, it may be well to advert to some principles estab- lished by experience. Many persons, habituated to excessive drinking, becom- ing incapable of resisting their craving for liquor while it can be obtained, can be cured only by withdrawal to a secure place at a distance from all opportunities of indulgence. Inehriate retreats or asy- lums have been established for this pur- pose ; and those at Boston, Philadelphia, Binghamton, Chicago, and elsewhere have noAv'been sufficiently long in existence for a fair judgment to be arrived at in regard to their utility. About 30 per cent, of all admitted to these institutions have been reported cured, after retirement for periods vary- ing from three months to a year or longer. Permanence of cure is, in such cases, more indeterminable than in cases of or- dinary insanity, as so much depends upon the will of the individual. A methoma- niac may be said to be cured, when he has recovered the power to continue ab- stinent while at full liberty, if he chooses to do so. But he may not so choose ; and then his cure has been in vain, however real it has been in itself, medically or therapeutically considered. The plan of management at such re- treats is essentially like that of the best hospitals for the insane ; only with less need of apartments and inclosures for confinement of their inmates. Occupation exercise, and wholesome diversion, by aid of o-arden or farm work, or various arts, etc?, with books, lectures, religious ser- vices, conversations, and excursions, make up the " moral treatment." Medically, the therapeutics most required will be, the use of tonics and calmatives to the ner- vous system. Iron, cod-liver oil, quinine, valeriiin, assafoetida, and the bromides (of potassium, sodium, or ammonium, at the option of the adviser) will be the only druTS likely to be called for ; unless un- G90 VERTIGO. usual insomnia may for a while demand the employment of hydrate of chloral at night. A nourishing diet, with abundance of animal food in most cases, will be of great importance. More free use of stim- ulating C(jndiments, as mustard and pep- per, will be suitable with these than witli any other class of patients. Bathing, particularly the cool (with tiie strongest, liie cold) shower bath, is also to be re- commended ; its elieccs, however, being ■v\atched caiv-fully in each case. Six months ought to be the shortest period of retirement. A year will be better, to promote a sec are recovery. The great dilficulty is to obtain tliis prolonged seclusion. Legislation is necessar}-, and to some extent has been effected iu a few of tlie United States, providing for the committal, upon proper evidence, and in due form, of persons rendered, by metho- mania, incapable of taking care of them- selves, to suitable institutions ; precisely as the same thing is done for otlier varie- ties of insanity. Two extreme views are still in conflict upon this subject : that of tliose who regard drunkenness as only and always a vice, to be visited by severe punisliment and outlawry from society ; and tliat of otliers, wlio consider it merely a form of insanity. Actually, it begins almost al- ways as a more or less vicious excess, the culpability of which depends upon a va- riety of circumstances. After long indul- gence, however, it becomes a psycho-phy- sical disease ; as positively as if it had its origin only in material conditions. A prominent fact, of great practical conse- quence, is, that the tendency to it becomes hereditary. Certain families are well- known to exhibit exceptional proclivity to habits of intemperance. Among the evils of Alcoholism, this is not one of tlie least; and to it may be added the very frequent predisposition of the children of drunkards to cerebro-nervous disorders, leading in many instances to their early death.— II,] In order to give as much continuity as possible to my description of the diseases grouped under the term "Alcoholism," I have purposely avoided long digressions upon the views held by other writers, and have made comparatively few quotations of their writings. But in order that the reader may have an opportunity of com- paring this article with the teachings of other modern writers, I subjoin the fol- lowing list of the principal works which are now looked upon as possessing author- ity on this subject : — Sutton, Tracts on Delir. Trem., &c. : Lon- don, 1813. Roesch, Papers in Ann. d'Hy- giene, t. XX. 1838. Rayer, Mimoire sur le Delir. Trem. : Paris, 1819. Ware, John, Re- marks on the History and Treatment of Delir. Trem.: Boston, 1831. Peddie, Dr. J., On the Pathol, of Delir. Trem. and its Treatment without Stimulants or Opiates : Edinburgh, 1854 (pamphlet). Laycock, Dr., Pathology and Treatment of Delir. Trem. : Edin. Med. Journ. vol. iv. 1858-9. Huss, Magnus, Chron- ische Alkohols-Krankheit (German Edit.) : Leipzig, 1852. Marcet, Dr., On Chronic Al- coholic Intoxication, Second Edition: London, 1863. Carpenter, Dr., Use and Abuse of Al- coholic Liquors : London, 1850. Various pa- pers by Dr. G. Johnson, in the Lancet. YERTIGO. By J. Spence Ramskill, M.D. Defixitiox. — The sensation of mov- ing, or the appearance of moving objects, without any real existence of movement. DESCErPTiON." — Vertigo may present two forms : in the one the patient com- plains of giddiness in himself, external objects remaining stationary; in the other external objects assume various abnormal positions: for example, articles of furniture in the room, or patterns of paper on a wall, seem to chase each other round the apart- ment; or, in rarer cases, the vehicles in the street appear upside down, or the pave- ment undulates, or feels elastic. On at- tempting to walk, the patient may feel himself drawn or impelled forwards, side- wards, or backwards, and he can only prevent himself obeying the impulse by a strong effort of volition. Minor degrees of disturbed balance, and the commonest sense of uncertainty of gait demand the same exercise of volition, for there is in all cases a perpetual fear of falling down or of rude contact against other persons or against surrounding objects. In slight cases Vertigo occurs only on movement ; in severe ones, when at rest also, and even during sleep. PROGNOSIS — STOMACHAL VERTIGO. 691 With both forms of Vertigo we occa- sionally tind perversions of "the special senses. Patients complain of mistiness of vision, of being unable to see more than half an object, or of one half being out of all proportion to the other half, of exag- geration in size of an object, of deafness, or of hyperassthesia of the sense of hear- ing, the noise of passing vehicles assuming the intensity of thunder, or of metsesthe- sia or a perverted sense, ordinary loud sounds appearing clear, but soft and dis- tant. In a distinct variety of Vertigo there is real deafness of one or both ears. Associated with these functional disor- ders there are complaints of tinnitus auriuni, a noise of pumping water, of in- termittent pulsations of fluids, of the hiss- ing of a tea-kettle, of the noise of ma- chinery, in fact of many kinds of noises which defy and escape description ; most commonly the noises are permanent, al- though they may vary in intensity whilst the Vertigo is intermittent, yet the noises are loudest during the vertiginous attack. Prognosis. — It may be taken as a rule that in Vertigo unconnected with visceral disease, and in persons under the age of fifty, there is not much danger to life, nor from what is most usually dreaded, viz., paralysis. Sudden and violent attacks of an intermittent character are unusuall}' eccentric in origin, whereas a constant sense of uncertainty in movement, and a susceptibility to the induction of giddiness from the movement of passing objects, especially if combined with a cloudiness of intelligence, or rather a want of the usual clearness, indicates usually a centric disturbance. When, however, a severe attack occurs, without any palpable cause, to a person after the cHmacteric has been reached, a cautious prognosis must be given, and the more so if it be associated with vomiting, or constant nausea, ting- ling of extremities, the sense of pins and needles in one hand or foot, or of neural- gia of a group of muscles, or of those of cue limb. The just fear in such a case is the fear of impending apoplexy. A dis- covery of dilated heart, of valvular disease of that organ, of degeneration of kidneys, with the presence of albumen in the urine, will make the prognosis more serious still. Organic disease apart. Vertigo has been known to exist during a long life, and indeed, unless some other suggestive symptoms are superadded, it cannot be considered a dangerous disease. In fact, the longer the complaint has existed in any given case, the less dangerous it ap- pears to be. Etiology. — The direct proximate cause of all Vertigo appears to be a disordered cerebral circulation ; whereby, on the one band, the special senses convey a false impression to the sensorium, or, on the other, a faulty co-ordination of muscular action is induced. Of remote causes, it seems probable that any acute disease, or any sudden perver- sion of function of any important viscus on the body, may cause Vertigo, either directly or by reflex action. Tims we find stomachal vertigo as the commonest of all forms of the complaint, excepting only the invasion of all, or almost all, acute inflammatory diseases, the exanthe- mata, &c. ; next, poisoning of blood, whether by disease, as from cachremia, ex- cessive smoking, intoxication, or paludal poison ; then organic disease of heart, of right or left side, after such disease has reached a certain point, which acts by altering the cerebral circulation in a two- fold manner. In like manner the sup- pression of a long-accustomed hemorrhage acts, whether it be in the form of epis- taxis, bleeding from haemorrhoids, or pro- lapsus ani, or from the menstrual flow ceasing too suddenly. The rapid suppression of an extensive chronic cutaneous eruption is an acknowl- edged common cause, and it is explicable on the same principle. Vaeieties. — The varieties of Vertigo may be practicall}' divided into eccentric forms, or those arising from functional disorder of any viscus or viscera in the body ; or centric, from organic disease in the brain itself, or by blood-poisoning. There is a third variety, important enough to demand separation from these groups. I have called it essential Vertigo. It is not associated with any other head symp- toms, and there is no appearance of de- praved general nutrition. It occurs mostly in persons about thirty years of age, and is a rare form of the disease, as compared with Vertigo arising from other demon- strable eccentric causes. In other re- spects, a patient suftering from it will de- clare himself in perfect health. In all the cases I have seen, the complaint has been associated with a decidedly weak heart, a feeble small pulse, and with symptoms I take to indicate a dilated right ventricle. Another characteristic may be said to be this, that it is not materially improved by remedies, unless these are accompanied by rest and freedom from anxiety of every kind. ST03IACHAL Vertigo. — The most common and most tractable eccentric variety arises from disorder of stomach, or of functional derangement of the liver and upper part of the alimentary canal. It often occurs suddenly in the middle of the night, or without any warning at any period" of the dav, and in a state of appa- rent robust health. From its violence it suggests the idea of imminent danger. 692 VERTIGO. The following case may be taken as a type : A merchant, some three hours after breakfast, after transacting some business of an exciting character, was quietly walk- ing from a neighboring office to his own, when he was suddenly seized with violent Vertigo. He reeled and immediately laid hold of an adjacent gas pillar ; he felt sick. Besting a few minutes, he felt the giddiness subsiding, and tried to walk ; but with the first step the Vertigo re- turned in greater violence, accompanied by a strange tightness of scalp. He asked a passer-bj^ to assist him, and with the help of this second person managed, reeling or rolling, to reach his office, a distance of a few hundred yards. Seated in his chair, the symptoms gradually sub- sided ; and in a few hours, after a free evacuation of the bowels, he was free from the Vertigo, but he felt weak and shaken, and complained of a heavy dif- fused headache. Prom a very careful examination these facts were elicited. The Vertigo seemed to be of both forms described at p. 690. He felt giddy in himself, and his legs were feeble, but the objects in the streets were also strange. The shop windows seemed moving for- wards, passers-by were racing after each other, the ground felt to his feet uneven, billowy, as if elevated and depressed, and he felt constrained to lift his feet over the apparent elevations. Yet he was dis- tinctly conscious of this illusion, and tried to conceal it. The headache occupied the entire head ; it was not acute ; it gave the sensation of weight rather than of pain ; it was not more frontal than vertical and occipital in its seat. There was no dis- coverable disorder of stomach or of any individual viscus, and, beyond the sudden attack of diarrhoea, nothing to suggest disorder of the abdominal viscera. He attributed the attack, and probably cor- rectly, to having eaten very heartily a breakfast of which sausages and Devon- shire cream formed a part, and to a hasty and very imperfect habit of mastication. During the ensuing month this patient had five separate attacks of the same violence, but without the same disturb- ance of bowels, and without being able to discover any cause, most assuredly not in the matter of diet, in which he had be- come exceedingly careful. Yet he was completely and permanently cured by the remedies adopted for stomachal Vertigo. As a matter of fact, it is very rare to find any positive signs of stomach disorder in these cases. They are named stomachal because remedies addressed to the stomach cure, and cure readily and quickly. "With respect to the kind of Vertigo experi- enced, it does not, exclusively, take cither of the two forms ; it assumes both charac- ters in some individuals. However, it is often so entirely connected with the ap- pearance of external objects to the patient's eye, that the internal sense of giddiness is with difficulty made manifest. Curiously enough, it is rarely that patients complain of exaltation or defect of hearing, or of tinnitus aurium, although both these complaints are very common in the chronic stomachal forms of Vertigo. The ra- tionale of the sj-mptoms would appear to stand thus : Digestion progresses satisfac- torily up to a certain point, when, owing to some temporary cerebral excitement, perhaps of transacting business or of deep thouglit, the process is suspended, an irritation is conveyed to the bloodvessels of the brain, rid the splanchnic or pneu- mogastric nerves, and a disorder of circu- lation and of brain nutrition follows, with a corresponding disorder of function of the particular parts of the brain affected. Like causes produce like efl'ects ; and, moreover, in disorders of the nervous sys- tem it seems that a perversion of function, once induced, is easily reinduced, and by slighter causes. Hence it is not surprising that, if a patient has sufi'ered from this acute stomachal form of Vertigo once, he will be subject to recurrent attacks. Chronic stomachal Vertigo is of very common occurrence, and one often sup- posed to indicate the commencement of congestion, of organic disease of brain, of minute tissue change, premonitory of softening, or of threatening apoplexy ; and the treatment which has been adopted under such erroneous diagnosis has only served to render the Vertigo permanent. Patients in this form of disease do not usually complain of the common symp- toms of dyspepsia. There is never any acute pain referred to the stomach after food ; often there is a slight weight, a somewhat tender epigastrium, only, how- ever, felt on deep pressure, evidences not so much of a perverted as of a slow diges- tion. Complaints are sometimes made of a pain radiating from the stomach to the back, to the cardiac region, or to a gen- eral undefined uneasiness about the entii'e epigastric region. Rarely can more than this be made out by a most careful cross- examination of the patient's stomachal symptoms. In the lower ranks of life, however, such as we find in hospital practice, we meet with all sorts of com- plications ; but that the symptoms apper- taining to the stomach are not urgent may be inferred from the fact that patients do not seek advice for their relief, but for the Vertigo, and some steadily refused to admit there could be any disorder of the stomach, when remedies addressed to that organ afterwards cured the Vertigo. Additional symptoms of functional dis- ease of other organs are, of course, in such a class of patients common, but they are found to be independent of, and to have little influence on, the Vertigo. ESSENTIAL VERTIGO. 693 [There is excellent reason for believing that disorder of the liver has a part in tlie production of Vertigo in some cases. It is not uncommon to find an attack of diz- ziness associated with a yellowish tongue, bitter taste in the morning, and yellow- ness of the conjunctiva. Here cholceniia may be inferrecl ; or, as it is preferably designated by Dr. A. Flint, Jr., on the basis of his elaborate investigations, c/io- lestercemia ; the ingredients of the bile, especially cholesterin, being present in excess in the blood, and affecting the brain with Vertigo as a symptom. — H. ] Very usual combinations of symptoms run tlius : Vertigo, pyrosis, leucorrhrea. Vertigo, menorrhagia, leucorrhcea, ano- rexia. Vertigo, weight of the entire head ; relieved after food. Vertigo, vertical headache, nausea both before and after food. Vertigo, clavus, obstinate consti- pation, amenorrhoea. Vertigo progres- sive, weakness of sight, formicatio. Ver' tigo, tinnitus aurium, and partial deafness. In all these combinations the collateral diseases may be cured, and yet the Ver- tiM remains. There are several points of interest connected with chronic sto- machal Vertigo which serve as a means of diagnosis from the graver forms of it. Thus it is never associated with loss of consciousness. There are intervals of hours in which the patient is perfectly free from it. It is made worse by excite- ment, by long fasting, and almost always the severe attacks occur when the stomach is empty. A stimulus in the form of wine or brandy relieves it ; so also does food taken in small quantity. Closing the eyes to exclude objects in motion often relieves. During the attack a steady gaze on some fixed object mitigates the inten- sity of the sensation of giddiness. It is right to say that closing the eyes and the steady gaze are not invariably productive of relief, although subsequent treatment may prove Vertigo to have been sto- machal. In some cases the giddiness is slight, but almost constant ; then it is usually associated with tinnitus aurium. More commonly it will occur several times daily, lasting from a few minutes to an hour, varying in degree, and accompanied by a singular general heaviness of the head, and a sense of heat at the vertex, ■vhich latter becomes aggravated when the Vertigo ceases. With respect to the peculiar form of Vertigo, no special con- clusions serving the purpose of diagnosis can be drawn. Almost always uneven- ness of the ground is spoken of, or an illu- sive opening of the ground under the feet. Objects race in the eye of the be- holder, and the patient feels' going round with the objects he looks at when confined to a limited space, as in a small bedroom. There are two varieties of chronic sto- machal Vertigo which resist ordinary treatment. ^ I allude to those forms com- plicated with, in some cases caused by, changes of tissue and alterations of the structure of the minute arteries, such as are known to occur in the persons of hard drmkers, or in those who have suffered from delirium tremens, and also in those who have suffered from latent or slight and irregular gout. It is in these cases we find the rarer forms of vertighious per- ception, —as, for instance, when objects in the street or in the room appear turned upside down. In such persons vertigi- nous perceptions and movements last for days, and are often so severe as to confine the patient to bed, incapable of the slight- est movement in the upright position without assistance. Nausea and disin- clination for food are the only stomachal symptoms present. Veetigo of the Aged is often stom- achal, but equally often has no reference to that organ. As years are added, arte- ries become atheromatous, and otherwise diseased and obstructed, the circulation in the brain becomes irregular, we may have congestion in one place and anasmia in the other — a ^-arying condition, abun- dantly sufficient to explain the frequent slight attacks of Vertigo in the aged. The essential condition of the brain is always one of anaemia. (Maclagan.) It is to be remembered that the prognosis is alwaj's more or less unfavorable when Vertigo has commenced only in old age, on account of the known pathological con- dition of the nerve centres. Essential Vertigo. — Some remarks have already been made on this variety. The following case will best illustrate its characteristics : A gentleman, aged thirty- four, of consideraljle energy of character and great bodily vigor, has for three years suffered from almost constant, for the last two years quite constant, Vertigo. He is in comfortable circumstances, and has been very free from the ordinary anx- ieties of life. He has led a temperate country life, and has never had syphilis, gout, or rheumatism. Excepting the Vertigo, he has enjoyed excellent health. He says the giddiness came on gradually, and was at the commencement so slight that he can hardly fix the time of its first appearance. In kind it was subjective. At first, he found himself giddy on dressing in the morning ; he felt as if he had taken too much wine overnight, and his legs were weak, and his gait unsteady. After breakfast he was well. The attacks be- came more prolonged, and occurred at various periods in the day ; and now he is rarely free from a sense of uncertainty rather than positive giddiness. Occa- sionally he becomes worse, and is obliged 694 VERTIGO. to sit down to prevent falling. He has no confusion or muddiuess ofintellect, hiis never lost consciousness, has no complaint of headache, dyspepsia, or disorder of any other kind. Alter many examinations, I have not been able to discover even func- tional disorder in any of tlie abdominal viscera. He has a solt, small, compressi- ble pulse. The impulse of the heart is not visible ; the area of dulness enlarged laterally to the right ; the sounds are feeble, close to the ear, and too clearly audible to the right of the sternum. This patient has undergone a variety of medi- cal treatment in the hands of various practitioners, including strychnine, which was pushed to the verge of producing in- voluntary spasms in tiie limbs. He has tried tlie hydropathic treatment, has passed a season at Vichy, but has not been able to find the slightest benefit. Very careful diet has not altered his con- dition, but excesses of any kind make him worse. Although there is no evidence of valvular disease, yet I cannot help con- necting the feeble heart, and perhaps en- larged right ventricle, vvith a disordered cerebral circulation, which is itself the proximate cause of the Vertigo. I have met with two cases of this kind which were apparently hereditary. The father of one of them is now sevent5'-one years of ag ; he suffers from spasmodic asthma, and has been the victim of Vertigo for the past thirty-five years. Vertigo from Overwork ranks next in frequency to the stomachal va- riety. It occurs in young persons who are underfed as well as overworked, as in some sempstresses ; in the middle-aged, who to spare diet add various irregulari- ties, as well as in the temperate and well- fed, who are constantly subject to mental anxiety and excitement. The attacks of Vertigo are of short duration, occur at intervals of some hours or days, after pro- longed exertion, or poorer diet than usual; it is only a sense of the abnormal appear- ance of external objects at first, and oc- curs only on movement ; it becomes more frequent, and then assumes, in addition, the character of an internal feeling of diz- ziness ; the recumbent position always re- lieves, but does not even temporarily cure it. It is often complicated with stomach disorder, as anorexia, rarely nausea, with constipation, and in the female sex with menstrual irregularities. But the simple stomachic remedies do not remove, they scarcely mitigate, the Vertigo. Patients complain of a want of clearness of intel- lect, an incapabilit}- of sustained mental exertion, together with occipital heavi- ness or headache. In the worst cases, irritability of temper, restlessness, a sense of impending evil, and more rarely insom- nia, are added. Sometimes the Vertigo is so easily induced by the appearance of objects in motion, that the patients are unable to go into the streets. In such cases there are functional ailments of other organs, palpitations, and lumbar pains, accompanied by the passing of phosphates in the urine. Oxaluria is a not unfrcquent cohiplication. Indeed, there is a general lowering of vitality, a universal deprivation of nutrition, and corresponding diminution of power, of which the Vertigo is only one of the ex- ponent symptoms. This is the form of Vertigo which most often amongst busi- ness men precedes softening of the brain. Vertigo from irritation of the auditory nerve has been noticed by my late col- league, Dr. Brown-Sequard. He men- tions, in his Physiology of the Nervous Sjstem (p. 195), this iresult produced by injecting cold water into the ear, and also by the topical application of nitrate of silver ; and he suggests that such appli- cations act in a reflex manner on the bloodvessels, producing temporary anae- mia and a disordered circulation and nu- trition of the brain, resulting in the pro- duction of Vertigo. Meniere, in 1841,' established before the Academy of Medicine in Paris, that certain affections of the ear produced a series of symptoms closely resembling those attending disease of the brain, as Vertigo, dulness, uncertain walk, occa- sional circus movement, and even falling down, accompanied also by nausea, vom- iting, and sjncope. He gives also a case of a young girl who, travelling one cold night in winter during menstruation, was seized with sudden and complete deaf- ness. Her chief symptoms were continual giddiness and irrepressible vomiting, pro- duced by the slightest movement. She died on the fifteenth da}'; yet no trace of disease was to be found in the brain, cere- bellum, or spinal cords. The semicircular canals only exhibited traces of disease; they were filled with reddish plastic lymph. Other cases are on record, by French authors, of a similar kind, some having associated with the Vertigo dys- esthesia ; that is to say, the slightest noise producing positive and even severe pain in the affected and deaf ear. It is remarkable that such cases may terminate fatally, without presenting one single symptom of feverish reaction, and with- out any extension of disease to the brain (Trousseau). It is well known that Ver- tigo in animals may be produced by punc- ture of the semicircular canals, as well as by wounding various parts of the base of the brain. Further information will be found in Dr. Brown-Sequard 's Physiology ' Bulletin de I'Academie de MMecine, vol. xxvi. p. 241 ; Gazette IKdicale, 1861, vol. xvi. pp. 88, 239, 597. TREATMENT. 695 of the Nervous System, and in the works of Schitf, Floureus, Magondie, and Claude Bernard. These are, however, matters rather of physiological than medical inte- rest. Cases of vertiginous movements arising from disease of brain are common, such as a tendency to gyrate, to fall for- wards, to one side, or backwards ; but we are not able in the present state of sci- ence to draw accurate conclusions as to the seat or nature of the disease, unless it be one of a group of symptoms involving paralysis, or having other special marks of disease in a particular locality. Ver- tigo accompanies, to a greater or less de- gree, alnio.st every organic disease of the brain, and every acute atl'ection of this organ. Its value as a sign of disease clearly depends on its association with other symptoms ; and it can only be prop- erly appreciated iu connection with a study of those diseases of which it forms a minor part. In a large number of hospital cases there is the association of Vertigo on movement with tinnitus aurium and par- tial deafness. The tinnitus and deafness appear first, and the Vertigo follows. I have never been able to trace anything like suddenness iu the invasion of tliese symptoms ; their accession is alwaj's gradual, and unassociated with pain in or about the ear, or with symptoms of fever. Persons in fair average health, and without any stomach or other obvious disorder, suffer most. There seems to be some mischief of a very slow kind going on, perhaps in the semicircular canals connected with the circulation, analogous to the more acute cases recorded by Me- niere. The occasional value of counter- irritation, and of iodide of potassium and of small doses of mercury, confirms this view. Trbatjlent.— Stomachal Vertigo, in its acute and chronic forms, often yields to a very simple method of treatment. This consists in the exhibition of alkaline remedies and of alterative aperients con- thiued steadily for some weeks, to be fol- lowed by bitters, and especially by the use of nux vomica or strychnia. The alkaline treatment is to be used after meals, so as to neutralize any formation of acid, and to excite a freer secretion of gastric juice ; the tonics to enable the stomach and bowels below to perform completely their functions. [Magnesia answers an excellent purpose in acute cases.— H.] Stomachal Vertigo of the Beverest kind yields most readily to the influence of these remedies. At the same time food is to be taken in small quantity, to be carefully masticated, at regular pe- riods ; and, for drink, Vichy water mixed with a small quantity of brandy acts most efficiently. All kinds of malt liquors are to be forbidden, whilst general hygienic measures are to be adopted. The splash bath in the morning, early retiring to rest, sleeping on a mattress in a large airy bedroom, are great adjuvants to the treat- ment. Freedom froni the cares and anx- ieties of business are not less necessary. In all varieties of Vertigo it is wise to commence the treatment as if the case were stomachal, not simply because the case may turn out one of this variety, but because stomachal disorder may compli- cate any variety of the malady. The chronic forms of the complaint are more ditlicult of cure, but the same principles apply, and the treatment nmst be varied according to the peculiarities of the indi- vidual case, always remembering, how- ever, that it will be wise to attack and remove the complications which are asso- ciated with it, before making a special treatment of the Vertigo. In more ob- stinate forms of disease connected with tissue degeneration, intemperance, or with chronic gout, measures adapted to these several conditions will of themselves relieve the Vertigo, and prepare the way for the restoration of tone and improve- ment of nutrition, on which any hope of a great amelioi-alion or cure must depend. (When the attack is attended by a yellow fur upon the back part of the tongue, with a bitter taste on rising in the morn- ing, and a yellowish tinge of the conjunc- tiva, it is a matter of frequent experience to find the use of a few grains of blue mass followed by improvement. The dose need not be larger than two gi'ains, at bedtime, for two or three nights in suc- cession. — H.] The Vertigo of the aged demands wine, and any plan of treatment which' the case may demand must be associated with stimulants, unless (a very rare occurrence) the Vertigo be premonitory of menin- gitis, and is accompanied by heat of the scalp and some congestion of the conjunc- tiva. A most eflective combination for Vertigo of the aged consists in very small doses of the bichloride of mercury, with tincture of iron and cantharides. In Ver- tigo from overwork, in the well-fed there are usually present restlessness, insomnia, depression of spirits, and a vague feeling of unhappiness or impending evil, for the relief of which I have found great help in bromide of ammonium, giv.en in an efl'er- vescing form, with the addition of casca- rilla. Amongst the poor, where scanty food accompanies overwork, this remedy is not of such value ; we shall gain more from measures calculated directly to im- prove nutrition, and from slight stimu- lants frequently repeated. Brandy or wine, under these conditions, is a better tonic for a time than bark or quinine, 696 CHOREA. which will be found most appropriate afterwards. The solutions of the hypo- pliosphites are also especially valuable. Essential Vertigo is most benefited by a long course of citrate of iron and strych- nia, given in an effervescing form, alter- nating month by month with tincture of larch and small doses of digitalis. The local application of belladonna does good, although there may be neither pain nor palpitation to suggest its use. I believe it is a direct tonic to the muscular tissue of the heart, in which respect it resem- bles the preparations of larch, and per- haps also of digitalis. The usual con- ditions of rest, freedom from care and anxiety, are, of course, as essential as in the other varieties of the disease. The treatment of Vertigo arising from grave disease of brain, from softening of its structure, from aneurism, or tumor, must be involved in the treatment of these diseases. CHOREA. By C. B. Radcliffe, M.D., F.R.C.P. Chorea is the disease known as St. j Vitus's dance in this country, as the ■ dance of St. Guy in France, and as the dance of St. Weit in Germany, St. Guy being the name which is the French equivalent of St. Vitus or St. Weit. It is chiefly characterized by irregular clonic movements of the voluntary muscles, and by weakness more or less approaching to paralysis in the same parts. 1. Symptoms. — Chorea is .sketched for the first time in the writings of the Eng- lish father of medicine. " St. Vitus's dance," says Sydenham, " is a sort of con- vulsion which attacks boys and girls from the tenth year until the time they have done growing. At first it shows itself by a halting, or rather an unsteady move- ment of one of the legs, which the pa- tient drags. Then it is seen in the hand of the same side. The patient cannot keep it a moment in the same place ; whether he lay it upon his breast or any other part of the body, do what he may, it will be jerked elsewhere convulsively. ' If any vessel filled with drink be put into his hand, before it reaches his mouth lie will exhibit a thousand gesticulations like a mountebank. He holds the cup out straight, as if to move it to his mouth, but has his hand carried elsewhere by sudden Jerks. Then, perh.aps, he con- trives to brinii it to his mouth ; and if so, he will drink the liquid off at a gulp, just as if he were trying to amuse the specta- tors by his antics." The symptoms of the fully developed disorder, as the following case will serve to show, are marked enough and charac- teristic enough. Cose. — Mary C , aged 11, admitted into the Westminster Hospital, under the care of the writer, on the 12th of March, 1864. She is suffering from pains in the limbs, slight feverishness, and some tenderness and fulness in the right wrist, the pains in the limbs being chiefly in the right arm. The day before, she got drenched to the skin in a shower, and was obliged to remain in her wet clothes for some time. She is a bright-faced, good-look- ing, exceedingly pale child, the reverse of dull and stupid in every way, never strong, but never ill, except with severe convulsions when cutting her first teeth. Her mother had four or five epileptic fits about the time of puberty. jMarch 14. — The pains in the limbs are better ; but the tenderness and swelling of the wrist have somewhat increased in the right wrist, and extended to both the ankles. The pulse is 100, and slightly irregular ; the action of the heart is a little excited, and there is a slight systolic bruit at the apex. The skin is moist, and the perspiration has a sourish smell. The appetite has gone altogether, and there is some thirst. The medicine ordered con- tains iodide of potassium and bicarbonate of potass. March 20.— The fulness and tenderness of the joints have disappeared, and so have the thirst and want of appetite ; but the cardiac murmur is more, rather than less, marked. Ordered to get up, and to have cod-liver oil. March 27. — She has just been greatly frightened by seeing a patient close by die suddenly, and is now crying and sobbing bitterly. Previously to this she had been playing with another child in the ward, and was to all appearance quite well. SYMPTOMS. 697 March 29. — A marked change has taken place since the last visit. There is now great restlessness, and impatience, and fretfulness, with curious wriggling, fidgety movements in the right arm. Her sleep has been much disturbed, and twice in the night she got up and went to the sister, crying and saying she was frightened. Four ounces of wine were ordered. March 30. — The restlessness is much increased; but, instead of impatience and fretfulness, there is now evident dulness and listlessness. The right arm is con- tinually jerking about, and in attempting to walk the right leg both jerks and drags. Though right-handed, the left hand is used in feeding, and on inquiry it is found that the right hand is useless for this pur- pose. The speech is thick. All the joints feel strangely loose. There is some diffi- culty in swallowing, and the food is rolled about in the mouth some time before dis- posing of it in the usual way. The fea- tures twitch and twist a little, but not much, the tongue is put out and kept out without difficulty, and it is not particularly unsteady. All the disordered movements are much increased by trying to be still, and during fits of crying and fretting, which fits are not uncommon. The pulse is quick and small, the hands are cold and rather damp, and there is a constant wish to huddle over the fire ; the bowels are very sluggish ; the urine is neutral, and rapidly becomes offensive. Ordered to have hypophosphite of soda and cod-liver oil thrice daily, and a single dose of castor oil. March 31. — The restlessness is much increased, and the tossings and jerkings have become almost general. Standing and walking are barely possible, partly from the jerks and tossings of the limbs, but chiefly from the weakness of the right leg. The grasp of the right hand is also much weaker than that of the left. The right foot is a little more sensitive to pinching than the left. The features are almost continually being twisted into the oddest grimaces, but when at rest they are so wanting in expression as to give the idea of extreme silliness. Indeed, the expression is so changed as to make it difficult to identify the patient as the bright-faced, intelligent girl she was when admitted into the hospital. The speech is quite inarticulate, her only question or answer being " um, " with a snort. Saliva (dribbles from the mouth, and even food, which she can only now get by being fed, is scarcely kept from falling out of the mouth. Mastication and swallowing are both matters of much difficulty. The tongue is unsteady, but it can be put out and kept out by an effort. The pupils are dilated and sluggish — the left especially. The pulse is quick and weak, but not irregular ; the hands are cold and moist. The movements are suspended during sleep, but sleep itself is only in compara- tively short catches. The same medicines to be continued, with brandy and milk at short intervals, in addition four ounces of brandy being given in the twenty-four hours. April 5. — No very material improve- ment. The grasp of the right hand a little stronger perhaps, and the right leg dragging and jerking not quite so much. April 14. — A marked improvement. The gait is much more firm and steady ; the features are less vacant and less dis- composed ; the sleep is comparatively sound ; the appetite is better ; the hands are warmer ; the pupils are now fairly sensitive and equal in size, but the speech remains inarticulate, and the child has still to be fed. No change in the treat- ment. April 21. — The irregular movements of the arms and legs are nearly at an end ; the features are comparatively at rest, and the expression of intelligence has re- turned ; the speech is distinct now, but the voice is low, and the articulation slow; the gait is slouching, but there is no drag- ging in the right leg ; the power of self- feecling has returned, though the left hand is still made use of rather than the right, and the sleep is sound and refreshing. No change in the treatment. May 1. — Nearly well. May 14. — Discharged well, except that there is still a systolic bruit at the apex of the heart. In this case the salient points are, the age and sex, the movements, the paraly- si"s, the numbness, the dulness and listless- ness, the relations to rheumatism and heart-disease, the absence of fever, and the neutral urine ; and the noticing of each of these points in turn will serve to bring out the general features of chorea' in its ordinary form. Age and ib'ea;.— Sydenham states that chorea, for the most part, attacks children between the tenth and fourteenth year of their a£;e, who have not reached the time of pube'rty. Sir Thomas Watson considers these limits to be too narrow, and extends them to the period of the second dentition on the one hand, and to that of puberty on the other ; nay, he extends them still wider, for he states that now and then, but only exceptionally, cases occur as early as 4 or 5, and as late as 20 or 25 years of age. Up to nine years of age the two sexes appear to be equally liable ; after this age females become much more liable than males, in the proportion ol nearly 5 to 2. Of 422 cases treated as out-patients at the Children's Hospital in Great Ormond 098 CHOREA. Street, and tabulated hy Dr. Ilillier, the iiumber.s of each sex at different ages were as follow : — Males. Feiimles. ToUl. From 3 to 6 months . . 1 2 3 " G"12 " . . 1 4 5 " 12" 18 " . . 1 1 2 " 18"24 " . . 1 3 4 ' ' 2 years to 3 years . 3 3 6 " 3 " 4 " . 6 5 11 " 4 " 5 " . 4 16 20 " 5 " 6 " . 7 23 30 " S " 7 " . 18 30 48 " 7 " 8 " . 17 34 51 " S " 9 " . 17 41 58 " 9 " 10 " . 23 57 80 " 10 " 12 " . 23 SI 104 Total 1^2 300 422 At the Children's Hospital patients are not admitted above the age of 12, so that these statistics do not include cases from 12 to l-j years of age — that is, about the age of puberty ; but judging from other statistics, as Dr. HiUier says, " it docs not appear that the period of puberty is more prone to the disease than the period be- tween the second dentition and pubertj-. ' ' Thus, of lUO cases occurring at all ages, and tabulated by the late Dr. Hughes in the Guy's Hospital Reports, 29 were be- tween 12 and 15 years of age, 9 being males and 20 females ; at 15 3'ears of age there were 5 females and 1 male. After puberty, chorea is comparatively rare. In 9G cases, of which the statistics are given by Dr. Ogle, 19 were above 15 — the as;cs beinsr 2 at 16, 6 at 17, 2 at IS, 1 at 19, 2 at 20, 2 at 21, 1 at 23, 1 at 24, 1 at 2(3, and 1 at 43 ; and of these 19, 10 (including the one at 43) were females. And of 17 cases of chorea during pregnancy which proved fatal, which cases form the basis of an excellent paper by Dr. Barnes on chorea in pregnancy, the ages range be- tween 17 and 24, -with one exception, in which the age was 47. The Movements. — These are the most characteristic feature of Chorea. They are clonic spasms, unattended by pain, and, as Dr. Ilillier says, "something like the restless movements of a child put out of temper." Usually they are more marked on one side of the body than on the other, and at first they may be con- fined to one side. Not unfrequently they make their appearance first in one arm, then in the leg of the same side, then in the face, then in the arm and leg of the other side. They are always increased by any attempt to exercise the will, or under any emotional excitement : and thej' are, for the most part, put a stop to by sleep. As a rule, it is enough to see the move- ments to recognize at once the nature of the disorder ; and some of the movements of the face are very characteristic. Still it does not do always to reckon upon find- ing movements which are looked upon as characteristic. Thus, in the case which has been cited as a text, the tongue was not put out with a sudden jerk after a pause, and retracted with equal sudden- ness, after the manner which is described as specially characteristic of Chorea; and most certainly this case is by no means exceptional in this respect. Paralysis. — Want of muscular power is shown by the readiness with which the patients become tired, and by the slow- ness with which they recover from fatigue, as well as in the soft, flaccid, and wasted condition of the muscles when the disease has continued for some time. But this is not all which may be noticed, especially in those patients in which the choreic movements are confined to one side ; for, in these cases, there is usually a want of power in the affected muscles which must certainly be spoken of as a shght degree of paralysis. This want, as Sydenham said, "often shows itself by a halting, or rather unsteady movement of one of the legs, which the patient drags:" or still more frequently, it may show itself in the helpless way in which the arm almost im- mediately falls when it is held out, for it is easy to see that this falling is a pheno- menon which has much more to do with paralysis than with choreic movement. As positive evidences of paralysis, must be reckoned the loss of speech, the loss of facial expression, the loss of the power of swallowing, the inability to use the hands for the purposes of feeding, the looseness of the joints, all of which symptoms were present in a marked degree in the case which has been given, and one or other or all of which, in a greater or less degree, are usually present in all cases. Para- lysis, indeed, is seen to be a marked fea- ture in Chorea, if only the attention is not allowed to be entirely absorbed by the contemplation of the movements ; and in some extreme cases it may be so marked as to lead to incontinence or retention of urine, or to involuntary stools. Usually, also, the muscles which are most affected by the movements are those which are most paralyzed. Nor is the connection of Chorea and paralysis altogether out of order ; for in many cases of paralysis pro- perly so called, the paralyzed parts are affected by movements which, without question, are not remotely akin to those of Chorea. li'umhncss.—Thia symptom is sufficiently marked in many cases to be detected with- out difficulty, especially in the parts in which the movements are most marked, but it is never as prominent a symptom as in hysteria ; and the same remark ap- plies to the opposite condition of over- sensitiveness. Trousseau says that numb- ness, when present, is usually accompa- nied by tingling. SYMPTOMS. 699 Didness and Listlessness. — The vacancy of expression resulting from the semi- paralyzed conditiou of the features, which may be so extreme as to suggest the idea of idiocy, must not be taken as the gauge by which to measure the mental condition of the patient. Matters mentally are cer- tainly not so bad as they look ; still there is always more or less dulness and list- lessness — dulness and listlessness rather than fretfulness, and undue excitability, as in the ordinary hysterical condition. It is to be remembered, also, that the children attacked by Chorea are com- monly distinguished by vivacity and rest- lessness of disposition. Bheumatism and Cardiac Diseases. — In his excellent digest of 3U0 cases of Chorea, occurring in Guy's Hospital, the late Dr. Hughes ascertained that, ' ' out of 104 cases in which special inquiries were made respecting rheumatic and heart affections, there were only 15 in which the patients were both free from cardiac murmur, and had not suffered from a previous attack of rheumatism." Nor is it possible to get over this fact by imagin- ing that the pains of the supposed rheu- matism may have been simply neuralgic, and the cardiac murmur merely anaemic, for in 11 out of 14 cases of death from Chorea recorded in this paper, there were actual vegetations upon the cardiac valves. Dr. Romberg says, " The rheumatic pre- disposition, noted by English medical men, was rarely traceable in the cases presenting themselves to my observa- tion;" but this opinion is not that of other German writers. Dr. West, who once had doubts as to the frequency of the connection between rheumatism and Chorea, now believes that the rheumatic diathesis is a powerful predisposing cause of Chorea. M. Eogers says, "The coin- cidence of Chorea and rheumatism is so common a fact, that it ought to be re- garded as a pathological law, just as much as the coincidence of heart disease and rheumatism;" and again, "The child affected with rheumatism is, after a longer or shorter interval, threatened with Chorea ; and the child affected with Chorea is sooner or later menaced with rheumatism." It may also, as Dr. Tuck- well points out, explain why it is that in adults rheumatism and Chorea do not go together as they do in earlier life, that in earlier life rheumatism is far more fre- quently complicated with heart disease. "The younger the patient," as Dr. Hil- lier remarks, "the more frequently is rheumatism accompanied by endocardi- tis." Cardiac disease is also very com- mon in Chorea. Thus, in 37 cases of which notes were taken by Dr. Ilillier, there was probably organic disease of the heart in 25, and of functional derange- ment in 4, whilst in 8 only was there no sign of cardiac disturbance. Heart dis- ease, however, does not necessarily point to rheumatism in children. On the con- trary, it may follow scarlet fe\cr or measles, and in some cases it may come on without any obvious reason. But, be the cause of the heart disease what it may, heart disease is a common accom- paniment of Chorea, in the refractory cases especially. Absence of i'ci-er. — Fever does not figure among the necessary symptoms of Chorea. In fact. Chorea is essentially a fevcrless malady. Not unfrequently, also, there are signs which point to a condition of circulation the very opposite to that which is met with in fever, such as coldness and clamminess of the hands, a disposition to chilblains if the weather be at all cold, pastiness or puffincss of certain parts of the skin, anajmic vascular murmurs, and the rest. In some instances, it is true, the temperature is increased; but such increase, according to my experience, is only met with in mixed cases of Chorea, where delirium is a marked feature, and where the movements point to delirium rather than to Chorea, and then only ex- ceptionally, and therefore it may have nothing to do with the Chorea. More- over, increahc of temperature is not alwaj'S a sign of fever in tlie ordinary sense of the word, for it is a fact, not unfrequently verified, that the temperature often rises remarkably in the moribund state, and that for some time after death the corpse may give a disagreeably hot sensation to the touch. Nor is an argument to the contrary to be found in the relation of Chorea to rheumatism. Chorea may oc- cur before or after rheumatic fever, but not along with rheumatic fever. This is the plain fact. Indeed, the very connec- tion of Chorea with rheumatism, when properly understood, may be only one other proof that Chorea is associated with a state of wanting vigor and activity in the circulation, for most assuredly a weak circulation and a lymphatic habit gener- ally is the state of things which is likely to be present in persons who are prone to rheumatic fever. Moreover, it not un- frequently happens that the symptoms of Chorea are suspended by the accidental development of scarlet fever or some other febrile disorder, and that they return again when the state of feverishness passes off. Neutral Urine.— In the case which serves as my text the urine was neutral, and readily becoming offensive ; and so far as my experience goes, this is the case gen- erally. In some cases, however, the urine seems to be of unusually high specific gravity, as has been shown, first of all by iDr. Walshe, and afterwards by the late 700 CHOREA. Dr. Todd and by Dr. Bence Jones. In a case of acute Chorea, of which Dr. Walshe gives the history in detail, lithates were deposited in large quantities during the first few days, then urea was found to be present in great excess, then oxalates made their appearance, and last of all there was a copious precipitation of oxa- lates ; and in another case, given in the Clinical Lectures of Dr. Todd, the specific gravity of the urine was never below 1-019, and often as high as 1'030 or even 1"035, and as a rule urea and oxalate of lime, but especially lithates of ammonia, were present in considerable excess. The state of the urine requires to be more carefully inquired into. In two cases I found, for a short time only, some excess of urea, and a thick deposit of lithates on cooling ; but this state of things soon changed, and what I noticed chielly was the rapidity with which the m-ine lost its acidity, and threw down phosphates. The case of Chorea which has served as the text for these comments is a little more marked in its symptoms than the average of cases. Usually, indeed, the speech is thick and confused, not lost, and the use of the hands is not so completely taken away. Usuall}', also, paralysis is a less prominent phenomenon. The symp- toms are, in fact, infinitely varied ; and as they are toned down on the one hand, or exaggerated on the other. Chorea may be a most trifiing disorder or a very grave malady. In its most trifling form Chorea may be nothing more than a grimace, or a shrug of the shoulders, or a catch in the speech, or some other odd or awkward in- voluntary movement, which in many in- stances appears to be little more, or no more, than an unchecked bad habit. In its gravest form, on the contrary, few dis- eases are more distressing to witness — the patient tossing ceaselessly to and fro, un- able to walk or even stand, turning, writh- ing, dashing about, and only kept in bed by being strapped down or fenced in ; without speech, perhaps with the lips torn, chapped, and bleeding, by being, in spite of all we can do to prevent it, continually drawn into the mouth and munched be- tween the teeth, which themselves, in some instances, are actually ground down and even forced from their sockets ; with the elbows and hips and other prominent points made raw by constant rubbing against the bedding — a sight which is forced upon one, for no care can keep the bedclothes in their place — sometimes rav- ing, and never sleeping, until death comes to the rescue. Once seen, indeed, it is noc easy to forget a scene so sad as that presented by Chorea in its gravest form, a scene than which there is none sndder in the whole ran^e of diseases, hydro- phobia itself not e.xcepted. 2. Exceptional ronjis or Chorea. .—Allied more or less closely to Chorea in its severest form is a disease whicli \\as first described by Dr. Dubini, of Milan, about twenty years ago, under the name of electric chorea. This disease seems to be peculiar to certain districts of Lom- bardy. Its symptoms are : — (1) Certain choreic or convulsive shocks in the limbs, repeated with a certain regularity of rhythm, persisting with scarcely any in- termission for days, or even weeks, and followed by paralysis, and, it may be, atrophy of the aftected parts ; (2) certain tonic convulsions of great violence, affect- ing the muscles in \\ hieh tlifi choreic con- vulsions are manifested, and occurring in not unfrequent paroxysms ; (3) epilepti- form attacks, sometimes general, some- times partial ; (4) certain head-sjmptoms, such as cephalalgia, delirium, and coma. One or the other of these groups of symp- toms may be predominant in diflerent cases. Electric chorea may be either acute or chronic, and in either case its termination is almost always in death. As a rule, It begins quietly, and is in no great haste to assume its serious charac- ters. As a rule also, a delirium, lasting for some days, and ending in coma, ushers in the fatal termination ; but not unfre- quently death is brought about more speedily and suddenly in an epileptic paroxysm. The electric shocks which form so conspicuous a feature in the dis- order, occur very frequently, as often as thirty, sixtj^, or a hundred times in the minute, and they are often, if not always, accompanied by feelings of pain, tingling, or cramp in the same parts, by vertigo, and by humming or singing sounds in the ears. At first the digestive organs are but little affected, but after a time the appetite fails, and gastralgia and frequent vomiting add to the distress. Fever, indeed, is not seldom present. The mean duration of the disease is from forty to seventy days, if we except a few acute cases in wliich death happened in a few days with urgent cerebral symptoms. Electric chorea was the name chosen for this disease by Dr. Dubini ; U/2jhm conmdsivo-ccrebralis was the name selected by Dr. Erua, a colleague of Dr. Dnbini's in the great hospital in Milan, who saw many cases, and whose description of the disease immediately followed that of this last-named physician ; and myelitis convul- sira was the name made use of by Dr. Hbrtel, in his account of the disorder. This difference of nomenclature shows how differently various observers were struck by what they saw, and proves, at the same time, what is plain from their description, that electric chorea has not, perhaps, the strictest claim to be admitted into the category of choreic affections. St. Vitus 's dance, however, is the very EXCEPTIONAL FORMS OF CHOKBA. 70t Proteus of diseases, and many strange maladies have to be passed m review before the description of all its various forms is complete. The disease to which the name of St. Vitm-s dance was originally given was of an epidemic character. It broke out at Strasburg in 1418, close upon the heels of the black death. It was, in fact, a fresh outbreak of a dancing epidemic called the dance of St. John, which made its appear- ance at Aix-la-Chapelle in the summer of 1374, and then spread like wildfire over the whole of Germany and the countries to the northwest. This dance of St. John appears to have been characterized chiefly by paroxysms of extravagant danc- ing and leaping and howling and scream- ing. In some cases the head was filled with ecstatic visions in which St. John was a prominent object ; in others the most frantic excitement was produced by certain sights or sounds. Sometimes the dancing movements were ushered in by symptoms of an epileptiform character : usually they were accompanied and fol- lowed by the most distressing flatulency : almost always they were carried on until they came to an end from sheer want of strength. For nearly two hundred years society was disorganized by persons suf- fering from this demoniacal disorder, and by rogues who simulated it for sinister purposes. Dr. Ileckcr tells us that the feast of St. John the Baptist was always hold as a day of wild revelry ; and that at the time when this strange malady made its appearance, the Germans were in the habit of mixing up with this Christian ceremonial an ancient pagan usage — the kindling of the ''nodfyr. " It was the custom on these occasions to leap through the flames of tliis fire, and .to consider that a year's immunity from the disease was gained in this way ; and in this leap- ing run mad, Dr. Hecker thinks, we have the origin of the dance of St. John. In its main characteristics the dance of St. Vitus does not appear to have difl'ercd from the dance of St. John. The differ- ence of name was owing to this — that at the first appearance of the disease in Strasburg, the sufferers, real or pretended, were so numerous that the city authorities divided them into companies, and appoint- ed persons whose duty it was to conduct them to the chapels of St. Vitus near Zabern and Eotenstein, as well as to pro- tect and restrain them by the way. They were taken to these chapels in consequence of a legend, invented conveniently for the occasion, which represented that this St. Vitus, when suffering martyrdom under Diocletian, A. d. 303, had, in answer to prayer, received power to protect from the dancing mania all those who observed the day of his commemoration and fasted upon its eve. At any rate to the shrine of St. Vitus these people went, and there priests were ready to sing masses, and to perform other services fitted for the occa- sion ; and thus the name of the disorder became changed from the dance of St. John into the dance of St. Vitus. Attention was first prominently directed to these two dances, at the times which have been mentioned, but there is good reason to believe that they had been known a long time previously. At the beginning of the sixteenth cen- tury, a change had taken place by which these disorders had become less unlike disorders which are now classed under the head of chorea. This is evident from the description given by Paracelsus and other competent observers. At this time these maladies were characterized by fre- quent fits of hysterical laughing or cry- ing, by odd movements, and now and then by fits of dancing, but not by the howling or screaming or mental delusions or distressing flatulency of former days. In some instances, also, the propensity to dance was not irresistible. Still, now and then the disorders in question ap- peared in their old form, and Dr. Ilecker tells us that so late as 1623 some women were in the habit of paying a yearly vifit to the chapel of St. Vitus, in the terri- tory of Ulm, in order that a dance at the altar there might save them from dancing elsewhere against their will, until the same time next year. Almost contemporaneously with the dance of St. Vitus, a dancing malady, called tarantism, appeared at Apuleia, and spread from thence with great rapidity over the rest of Italy. This malady was attributed to the bite of a tarantula, or ground-spider, common in the country ; but it is more probable that undue fears as to the evil consequences of the bite — fears arising easily in the gloomy and de- spondent temper of the times— had more to do in causing the malady than the bite itself. Those-who were bitten remained dejected and stupefied, or else, becoming greatly excited, went about laughing, singing, or dancing. In any case, they were utterly unable to restrain themselves if acted upon by music of a certain kind. A bacchantic furor was excited by the first notes, and as the performance went on they would dance, and leap, and shout, and scream, until they fell down from sheer exhaustion. Some colors appear to have excited them, others to have calmed them. Some had a strong dispo- sition to ru^h into the sea; many were carried away by strong sensual passions into deplorable excesses. Some, again, were tormented by the flatulent distress which was a symptom in the dance of St. John. In this malady, music was looked upon as the only remedy, and the country everywhere resounded with the merry 702 CHOREA. notes of the tarantella. The favorite in- struments were the shepherd's pipe and the Turkish drum. It was supposed tliat the poison of the tarantula was diffused over the system by the exercise of the dancing, and expelled along with the per- spiration. It was' customary for nume- rous bands of musicians to traverse the length and breadth of the land during the summer months, and the seasons of danc- ing at the different places were called "the women's little carnival," "carna- valetto delle donne," for it was the women, more especially, who conducted the arrangements, and defrayed the ex- penses. Tarantism continued in Italy long after the dance of St. Vitus had died out in Germany ; indeed, the epidemic can scarce!}' be said to have been at its height until the middle of tlie sixteenth century. It would seem also that the tigrHier or dancing mania of Abyssinia, a malady occurring most frequentl}' in the Tigre country, is, in some respects, not unlilce the ancient dances of St. Vitus and St. John. Beginning with violent fever, this malady soon turns to a lingering sickness, in which the patient becomes reduced to the last degree of emaciation and ex- haustion. This sickness may continue for months, and end in death if the pro- per cure be not sought after. The first cure, which is also the cheapest, is one in which a priest ministers. It is a kind of water cure, with a blessing superadded. If this fail, the aid of music is appealed to, and arrangements are made for a pro- longed ijerformance. The place chosen generally is the market-place. Under the influence of the music the patient soon bestirs herself, and begins to leap and dance in the maddest manner possible, and, having begun, she goes on in the same way until the day is nearly, and the musicians altogether, spent, and then she starts offi and runs until her legs refuse to carry her any further. Then a young man who has followed her fires a gun over her head, and, striking her on the back with the flat of a broad knife, asks her name, when, if cured (she had never ut- tered this name during her strange ill- ness), she repeats her Christian name. After this she is re-baptized, and consid- ered convalescent. The account of this extraordinary affection is by Mr. Na- thaniel Pearce who lived nine years in Abyssinia, who saw what he describes, and who published the story about thirty years ago. A place in this strange category of dis- orders must also be conceded to those ex- travagant leapings and dancings •s\-hich have been met with at various times among certain sects of religious enthusi- asts — the jumpers of tiiis country and America, the "couvulsionnaires" in France, and the victims of "leaping ague," who some time ago startled and shocked the grave people of Scotland. These latter enthusiasts complained of pains in the head and elsewhere, and soon aftei-wards they began to suffer at certain periods from fits of convulsion and fits of dancing. At these times they acted in the maddest way, distorting their bodies, springing to a surprising height, or run- ning with amazing velocity until they fell down exhausted. "When confined in cot- tages, a favorite practice was to leap up and swing about among the beams sup- porting the roof. The effects of music do not appear to have been tested. The time for a general visitation of maladies such as these would appear to have passed by, at least in this country ; but there are still to be met with, now and then, isolated cases which have some claim to be included in the same category — cases distinguished by involuntary leap- ing, turning, or rushing backwards, for- wards, or sideways. One of these, often quoted before, is recorded by Mr. Kinder "Wood ; and this, with two wliich have fallen under my own observation, may serve as illustrations. Mr. Kinder "Wood's patient was a young married woman who had suffered for some time from headache, nausea, quick involuntary movement of her eyelids, and various contortions of the limbs and trunk. The paroxysms themselves were not always of the same kind. At one time she would be violently and rapidly hurled from side to side of the chair in which she might happen to be sitting, or else, suddenly gaining her feet, slie would go on jumping or stamping for a while, or she would rush round and round the room and rap with her hand each article of furniture that lay in her course. Or she would spring aloft many times in succes- sion, and strike the ceiling with the palm of her hand, so that it became necessary to remove some nails and hooks which had done her an injury. Or she would dance upon one leg, with the foot of the other leg in her hand. These movements always began in the fingers, and the legs were not affected until the arms and trunk had been first seized upon. No- ticing a rhythmical order in some of her movements, as if they were obedient to the memory of some tune, a drum and fife were procured, and the result of play- ing upon these instruments was, that slie immediately danced up to the musicians as closelj' as she could get, and continued dancing until, missing the step, she sud- denly came to a standstill. On another occasion a continuous roll of the drum at once put a stop to the dancing movements. Afterwards, the drum was used in this manner with the happiest results, and at the end of a week tliese movements may EXCEPTIONAL FORMS OF CHOREA. 703 fairlj' be said to have been stopped and cured in this way. Unfortunatel}', how- ever, the drum and tlie hfe were alike found to have lost tlie power on two subsequent occasions when the dancing recurred. These strange paroxysms were generally accompanied by some headache and nau- sea, and followed by a feeling of great weakness and exhaustion, but the patient was always able to go about her household duties in the interval. A young lady, between twelve and thirteen years of age, who had suffered for about three j-ears from a choreic practice of "making faces," and bobbing her head forwards in a curious manner, was the patient in one of my cases. About three weeks before the date of my first visit (24th June, 1857) she suddenly be- gan to suffer from the paroxysms which have now to be described, and a few months previously she had sullered for some weeks in a similar manner. In one of these paroxysms she would sink or rise into a sitting posture, witli her legs folded under her, and then her head would be agitated by a violent, alternating, semi- rotatory movement, until the hair would stream out horizontally on all sides, like the strands of a mop when twirled over the side of a vessel. Then followed a movement in which the whole body was thrown round and round by a succession of rapid vaults. In making these vaults, the hands were placed upon the floor or bed, and the arms used as a kind of leap- ing-pole ; and except at the instant of swinging round, when the feet and legs were thrown horizontally outwards, the half-sitting, half-kneeling posture was never abandoned. The movements of alternating semi-rotation of the head, and of circumvolution of the whole body, oc- curred separately and without any order, and lasted from a few minutes to half an hour. At their worst the paroxj^sms were only separated by short intervals ; and it is difficult to say whether the move- ments themselves or the state which fol- lowed—a state in which the patient lay panting, dripping with sweat, and ex- hausted to the last degree — were most distressing to witness. Paroxysms such as these occurred several times a day dur- ing the first fortnight of my attendance, and then ceased suddenly. After this the patient rapidly improved in general health, and the choreic twitchings of the muscles of the face and the bobbings of the head became much less frequent. This im- provement, however, was only temporary, and at the end of three months the fits returned, though in a modified form, and much less frequently. At this time, in- deed, the alternating semi-rotatory move- ment of the head did not return, and the movement of circumvolution was varied by other movements. Thus, instead of turning, the patient would at times make a succession of leaps in a straight line, so that it was necessary to run in order to prevent her from rushing out at the foot of her bed ; and now and then, after fall- ing back exhausted at the end of such a paroxysm, she would roll over and over sideways for three or four times. During these strange attacks there was not the least trace of stupor, and she would often complain of pains in her head, or of being excessively tired even while the muscular disturbance was at its height, In some instances after the relapse, however, her mind was in a rapt or entranced state, and now and then words escaped which showed that she was absorbed by some alarming dream or vision. At those times the eyes had a fixed stare, and the cheeks were somewhat flushed. After the paroxysm she would be for some time in an intensely nervous and excitable state, starting at the slightest noise or the gentlest touch, and now and then bol^bing her head with much violence ; or if the mind had been entranced while the move- ments were going on, this state would continue for some time, and then pass off with a succession of sighs. Ordinarily, however, the mind was perfectly clear, and the first moment of rest was occupied in complaining of the feeling of headache and fatigue from which she suffered. In the intervals, the patient was nervous and excitable, hut in every respect an acute, clever, accomplished, amiable girl. At these times her principal complaint was of a dull pain across the top of tlie head, or of a feeling of tingling in the back and limbs. In this case, the pulse was quick and weak, the hands and feet were habitually cold, chilblains were scarcely absent in summer, ancemic sounds were audible in the heart and great ves- sels, the appetite was very defective, and the digestion sluggish. There were no worms or any other evidence of derange- ment in the alimentary canal beyond a slight disposition to tympanitic distension of the abdomen. Nor was there the slightest evidence of uterine derangement ; indeed, in this point of view, the patient was a mere child. Recovery was tedious, and more than once interrupted by a re- lapse, but it was complete in the end ; so complete that there was no relapse when menstruation was established about twelve months later. The next case is that of a young gentle- man, Mr. E , set. 22, who came up from the country, about six years ago, to consult me for what he considered to be epileptic attacks. These attacks he had, but he also had other attacks, for the sake of which I now refer to the case. In the first place, he had a curious pursing up of the mouth, attended with frequent i=hrug- gin'TS of the right shoulder, and frequent 704 CHOREA. tossings ont of the right leg ; in the next place, he liad attacks of shuddering, which were so violent as to shake things out of his liand, or to pitch him bodily out of the chair in which he might be sitting, or even out of the bed in which he might belying; in the third place, he had what he called a " fit of turning." He had scarcely told me this story, when, after two or three shudders, as if a shock of electricity had been passed through him, he get up from the chair on which he was sitting, and be- gan to turn slowly on his heels upon the hearthrug. He turned round and round in this way perhaps twenty times and then sat down. Before getting up from the chair he told me not to be surprised at what I saw, and begged me not to attempt to stop him. He said, moreover, that the impulse to turn was not altogether irre- sistible, but that he could not resist the impulse successfully without being much agitated afterwards. This gentleman had gained honors at college, and there was no reason to conclude that his mental powers were at all impaired. He had suffered for sometime from vertigo, and now and then from headache, but never distressingly so. His pulse was 60, and weak, and during one of the paroxysms which I have de- scribed it fell full 10 boats, and became much weaker. I noticed, also, that the breathings were slow and embarrassed, and that he drew several long breaths in suc- cession as soon as the paroxysm was over. It is also customary to regard as varie- ties of Chorea those distressing and not very uncommon cases in which the head is aftected by semirotatory, oscillatory, bowing, or bobbing movements. These movements are very varied in character and degree : they may be combined in various ways; and not unfrequently one kind changes into another in no very regu- lar or intelligible order. The contractions giving rise to these movements may take place suddenly or gradually ; very often they recur with monotonous regularity so long as the patient is awake ; in some in- stances they may now and then be sus- pended for a time by a strong effort of the will, or by holding the head firmly between the hands : not unfrequently they are ac- companied by muscular contractions else- where, especially when the patient begins to be worn out by want of sleep and annoy- ance, and in some degree by bodily suffer- ing also, for, after a time, the muscles affected become very sore, especially about their insertions, and the contraction is at- tended with a good deal of pain. Xor does this exhaust the list of affec- tions which have or are supposed to have some relationship to Chorea. On the con- trary, it remains to mention certain move- ments which are, often at least, little more than bad habits or awkward tricks, such as semi-uncontrollable grimacings, wink- ings, and other movements, which are sometimes spoken of as tics-jion-doulou- reux. Nay, even stammering, stuttering, giggling, sneezing, and some forms of hys- terical coughing, are not excluded, nor yet the convulsive shakings which are often seen in certain paralyzed parts, or the jerks and starts which are not unfre- quently met with in connection with epi- lepsy. In fact, the term Chorea is of the widest and loosest significance ; for it is scarcely too much to say that it is made to include every form of disorderly in- voluntary movement, partial or general, which has not altogether the specific cha- racters of tremor proper, or convulsion proper, or spasm proper. 3. Pathology.— During the last two years Drs. Ilughlings Jackson, Broadbent, Tuckwell, Ogle, Barnes, and others, have done much to elucidate the pathology of chorea ; the investigations of Dr. Kirkes, made four or five years previously, serving as the starting-point to these new in- quiries. Dr. Kirkes was of opinion that "Chorea is the result of irritation produced in the nerve-centres by fine molecular particles of fibrin which are set free from an in- flamed endocardium, and washed by the blood into the cavities of these centres ;'' but he did not venture to fix upon the precise seat of the mischief thus done in these centres. He merely pointed to the vegetations on the valves of the heart which he believed to be constantly present in fatal cases of Chorea, and to the signs of heart disease during life in these and other cases, and drew his conclusions. Adopting this theory of embolism. Dr. Ilughlings Jackson goes further than Dr. Kirkes had done, and attempts to prove that the plugging of the vessels, which he regards as the cause of Chorea, is in the nerve-tissue forming the convolutions near the corpus striatum — a part supplied by branches of the middle cerebral artery ; and that the tissue is thereby not de- stroyed, but rendered unstable from under- nutrition resulting from a diminished sup- ply of blood. And, without doubt, the clinical evidence adduced in favor of this view is very cogent. Taking Chorea of one side of the body, hemichorea, as the simplest form of Chorea, and putting it side by side with hemiplegia, the result of embolism, good reason is found for believ- ing that the disorder of movement and the palsy both point to the region of the corpus striatum as the seat of mischief K this be the seat of mischief in hemi- plegia, why not in hemichorea ? The muscles most moved in hemichorea are those most palsied in hemiplegia. In hemichorea, as in hemiplegia, the arm, as a rule, is more affected than the leg. In right hemichorea, as in right hemiplegia, PATHOLOGY. 705 the speech is generally very much affected. Again, hemichorea is al\vay.s more or less mixed up with, aud sometimes ends in, hemiplegia ; and, on the other hand, hemiplegia from various causes is not un- frequently attended hy chorea, or move- ments of some kind or other. The fact that the face is involved in chorea shows that the seat of the disorder must be above the spinal cord. The facts which have been instanced point to the convolutions near the corpus striatum, rather than in any other part of the brain, as the part affected. In this way Dr. Jackson rea- sons, and reasons to good purpose ; for most assuredly the difficulties which beset any attempt to localize the choreic lesion in the nerve-centres are not a little simpli- fied by thus insisting upon the clinical relations between hemichorea and hemi- plegia, as a ground for believing that the region of the corpus striatum is the part affected in both disorders. Dr. Broadbent also accepts the same doctrine of embolism up to a certain point, and, not knowing that any one had gone before him, travels by the same way to the same conclusion as that which Dr. Hughlings Jackson had arrived at only just before. He is, however, inclined to localize the seat of the cerebral mischief in chorea in, rather than near, the sen- sori-motor ganglia, and he looks upon embolism of the fine vessels of these gan- glia only as the chief cause of Chorea. As with paralysis, so with Chorea, he believes that the symptoms point to the seat of the mischief, not to its nature ; and that, be- sides embolism, hemorrhage, softening, irritation, and other causes, may figure among the causes of Chorea ; the differ- ence between the mischief causing Chorea and that causing paralysis being this — that in the one case it is impairment of function only, and in the other case abo- lition of function — a view which is also insisted upon by Dr. Hughlings Jackson. In addition to embolism as a cause of Chorea, Dr. Broadbent instances local innutrition, reflex action from peripheral irritation, and direct action upon the sen- sori-motor ganglia, from shock, &c. He shifts his ground, in fact, considerably, from embolism as a cause, but at the same time he refers to the discovery by Dr. Bastian of the proximate cause of the delirium of febrile diseases in embolism by altered and cohering white blood-cor- puscles, as bringing some of the causes j\\\ch. might he referred vaguely to local innutrition or blood disease within the category of the cases caused by embolism. Much evidence to the same effect, at least so far as showing that the condition of the heart is favorable to embolism, is also supphed by Drs. Ogle and Tuckwell, though Dr. Ogle himself is not in favor of this theory of embolism. VOL. I.—i:b Dr. Ogle reports sixteen cases of fatal Chorea occurring at St. George's Hospital smce 1K41, and all taken from the hospital books. In ten of these, fibrinous bands were present on the cardiac valves ; and in eight of these ten, their seat was on the auricular surface of the mitral valves. In another case also, not included in these ten, the carotid artery was plugged up. Dr. Tuckwell has witnessed five fatal cases, in all of which the A-ah-es of the heart were affected in the same w.ay— a way so constant as to lead him to speak of hearts thus altered as choreic hearts, the peculiarity being in the presence on the auricular aspect of the mitral valves, along the free margin of each cusp, of a line of numerous, bright, clustering, warty vegetations, some as large as a pin's head, others so minute as to be just visible to the naked eye, and that only in a certain light, but shining like little white beads when slightly magnified, which bodies might be easily detached by lightly brushing the part with a camel-hair brush or with the tip of the finger, and some of which had been detached, and were cling- ing to the chorda; tendinete of the valve, ready to pass into the circulation at the next contraction of the heart. In order to find these evidences of valvular dis- ease, as Dr. Tuckwell points out, it is not enough to open the heart in the ordinary manner, and look at the mitral valve from below : for, looked at in this way, the valve may appear quite healthy. It is ' necessary to slit up the left auricle and look at the valve from above ; and be- cause this is not always done, no doubt the disease has been" often overlooked when it only wanted looking for to be de- tected. [Dr. Dickinson has reported au- topsies of 22 cases of fatal Chorea, in 17 of which recent vegetations were found on one or more of the valves of the heart. -H.] The appearances met with, after death, in the nervous system, are more difficult to explain in accordance with what has been already said. In a few instances only do they tend to confirm the notion of the choreic lesion being caused by embol- ism, and localized in the region of the sensori-motor ganglia. In one of two fatal cases, of which Dr. Tuckwell gives the details, mania was the most promi- nent symptom during life, and the post- mortem examination discovered an exten- sive red softening of the convolutions— "a consequence of embolism;" and in the other, in which there was no mania or de- lirium, there was no superficial softening of the gray matter, but a deeper seated softening of the right, and in a less degree of the le'ft hemisphere, in that part which lies outside and beneath the senson-motor ganglia, without any recognizable evi- dence of embolism, the corpus striatum 706 CHOREA. and optic thalamus lying, as it were, em- bedded in a nest of softened cerebral mat- ter. Dr. Tuckwell also cites a case of embolic hemiplegia, with choreic move- ments supervening upon the paralysis, in which the same parts were found softened after death. " In the beginning of May, 1860, a girl, aged 19, was admitted into St. Bartholo- mew's Hospital, under Dr. Burrows, with complete hemiplegia of the left side, and a loud musical systolic murmur at the apex of the heart. The diagnosis made was ' plugging of some cerebral vessel by fibrin detached from a diseased mitral valve. ' Within a fortnight from the time of her admission, while the paralysis of the left side was steadily improving, the right side became paralyzed, and both the right and left sides became affected with well-marked Chorea. On May 27, double pneumonia, involving the right more than the left lung, came on ; and she died on May 29. The post-mortem examination was made by Dr. Harris, and I took down the following from his dictation : — The brain was found healthy at all points except at the under part of the middle lobe in either hemisphere, where there was a well-marked patch of softening, about as large as a hen's egg, larger in the left than in the right hemi- sphere. The brain tissue at the softened part had a reddish-yellow tinge, more marked on the left than on the right side. The middle cerebral artery, on either side, at about its third division, was found obstructed, at an angle of bifurca- tion, by a firm fibrinous deposit. The heart had its left ventricle hypertrophied, and the auricular surface of its mitral valve studded with numerous warty growths. The right lung was partly in the first, partly in the second stage of pneumonia. The upper lobe of the left lung was in the first stage of pneumonia. There were no deposits in the liver, spleen, or kidneys. ' ' Dr. Bastian also refers to a fatal case of bilateral Chorea, with delirium, of which he promises to give the details presently, in which embolisms, consisting of masses of irregular shape and size, and evidently made up of an agglomeration of white blood-corpuscles, had led to ruptures and obliterations of small vessels throughout the corpora striata and the course of the middle cerebral arteries generally. So fixr the appearances in the nervous system after death from Chorea agree with the premises, but not so what remains to be stated. Thus, in fourteen cases of deaths from chorea, collected by the late Dr. Hughes, the brain was quite healthy in four, and only congested in three cases, while of the remaining seven cases the particulars are these : — In the first, serous eflu«ion beneath the arachnoid and into the ventricles, slight effusion of blood be- neath the right cerebral hemisphere, soft- ened brain ; in the second, arachnoid opaque, brain dark and soft ; in the third, pia mater watery, cineritious matter, red, soft, and partially adherent ; in the fourth, brain soft and vascular, much fluid in ventricles ; in the fifth, arachnoid opaque in parts, cerebrum vascular, left thalanms rather soft ; in the sixth, dura mater ad- herent very firmly to calvarium, more opaque than natural, cerebral vessels turgid ; in the seventh, blood effused into arachnoid, fornix and edge of third ven- tricle soft, red, and tumid, brain softened. In the same fourteen cases, the spinal column was not opened in six : of the remaining eight, the cord and its mem- branes were quite healthy in three, and only a little congested in one ; and of the four others, the particulars are these : — In the first, fresh adhesions of the arach- noid, gray matter dark ; in the second, vessels rather large and numerous, serous surfaces opaque, old adhesions of the membranes, especially posteriorly ; in the third, medulla slightly softened, rachidian fluid opaque, yellow, and densely coagu- lable by heat ; in the fourth, softening of the cord opposite the fourth and fifth dorsal vertebrse. Nor is the information supplied by Dr. Ogle in the paper already referred to less vague, for the sum of it is only this — that the brain or cord, one or both, were more or less congested in six cases, that the central parts of the brain were much softened in one, and that the cord was softened in one and otherwise affected in another. Very possibly a dif- ferent result might have been arrived at if these cases had been examined with special reference to the condition of the sensori-motor ganglia, especially if more men like Dr. Bastian were concerned in the investigation. As it is, all that can be said is that the facts of morbid an- atomy do not supply much support to the notion that the choreic lesion is caused by embolism and localized in the sensori- motor ganglia. There is nothing in the facts to contradict the notion that the choreic lesion may begin in the sensori- motor ganglia ; there is something to show that all parts of the nervous centres may become affected in the end — the cord as well as the brain. No doubt, as Dr. Keynolds remarks, the symptoms of Cho- rea point from, rather than to, the cord. No doubt the spasm should be tonic rather than clonic, as it is in Cliorea, if the cord were specially at fault in chorea. No doubt the cessation of the spasm of chorea in sleep points to the brain, which does sleep, away from the cord, which does not sleep. Nor are these the only reasons which point away from the cord ; but the fact remains that after death from Chorea the cord is often found to be affected, and PATHOLOGY. 707 also that a particular part of the cord, the posterior columns, is especially afFected in a disease which agrees with Chorea in this, that it is marked by inco-ordination of movement, namely, locomotor ataxy. [The order of succession of the sj^mp- toms in some cases, where Chorea follows articular rheumatism, makes it not im- probable that a subacute rheumatic me- ningitis may occur, bringing on the attack of Chorea by cerebro-spinal irritation. More acute and violent manifestations of cerebral rheumatism are, although un- common, famihar to most physicians. — H.] Neitherdo the teachings of experimental physiology help much towards exactly localizing the particular mischief which operates in the exceptional cases of Chorea. These teachings show that movements of a rotatory character may originate in various parts of the nervous system — in the thalami optici, corpora quadrigemina, crura cerebri, pons Varolii, crura cere- belli, in certain parts of the medulla ob- longata, and also in the upper portion of the spinal cord ; that choreic agitation may be caused by slicing away the cere- bellum, and by puncturing one of the corpora quadrigemina ; that the removal of the encephalon in front of the thai- ami optici may result in an impulse to go forwards ; and that a deep wound iu the cerebellum maij be attended by an impulse to go backward. "The parts injured,'' says Dr. Brown-Sequard, "seem to be quite different from those employed in the transmission of sensitive impres- sions or of the ideas of the will to the muscles, at least in the medulla oblongata and pons Varolii. They constitute a very large proportion of these two organs, per- haps three-fourths of the first one : they are placed chiefly in the lateral and pos- terior columns of these organs : they seem to contain most of the vaso-motor nerves, by which, directly, or through a reflex action, they may act on other parts of the nervous system ; and they can give rise to spasm on the same side of the body — a fact which shows that many of their fibres do not decussate." Moreover, another lesson to be learnt from experimental physiology is, that rotatory movements may have their starting-point in a nerve at a distance from the nervous centres. Thus, Dr. Brown-Sequard has made a rabbit turn or roll towards the injured side by puncturing the expansion of the auditory nerve within the ear ; and M. riourens has produced similar movements in a pigeon, by simply tying a bandage over one of its eyes. It would seem, indeed, as if the parts of the nervous ceotres which are concerned in the pro- duction of choreic movements may be affected from a distance by reflex action. Nor is this to be wondered at. seeing that there are facts without number which show that distant parts of the nervous system are continually being affected by reflex action, and that the varied conse- quences of a particular injury are only to be accounted for by supposing many of them to be reflex phonomena. Indeed, there is no lack of instances to show that any part of the nervous system may act on any other part, and the exact localiza- tion of many disorders of the system is a difficult if not hopeless task, for the simple reason that any given lesion in any part may be attended by a wide range of symp- toms depending upon sympathetic dis- order set up in other parts. At first sight it may be supposed that the pathological facts which have been given, favor the idea that inflammation of the brain or spinal cord, one or both, has to do with the production of Chorea ; but a moment's reflection is sufficient to dis- pose of this supposition. It is plain, in fact, that this inflammation cannot be re- garded as essential to the Chorea, for in some of the cases there are no traces of inflammation. This inference is inevita- ble. Moreover, the clinical history of these very inflammations, apart from Chorea, leads to the same conclusion, for the symptoms of these inflammations are not those of Chorea. There are also on record many cases in which inflammation in other parts, as in the lungs, has been developed in the course of Chorea, and in which the choreic symptoms have been suspended during the inflammation. The case, indeed, is one which seems to justify the inference that the Chorea is connect- ed, not with inflammation, but with a state which may issue in inflammation. The case is one in which all seems to be explained if it be supposed that the Cho- rea is connected with irrUaiion, not with inflannnation — with the state, that is to say, which precedes inflammation always, and which may or may not issue in in- flammation. In this way, then, the cases which have been given, in which the traces of inflammation are absent after death, must be looked upon as cases in which the Chorea proved fatal before irri- tation issued in inflammation, and the cases in which the signs of inflammation were present, as cases in which before death the irritation had issued in inflam- mation. Nor is there anything contra- dictory to this conclusion in the clinical historv of the cases of which the post- mortem appearances were those of inflam- mation, for there is nothing in this history to show that this inflammation may not have occurred very shortly before death, and that the true choreic symptoms may not have disappeared as the true symp- toms of inflammation made their appear- ance. And, certainly, there is little reason for connecting Chorea with fever. On 708 CHOREA. the contrary, there appear to be good grounds for belif ving that the maxim of Hippocrates holds good here as in other cases— /efcris accedens solvit spasmos. At any rate, there are many cases on record of measles, scarlet fever, rheumatic fever, or some other fever, being developed dur- ing the course of Chorea, and in which the choreic symptoms have been sus- pended during the fever. I have met with seven such cases. Indeed, so far as I have had the opportunity of judging, the constant rule appears to be, that the Chorea is aggravated in the initial stage of the fever-^that is, in the cold stage, or stage of irritation — and suspended more or less completely when the stage of re- action, or hot stage, is established ; and that, in relation to rheumatic fever, the place of Chorea is either before the fever (often a long time before) or after the fever (often a long time after). The history of Chorea in relation to in- flammation and fever, indeed, so far as I can see, would seem to be like that of dis- orders which are more or less akin to Chorea — namely, tremor,' convulsion, and spasm in their various forms. For what is this history ? In an attack of com- mon trembling, the circulation is greatly depressed, and the pulse does not recover itself until this paroxysm is over ; and in paralysis agitans the paleness and chilli- ness of the .surface of the body, and the decided relief afforded by wine, tell a sim- ilar story. In delirium tremens the cold perspirations, the quick and fluttering pulse, the moist and creamy tongue, are all significant facts. The initial rigor of fever, moreover, is coincident with cJefec- tive surface-warmth, miserable pulse, sunken countenance, blueness of nails, cutis anserina, and other signs of vascular collapse, and subsultus goes along with the most utter prostration of the powers of the circulation. And in mercurial tre- mor, an inference as to the real state of the circulation may be drawn from the fact that the subjects of this disorder are not unfrequently in the habit of resorting to gin and other stimulants for the pur- pose of making themselves steady. There even appears to be something uncongenial between tremor and an excited state of the circulation. The state of the circula- tion in the delirium of which trembling is the distinctive feature— delirium tremens — is quite different from the state of the circulation in the delirium in which there is no trembling. In the latter case — in the delirium of acute meningitis, for ex- ample—the skin, especially the skin of the head, is hot and dry, not cold and damp ; the pulse is hard and strong, not weak and fluttering ; the tongue is parched and [■ Choreic movement is, however, a phe- nomenon very different from tremor. — H.] brown, not moist and crnray — the condi- tion is one, in fact, of high fever, and not one which, as in delirium tremens, is more akin to collapse than to high fever. And it is not less certainly a fact, that delirium tremens loses its characteristic trembling if acute head-symptoms and high fever make their appearance in the course of the disorder. Moreover, it must be borne in mind, as pointing to the same conclusion, that the initial rigors of fever disappear pari jmssu with .the establish- ment of the vascular reaction of the hot stage, and that they return in the form of subsultus when the state of reaction has died out, and the patient is left utterly prostrate and helpless. Again, there is reason to believe that spasm is associated frequently with a de- pressed state of circulation. During the attack of catalepsy, the appearance of the patient is very like that of a corpse, and it may even be necessary to apply the ear to the chest to know of a certainty that the heart continues to beat. In tetanus, as all are agreed, there is no fever ; and in the tetanus arising from strychnia, as Dr. Harley has shown, one effect of the poison is to prevent the blood from be- coming properly oxygenated. In cholera the cramps are coincident with a state of almost pulseless collapse. In hydrophobia the condition of the circulation is as far removed from feverish excitement as in tetanus. And, certainly, a similar infer- ence may be drawn with respect to the state of the circulation in cramp in the leg and elsewhere, for these seizures are met with, not in strong persons, but in those who are weakly, and especially in those who are elderly as well as weakly. Nay, there is reason to believe that spasm in its various forms is antagonized rather than favored by an excited state of the circulation. In tetanus it appears to be the rule for the spasm to gain ground al- most in exact proportion to the degree in which the pulse loses its true power. In hydrophobia it would seem as if the same law held good, for on analyzing the his- tories of a considerable nuniber of cases, I find that there was less agitation, less convulsion, less spasm, where the circula- tion was less depressed than it is in the ordinary run of cases. Nor is a different conclusion to be drawn from the history of spasm as it is set forth in whooping- cough. For what is the fact ? The fact is simply this — that the whoop, which is the audfible sign of the spasm, does not make its appearance until the febrile or catarrhal stage has passed off; that it dis- appears if pneumonia, bronchitis, or any other inflammation be developed in the course of the malady ; and that it returns when the inflammation has departed. And most assuredly there is no clinical evidence to show that convulsion is asso- CAUSES. 709 dated with an over-active condition of the circulation. In tlie fevers of infancy and early childliood, especially in the ex- anthematous forms of these disorders, convulsion not iinfrequently occupies tlie place which belongs to rigor in the fevers of youth and riper years. It occurs in the cold stage of the fever, when the powers of the circulation are greatly depressed in e\'ery way ; and it is confined to this stage, except in those cases in which there are certain brain and kidney complica- tions, when it may also take the place of subsultus, or rather of death itself, for when it occurs at this time the patient has all but ceased to strive in the ' ' struggle called hving." Nay, I am even disposed to think that there is something altogether uncongenial between convulsion and the hot stage of the sympathetic fever con- nected with intiammation, for it is a fact not unfrequently verifled that fits of com- mon epilepsy are often suspended for the time by causes which give rise to a state of sympathetic fever in the system. For example, I can call to mind four or five cases of epilepsy, in which high sympa- thetic fever was set up by a burn or other injury inflicted during a fit, and in which fits, which were of daily occurrence be- fore the accident, and which recurred with the same degree of frequency afterwards, were altogether suspended so long as the fever continued. JSTor is a contrary con- clusion to be deduced from the history of the convulsion connected with teething, with worms, or with any other condition in which what is called "morbid irrita- bility" is the prominent characteristic ; for it is found, not only that fever is al- most entirely foreign to the state of "morbid irritability^" but also that con- vulsion, when it does occur, is associated with seasons of decided vascular depres- sion. In a word, the result of bed-side study has been to convince me that the true place of convulsion, in connection with any form of febrile disorder, is in the cold stage before the hot stage, or in the cold stage after the hot stage, and not in the hot stage itself ; that, in fact, there is something uncongenial between convul- sion and an excited state of the circula- tion. And so also with ordinary epilepsy, the general history of the disorder appears to be that the convulsion is antagonized by an excited state of the circulation rather than favored by it. As it seems to me, then, there is no- thing unintelligible in the fact that Cho- rea, instead of being connected with a state of inflammation and fever, is con- nected with a state which must be looked upon as the very opposite of inflammation and fever. As it seems to me, indeed, there is nothing in this part of the history of Chorea but what was to be exjiected from the history of tremor, convulsion, and spasm in their various forms. Nay more, the antagonism between chorea and inflammation or fever is, as it seems to me, nothing but what is necessitated by the physiological as well as by the pathological history of uuiscidar contraction. But tliesc are topics upon which I may not dilate further in this place, and I therefore bring my remarks under the present head to a close, by simply saying, that those who care to know more of what I think on this su)> ject will find the latest statement of my views in a book about to be published under the title of "The Dynamics of Nerve and Muscle." 4. Causes.— " The patients who suffer from Chorea," says Dr. Hillier, " are very impressible and emotional, and very liable to derangements of the nervous system." Often too, as in the case which has been given as an example of the disease, where there were fits at the time of teething, they have suffered from some other de- cided disorder of the nervous system, and quite as frequently ; as also is illustrated in the case in question, where the mother had epilepsy at the time of puberty, an inherited disposition to disorder of the nervous system may be suspected. Thus, out of 48 cases in which I have inquired into the family and personal history of the patients, I find 27 cases in which father or mother, or brother or sister, had been, or was, subject to epilepsy, pa- ralysis, apoplexy, hysteria, Chorea, or in- sanity ; and 11 in which the patient had bad infantile convulsions. Chorea, or epi- lepsy. As in hysteria, it might be ex- pected that sympathy and imitation would figure among the causes of Chorea ; but this anticipation does not appear to be borne out by the facts. " The disease," says Dr. Hillier, "is never induced by the assemblage of several choreic patients in a ward of children, nor does it appear that the symptoms are in any way aggra- vated by mutual association." Fright, on the other hand, is without question a frequent cause ; it is distinctly stated to be the exciting cause in 31 out of 56 cases collected by Dufosse and Bird, in 34 out of 100 cases reported by Hughes, in 9 out of 31, and in 9 out of 38, related by Dr. Peacock and Dr. Hillier respectively. Still it is certain that in many of these very cases the cWmt of the choreic symp- toms is so long deferred as to make it dif- ficult to believe that fright has had very much to do as an exciting cause, and not unfrequently also a doubt as to the opera- tion of any sudden exciting cause is sug- gested by the very slow development of the choreic symptoms. Indeed, when the matter is strictly inquired into, but few cases are to be met with in which the patient was at once suddenly sent into a state of Chorea from any cause, emotional 710 CHOREA. or other. Some special cause of irritation maj' also be suspected in some cases, as "worms in the intestines, a foetus in tlie viterus, and especiallj' unnatural irritation of the sexual organs ; but here again the evidence is less conclusive than it might be supposed to be. One or two cases are on record in which choreic symptoms have ceased almost abruptly on the expulsion of a tape-worm by a vermifuge. Chorea in pregnancy has also been found to cease on delivery. Still it may be questioned wliether Chorea in pregnancy is always true Chorea, and whether an altered state of the blood rather than irritation may not be the true cause in those cases where there is no good reason to be in doubt as to the nature of the disease ; for in preg- nancy there is a hyperplastic state of the blood which may favor embolism, from the direct deposit of white corpuscles in the minute vessels, as is pointed out by Dr. Bastian, if not by the floating into these ^'essels of minute vegetations de- tached from the cardiac valves. In -5 out of 16 cases of fatal Chorea reported by Dr. Ogle there were " proofs of congestion and other graver lesions of the genital sj's- tem ;" and most certainly I have in not a few cases found reason to know or suspect the existence of practices which might lay the foundation of such congestioii, and give rise to any amount of irritation, and this too in cases where the age of the pa- tient might be supposed to be a sufficient contradiction to the notion. Again, the causes of Chorea and rheumatism would seem to be closely allied, if not identical. "Chorea," says Dr. Tuckwell, "is a dis- ease which is common among the poor and ill-nourished, rare among the rich and well-favored ; and exactly the same holds for rheumatism. " Chorea also resembles rheumatism in being more common in damp and cold than in warm and dry cli- mates. At the same time, season does not seem to influence the development of Chorea very much. Thus, in 27 cases given by Dr. Hillier, 1.3 occurred in the six winter months and 14 in the six sum- mer months — viz., 2 in January, .5 in Feb- ruary, none in March, 3 in April, 2 in May, 4 in June, 2 in July, in August, 2 in September, 1 in October, 3 in Novem- ber, and 2 in December. .5. DiAGXOsis.— In a well-marked form. Chorea cannot well be confounded with other maladies. It does not even suggest the idea of hysteria, and therefore there need be no confusion on this score. Xor need Chorea be confounded with inflam- matory diseases of the brain and spinal cord. In the more aggravated cases there is, I believe, a tendency to run on into one or otlier of these diseases, and the moment of transition may not always be easily definable : but, as a rule, the acces- sion of the new disease will be indicated, not by the aggravation, but by the cessa- tion of the choreic symptoms proper, and the substitution for them of delirium, pain in the head, convulsion, paralysis, numb- ness, pain in the back increased by move- ment, and others, in groupings which will leave no doubt as to what their true mean- ing must be. I have seen two cases of Chorea in children which ended in cere- bral meningitis, and in which the choreic movements ceased when convulsion and delirium made their appearance ; and I have seen one case of severe Chorea in a youth which ended in inflammatory dis- organization of a considerable portion of the spinal cord, and in which the choreic symptoms did not continue after the de- velopment of the numbness, paralysis, and other sjauptoms of myelitis. Indeed, it may be stated broadly that the symp- toms of Chorea are not the symptoms of acute inflammatory affections of the sub- stance of the brain and spinal cord, or of their meninges. Delirium is reckoned among the symptoms of acute Chorea in some cases. But I am very much dis- posed to believe that the case has changed from Chorea to some other disease of the brain, not always inflammatory, of course, A^•hen delirium makes its appearance ; and that this case will be spoken of, not as Chorea, but as a consequence of Chorea, when more is known of the diagnosis of diseases of the nervous system, and when greater exactness of nomenclature is at- tained to. Nor need Chorea be con- founded with any chronic afliection of the membranes or substance of the brain or cord, the points of difference to be noted being always more numerous than the points of resemblance. In locomotor ataxy the disorderly movements are mostly in the legs, and in these parts only when attempts are made to stand or ■s\alk ; whereas in Chorea the movements, which are chiefly in the upper part of the body, though aggravated by any attempt to use the will, continue at all times with little or no intermission so long as the pa- tient is awake. In Chorea also there are none of the severe neuralgic pains which are so characteristic of locomotor ataxy. Again, Chorea is emphatically what loco- motor ataxy is not— a disease of child- hood. The history of Chorea is also suf- ficiently distinct from that of the jerks and shocks attending epilepsy and paral- ysis agitans. In the former case I have sometimes seen movements so repeated, and so like those of Chorea, that a mis- take might have been possible if the fact of the fits had been overlooked ; but usu- ally the movements attending epilepsy are jerks and shocks, separated afterwards by wide intervals and extending over a long period, and not at all choreic in them- selves. The history of paralysis agitans, PROGNOSIS — TREATMENT. 711 let alone the age of the patient, is suffi- ciently distinctive. And so is the histt)ry of those cases of paralysis complicated with choreic movements, in which paral- ysis is the primary disorder, and which may be spoken of as a sort of local paral- ysis agitans ; for this history points to previous brain disease in a way not to be mistaken, and to a time of life which is in itself inconsistent with the idea of Chorea. In fact, it is scarcely possible to confound ordinary Chorea with any dis- order of the bain or cord, acute or chronic, if only moderate care be used in the diag- nosis. And this is all that need be said under this head ; for with respect to the exceptional forms of Chorea, general or partial, it is more than probable that they ought to be taken out of the category of Chorea and placed with hysteria, or re- ferred to some special disease or disorder of the brain or cord. 6. Prognosis. — The natural tendency of Chorea is, without doubt, towards re- covery. Sooner or later, as a rule, the patient gets well ; and too often, as it would seem, the treatment deserves very little credit for this result. The mean time occupied in recovery, according to See, is 69 days, or a trifle under 10 weeks; and Dr. Hillier, basing his calculations on 30 cases treated by himself, arrives at the same conclusion, the longest time occu- pied by these cases in recovery being 28 weeks, the shortest two weeks, and the mean 10 weeks. The disposition to re- lapse is considerable, and usually primary attacks are more protracted than relapses. Now and then, in the proportion of six per cent, according to See, Chorea takes an acute form, and is rapidly fatal. Local chorea, as exhibited in the muscles of the neck at least, is notoriously obstinate ; and instead of wearing itself out, it is more Ufcely to go on year after year until the patient is worn out by it. How far the occurrence of Chorea implies a ten- dency to other disorders of the nervous system, especially to epilepsy, is a ques- tion which has not yet been fully enter- tained, and I cannot supply an answer from actual statistics. But this I may say— that I have frequfntly met with epi- leptic patients who were choreic at one period of their life, and that the impres- sion left on my mind from what I have seen is, that the chances of Chorea being followed, sooner or later, by some other disorder of the nervous system are too much made light of. 7. Treatment. — Nothing can be more perplexing than the statements made by various authorities respecting the efficacy of remedial agents in the treatment of Chorea. Few voices, it is true, are now raised in favor of the old-fashioned anti- phlogistic ways of treatment, in which bloodletting and purgatives and low diet figured so conspicuously ; but beyond this all that is uttered seem's to be dictated by the spirit of contradiction or scepticism. Indeed, so little unanimity of opinion is there respecting the treatment which ought to be pursued in Chorea, that the only course is for each one to glance at the principal remedial agents recom- mended, to weigh the stat'ements made respecting them as well as he can, and to take upon himself the responsibility of de- ciding upon his own course of action. Sir Thomas Watson considers that the most suitable medicine in cases of Chorea is, as a rule, some preparation of ircni; and this verdict is accepted by the great majority of English practitioners in medi- cine. Dr. Elliotson says that he cured forty cases in succession by the use of full doses of sesquioxide of iron, the time spent in the cure varying from six to eight weeks. I have not used iron much in the treatment of Chorea, and I have not seen it used to any great extent by others. ISTot unfrequently, however, I have known a person using this agent go on for a while with it, and then discontinue its use, ap- parently as if he were not satisfied that all the good was being done which ought to be done. Of the several preparations of iron which have been recommended, I am disposed to believe most in the syrup of the iodide, the use of which was first suggested by the late Dr. Barlow, of Guy's Hospital. I have certainly seen several cases in which the use of this preparation seemed to be followed by unequivocal evi- dence of improvement; but, on reflection, I find it difficult to refer this change for the better to the iron altogether, or even to the iron chiefly. On the contrary, I am disposed to think that the iodine is entitled to a fair share of the credit, to say the least ; and that the iodine in the doses usually given is stimulating or re- storative in its action rather than altera- tive, in the sense in which it is usually supposed to be alterative. I fancy, also, that there is a growing doubt as to the efficacy of iron in cases of Chorea, and that many would now be disposed to agree with the late Dr. Hughes, who says only that iron has been administered in num- bers of the cases of Chorea recorded in his admirable report, and that it has "sometimes succeeded where zinc has failed." Zinc is £;iven very largely m the treat- ment of Chorea. In the cases of Chorea occurring in Guy's Hospital, the late Dr. Hughes says that "zinc in the form of sulphate has been the most frequently employed as a remedy, and has generally been most successful ;" and forty-five cures out of sixty-three cases, or five m seven, are credited by him to this medicme. Dr. 712 CHOREA. Barlow says, "In ordiuaiy cases, the ex- hibition ot purgatives to keep the bo«'els freely open, and the sulphate of zinc in doses gradually increased from a grain to even fifteen or twenty grains, or even more, will efl'ect a cure. When, however, the sulphate has been used in these large doses, its sudden discontinuance seems to be felt by the system, and a return of the symptoms ensues. The best rule, there- fore, for its exhibition is as follows:— "the bowels being kept open, the sulphate of zinc should be given in doses commencing with a grain three times a day, and in the case of a child about twelve years old the quantity should be increased by the addi- tion of a grain daily, until the medicine causes sickness, or there is an obvious diminution of the choreal movements. In the former case the dose should be dimin- ished by at least one-half, and so con- tinued for several days, with a view to establishing a tolerance ; but if, on the other hand, there be a marked improve- ment, it should be no further increased, but continued without alteration until either the improvement ceases — in which case it should be again gradually increased — or the disease has altogether subsided. Whenever the latter is the case, we ought to diminish the dose day by day, rather than discontinue it suddenly, as by follow- ing the latter course we have less reason to dread a relapse." In continuation of these remarks. Dr. Barlow adds, "In some cases, however, especially those in which there is considerable anaemia, the iron seems to have more control over the disease than has the zinc, though these cases are rather exceptionable ones. " The late Dr. Bright tells us that he found the sulphate of zinc answer where the car- bonate of iron had failed, and that where iron succeeds, there the zinc had done no good ; and Sir Thomas Watson, who re- peats this statement of Dr. Briglit, leaves us to infer that these words express his own experience in the matter. Arsenic is another favorite medicine in the treatment of Chorea, especially in Great Britain and Ireland. Thomas Mar- ten was the first to recommend it, now sixty years ago ; and since his time it has been very extensively used. Dr. Rom- berg, speaking of the various remedies recommended, and alone deserving confi- dence as capable of arresting the disease in a short space of time, says, "The fore- most among those an experience of seve- ral years has taught me to be ai'senic. " Dr. Begbie also writes, "In an experi- ence of nearly thirty j'cars I have never known arsenic fail." Nor would it be at all difficult to cite other authorities to the same effect. Dr. Begbie gives five drops of Fowler's solution twice a day, an hour after a meal, and adds a drop to the dose every day until the specific effects of the mineral upon the system arc observable, and then he suspends the treatment for a while. He goes on with the medicine, that is to say, until he is warned to .stop by itching and swelling of the eyelids, by redness of the conjunctivae, by a white, silvery appearance of the tongue seldom accompanied by tenderness, and by nau- sea and unea.siness at the pit of the sto- mach. I have often used arsenic in the treatment of Chorea, and I have great faith in its efficacy as a medicine in the malady. At the same time I have often abandoned its use in consequence of the gastric disturbance which, do what one will to prevent it, was set up by it. It seemed, indeed, as if in these cases the stomach would not tolerate the medicine in doses large enough to produce a suffi- ciently rapid action in the cure of the disease. It did not follow, however, that this intolerance of the stomach was a suf- ficient reason for abandoning the arsenic in these cases, for the stomach is not the only channel by which this medicine could have been introduced into the system. Failing the stomach, indeed, the hypo- dermic or endermic method might have been tried, and tliat too, I have now' rea- son to believe, with many chances of ad- vantage to the patient. The case which suggested to me the hypodermic use of arsenic was that of a patient in the West- minster Hospital (Hallett Ward), Marga- ret S by name. This patient had suf- fered for nine years from a distressing choreal affection of certain muscles of the neck, by which the head was continually kept turning and bobbing. At different times various modes of treatment had been tried, including the hypodermic injection of morphia and atropine, without the least benefit. When first admitted under my care, and for the three weeks follow- ing, I gave her bromide of potassium and morphia, my chief object being to procure sleep and alleviate pain in the neck ; for the muscles in the neck, which were the seat of the morbid movements, were very tender in many places, and the move- ments themselves attended with much pain; but harm, rather than good, seemed to be done by these means. The idea of injecting arsenic hypodermically occurred to me on the 12th of January, 1866, and was carried out on the same day. Fow- ler's solution was chosen, and the part selected was the most tender point over the contracting muscle. Three minims were injected on the 12th, TTlv. on the 1.5th and on the 27th, TTLvj. on the 19th, TTlviij. on the 22d, 111 vij. on the 25th, and again on the 29th, Tllviii. on February 1st, TTfix. on the 3d, Tllx. on the 6th, tTLxj. on the 8th, TTLxij. on March 1st, and again on the 10th, TUxiij. on the 12th, TTl xiv. on the 14th. On the 21st the patient left the hospital almost well. Before the fourth TREATMENT. 713 injection was practised, a marked cliange for the better had taken place ; before the eighth the choreal movements were al- most at an end, and the cliange for the better had gone on steadily progressing from the beginning. Between the eighth and the ninth injection there was an in- terval of three weeks' — the injections being suspended on account of the local irritation and inflammation which they had set up. When the patient left the hospital there was some stitTncss in the musok'S which had been the seat of the disturbance, by which the head was slightly twisted, and the voluutary move- ments of these muscles were not free; but every day there was a change for the bet- ter in these respects. In the hospital, the only treatment associated with the injec- tions was a g3'mnastic one, the patient being made to move her head from side to side, and backwards and forwards, in time with a slowly moving pendulum, together with an occasional dose of morphia at bed- time, the drug being given less on account of the malady in the neck, though pain in this region was still complained of at night, than on account of a distressing habit of sleeplessness. Two months have now elapsed since the patient left the hos- pital. She occasionally presents herself for inspection, and her state continues very much the same as it was, just one step from being quite well, and not bad enough to make her wish to have the in- jections repeated. She goes on exercising the muscles of the neck with the pendu- lum, and having them shampooed, and for medicine she has now and then had some cod-liver oil. In this case the object in introducing the arsenic hj'podermically was, not to escape gastric irritation, but to produce some local change in the nerves of the parts which were tlie seat of the disorder, as well as to bring about some more general change in the system. I have employed, with results more or less satisfactory, the hypodermic injection of arsenic in several analogous cases, and also in certain cases of neuralgia, epi- lepsy, and other aifections of the nervous system ; and thus the case which I have given is not the only case which furnishes to my mind reasonfor believing that this mode of treatment may be of use in the treatment of certain eases of Chorea. I ■ Up to the eighth injection iindiluted Fowler's solution was used ; when the injec- tions were resumed, and after this time, this solution was diluted with an equal quantity of water. In other cases, also, where the same mode of treatment has been carried out, I have employed a mixture of equal parts of this solution and water, for I found that the solution diluted to this extent produced very niuch less local irritation than the undiluted Fowler's solution. have also used arsenic endermically as well as hypodermically in a few cases of Chorea. In order to this I have dropped from fifteen to twenty drops of Fowler's solution upon lint moistened with water, and applied this, under oil-silk, night and morning, to a raw blistered surface. This application gives rise to considerable local irritation; indeed, it generally, before the week is over, has the cll'ect of covering the blistered surface with a thin, dry eschar, and of causing a zone of angry pinii)les to crop up in the skin innnediately surround- ing the part which has been blistered. Owing to this irritation, indeed, it is gen- erally necessary to make pauses in the treatment after going on for six or seven days at a time. As yet, however, I have little practical experience of the efiects of this mode of treatment in actual cases of Chorea. I have tried it in two cases of ave- rage severity, in one of which the patient was well in twenty-eight days, in the other in thirty-two days ; and this is all that I can say respecting it, except this, that as with the hypodermic method before men- tioned, so also with this, 1 have given it a trial in certain cases of neuralgia and epi- lepsy, and that the results arrived at in these cases lead me to hope that this mode of giving arsenic may prove to be a not unimportant addition to the arma- menta therapeuticu. With respect to the comparative merits of the hypodermic and endermic methods of introducing arsenic into the system I cannot yet speak. I in- cline to give the preference to the former method, both as least distressing to the patient and as most efficacious ; but I have, as yet, no sufficient practical expe- rience to justify the expression of a defi- nite opinion. During the last twenty-five years strych- nia has been employed somewhat exten- sively in the treatment of Chorea, espe- cially in France. Dr. Trousseau was the first, or among the first, to do this, and after an experience of a quarter of a cen- tury he is still disposed to give the prefer- ence to this practice. The preparation employed by this physician is a syrup of the sulphate of strychnia, made liy dissolv- ing 3 grains of the sulphate in ,^x of simple syrup ; and the manner of giving it, which is peculiar, is as follows:— In children from five to ten years of age, the treat- ment is commenced by giving a teaspoon- fid of this syrup (containing j'jth of a gram) twice or thrice a day— one dose m the morning, another in the evening, and the third, if there be a third, at noon. On the next day these doses are repeated. On the following days, each day an addi- tional teaspoonful of the syrup is given until six teaspoonfuls are given, care be- ino- taken to distribute these four, five or six doses at equal intervals through the day. Having arrived at this point, it the 714 CHOREA. plij'siological eflfects of the closing are not j-et produced, dcfsscrt^pooiiful doses are substituted for teaspoonful, and tlie same rule is observed with these larger doses as with the smaller. Beginning with two or three dessertspoonfuls in the course of the day, and giving three on the next day albO, the doses are increased b}' a dessert- spoonful each day, until six dessertspoon- fuls are taken in the course of the day, care as before being taken to distribute these doses, few or many, with intervals between them as wide as possible. If the desired effect be not yet produced, a still bolder practice is pursued, and a table- spoonful of the syrup is substituted for one of the desertspoonfuls ; and you are to go on, still augmenting, but in a way which is not very clearly laid down. "En aug- mentant progressivement, " M. Trousseau saj's, "avec la meme prudence, avec la precaution essentielle de distribuer le medicament a des intervalles sensible- ment egaux dans le courant de la journee, vous arrivez a donner aux cnfans de cinq a six ans 50, 60, 80 et jusqu'a 120 grammes [5 grammes go to the teaspoonful] 25 milligrammes de sirop ; 3, 4, jusqu'a 6 ecutigrammes de sulfate de strychnia." In persons older than ten j-ears. Dr. Trousseau begins with large doses, with dessertspoonfuls in place of teaspoonfuls, and goes on until he reaches 200 grammes of the syrup — a quantity containing no less than 10 centigrammes, or 1^ grain, of the active principle. The object is to pro- duce the full physiological effects of strych- nia, and to maintain them for a while, and the duration of the treatment is said to be thirty - three days for girls and seventy-four days for boys. When the medicine begins to tell upon the S3"stem, the symptoms are, twenty minutes after taking it, or thereabouts, slight stiffness in the jaw or neck, some headache, eon- fusion of sight, and giddiness, and some disagreeable " demangeaisons" in the parts of the skin covered with hair. Afterwards as the system becomes more deeply impressed, the stiffness extends from the jaw and neck to the limbs and elsewhere, especially to the limbs most affected with Chorea, which limbs are also in all probability more or less paralyzed, the itching of the skin is no longer con- fined to the hairy parts, and painful jerks or shocks, or still more obvious tetanic symptoms, make their appearance. The tolerance of strychnine varies not only in different individuals, but in the same individual at different times, so that the dose which w^as not more than enough one day may be poisonous the next. In fact, the treatment is one which requires to be most carefully watched, and which can- not well be watched with comfort, especi- ally by the friends of the patient, however enlightened or forewarned they may be. Another heroic treatment for Chorea, which has found some favor in France, is that by turtur emetic. Laennec has left on record three cases of Chorea treated by large doses of this medicine, and others have tried the same method with results, as they seem to think, more or less satis- factory, especially MM. Boulay, Gillette, and Henri Roger. M. Gillette's method, which is that adopted by M. Eoger, is to give the antimony for three days, to with- hold it for three or five days, and again to give and withhold it for the same period, a.s often as may be necessary, if the symp- toms have not yielded to the medication of the first three days. On the first day of the first triple series of days, the dose given in the twenty-four hours is from 20 to 25 centigrammes (1 centigramme is = •15, or nearly ^th of a grain). This dose is doubled on the next day, and tripled on the third daj'; then the patient is allowed to rest from three to five days. On begin- ning again, if this be necessary, the dose given on the first of the three days, which is to be doubled on the next day, and tripled on the day following, is 5 centi- grammes larger than that used on the day in which the treatment was commenced. If this be not enough, after waiting again for from three to five days, the dose for the first of the three days is 5 centi- grammes larger than that used on the first of the last series of three days, for the second day the dose is doubled, and for the third day the dose is tripled ; so that, if the dose given on the first of these three days was 30 centigrammes, the dose on the last of these three will be 90 centi- grammes, or nearly 14 grains I In the majority of cases we are told the first doses are followed by nausea and vomit- ing of a glairy matter, but these symp- toms soon pass off, and complete tolerance is established, especially if care be taken to withhold as much as possible all dietetic drinks. "We are told also that diarrhoea is uncommon, that constipation is not un- common; that the pulse becomes slower, that the skin moistens, and that the gen- eral health improves. Indeed, Dr. Bour- guignon, speaking of certain children, pa- tients of M. Gillette, under this mode of treatment in the Hopital des Enfans Malades, at Paris, says: "Les enfans ne sont nullement abattus, lis conservent leur gaiete. ' ' Dr. Bourguignon, who is strongly in favor of this treatment, tells us also that in ten cases — whether in M. Gillette's practice, or in his own, he does not say — the patients got well in sixteen days, as an average, the shortest time being four days, the longest twenty-four. Iodide of potassium is another remedy which has been tried somewhat exten- sively in the treatment of Chorea, and to a less extent so has bromide of potassium. This iodide was supposed to be indicated TREATMENT. |15 hy the probable existence of a rheumatic or lymphatic predisposition in the patient, or by the actual presence of some menin- geal irritation or inflammation, and these indications have been carried out fully and frequently ; but the practical results of this treatment, so far as I know, are unsatisfactory. Nor is a difterent opinion to be expressed with respect to the bro- mide. I have tried this medicine in sev- eral cases, and tried it fully, and from what I knew of its strange efficacy in epi- lepsy I was strongly prejudiced in its favor ; but the result, as 1 have said, is (hat the bromide appears to be no more justly deserving of confidence than the iodide. As might be expected, opium is a medi- cine which has not been overlooked in the cases in question, especially in the severer cases. As in tetanus, there appears to be a remarkable tolerance of this medicine in Chorea, and in several cases enormous doses have been given ; indeed, in any case it appears to be necessary to give large doses, in order to procvire what may be supposed to be the object in view, that is, sleep. I have seen opium employed in five very severe cases of Chorea, largely, and from wliat I saw in these cases I am not wishful to see the experiment re- peated. I am speaking now of the free use of opium by itself, and not of opium in moderate dose along with other agents, with the free use of alcoholic stimulants especially. This, I believe, is quite a dif- ferent matter, Nor does there appear to be sufficient reason for supposing that other narcotics, not excepting cannabis indica, are more to be trusted than opium in cases of Chorea. The inhalation of chloroform or ether has been had recourse to in many severe cases of Chorea. I have seen three such cases in which chloroform was used in this way, and my impression was that harm, not good, was the result. I believe, also, that harm rather than good is likely to be done in these cases, unless alcohol is given in sufficient quantities before the inhalation. If this be done, the patient may remain asleep for some time, and awake the better ; if this be not done, there is great danger, so far as my expe- rience of the use of chloroform inhala- tions is concerned, of the patient waking almost immediately, and of being more unnerved and more agitated than lie was before he was put to sleep. At the pres- ent time I am in attendance upon a case of Chorea, attended with much sleepless- ness, until the practice was adopted of giving at bedtime a few whiffs of chloro- lorm after a glass of hot negus. The chloroform had been tried for four nights ■Without the negus, and harm rather than good had been the result. It has now Been tried with the negus for a week, and. as it would seem, with unmistakable ad- vantage. Xor is this an isolated case. Antispasmodics, such as camphor, ether, valerian, assafa-tida, and musk, have been tried extensively, and the general verdict appears to be that they are not useless. I am disposed to place considerable con- fidence in cmnphtir, and also in ether; in camphor esjiecially. I often give very generally this last-named medicine dis- solved in cod-liver oil, and my impression, from what I have seen, is that this addi- tion to the oil is a decided advantage to the patient. Turpentine has been given for various reasons in Chorea— as an anthelmintic and purgative chiefly. At one time I gave it rallier as a general stimulant, and, as it seemed, with benefit to the patient. I then tried mineral naphthei, with the same view, and came to the conclusion that this medicine was more pleasant than turpentine, less trying to the system, and not less efficacious. During the last six or eight years, however, I have rarely given either one or the other of these medicines, and one chief reason for this seems to be that I have gradually come to prefer the treatment of which I have to speak in a few moments. Ammonia is also a remedy which has some good claim to be mentioned in the present place. I have tried the sesqui- carbonate in several cases, singly and in combination, and the trial has been to my mind eminently satisfactory. I am, for example, at present seeing a little choreic boy who had been for three weeks treated, without any benefit, with sulphate of zinc, and who has wonderfully im- proved during the last three days, by leaving off" the zinc, and by substituting sesquicarbonate of ammonia in five-grain doses every three hours. In other re- spects there was no change in the treat- ment, and the patient is too young to allow it to be supposed that he was af- fected beneficially by the change of the practitioner. For various reasons, theoretical and practical, the free use of alcoholic (h-inks has long seemed to me to be the founda- tion of a rational plan of treatment in Chorea, and the larger experience of the last few years has only served to confirm me in this opinion. I have seen enough to know that, as a rule, the change for the better is unmistakable when, after the carrying out of a contrary mode of prac- tice, alcoholic drinks are giveij with a liberal hand. I have notes of three cases of great severity, where rapid amendment was brought about by giving, at frequent intervals," an egg beaten up with a large glass of sherry or with an equivalent dose of brandy, and I verily believe that this plan would rarely fail if carried out in time— a carried out, that is to say, before 716 CHOREA. the nervous sj-stem had become thor- oughly exhausted and broken down, as it does do in the end. Indeed, in a bad case, where a dangerous degree of sleep- lessness had to be dealt with, there is nothing in which I should have more con- fidence than in the free use of alcoholic drinks. I should look upon these means properly, that is freely, used, as the natu- ral means of procuring sleep and all the beneficial consequences of sleep. I should be afraid of attempting to attain the same end by the use of medicines more or less analogous to alcohol in their action, be- cause these medicines -would all of them be more likely to disturb the action of the stomach, and so interfere with the re- storation of the system by food. And for the same reason I should even be almost afraid of giving small doses of opium with the view of conciliating sleep, though I have no doubt that the proper dose of this drug at the proper time, in conjunction with the proper dose of alcohol, might be very satisfactory practice. In a word, I cannot but think that it is a perfectly rational way of dealing with severe cases of Chorea to push alcoholic drinks until they produce drowsiness — until, that is to say, they exercise a decidedly sedative action upon the system. At any rate I have carried out this idea in more than one case of the kind with what seem to me to be very satisfactory results. In bad cases of Chorea, as a matter of course, the recumbent position is a neces- sary part of the treatment ; and in cases of ordinary severity my own impression is that the patient would improve more rapidly if he were kept longer in bed. Indeed, it surely stands to reason that rest, properly used, is a right means of remed^dng a state of muscular disorder, in which muscular fatigue is an unmis- takable element. Nay, it is not too much to imagine, that the persistency of many cases of Chorea may be not a little owing to the patient being allowed to be up and fidgeting about when he ought to be in bed. Exercise, on the other hand, properly used, cannot well be dispensed with as a means of treatment in Chorea. In ordi- nary cases, indeed, it is difficult to over- rate the importance of suitable gymnastics as a means of cure. This is no new idea. Darwin insisted upon it long ago ; and from what has been done in this direction since his time, especially by Ling and his successo^rs in the practice of the so-called ''movement cure," it is perhaps not too much to say that Chorea may be one of the consequences of neglecting gymnastics as a means of education in children. Cer- tain it is, that ordinary cases of Chorea get better rapidly — the average duration of the period of treatment being sixty days— under a properly arranged" course of gymnastics, with little or nothing else. The practice of M. See, at the llopital des Enfans Malades in Paris, may be cited in support of this statement ; and it would not now be difficult to find corrobo- rative passages in the practice of others. For myself, I should think that I was omitting an important duty if I did not prescribe the use of some suitable exer- cise for a patient suffering from Chorea — the use of a skipping-rope or trapeze, if nothing else. Dancing has long been a favorite idea with me as a means of exer- cise in cases like these ; and so have calis- thenics regulated by music. More than one choreic patient I have known to be cured by learning to dance, and I think that music might be employed with advan- tage now, as it was in the case of the tarantula dance of old, in quieting severe cases of Chorea, anomalous or not. In- deed, there is more than one case on re- cord in which music has been so employed. It may be supposed also that music will help the choreic patient in his gymnastic efforts in the same sense as that in which it nerves the acrobat to the performance of his wonderful feats. In a word, it is not necessary to think long before it must become self-evident that orderly move- ments, be they those of dancing, calis- thenics, or more special gymnastics, and be they regulated by music or not, are natural remedies for disorderly move- ments such as are met with in ordinary cases of Chorea, and that a very impor- tant means of cure is neglected if they are not provided. Indeed it is to be hoped that the time is not far distant when a suitable gymnasium will be considered as much a part of the proper fittings of a hospital as the dispensary, and when medical men more generally will be ahve to the importance of suitable gymnastics, not only as an educational, but also as a curative measure. Surely there is a lesson to be learnt from the results of the carry- ing out of the "movement cure," — a lesson which the practitioners of orthodox medicine are not justified in continuing to decline to learn because it happens to have heterodox belongings ! Baths, of one kind or another, have been extersively employed in the treat- ment of Chorea. In this country the cold sliower bath has been the favorite mode of bathing, and there are some good grounds for this preference. Part of the good result is ascribed to the shock ; part — a greater part, perhaps — to the reaction. Still there are, unquestionably, many cases in which the shock is not tolerated, and where reaction is not easily estab- lished—cases in which the patient is ren- dered worse rather than better, so far a,s the Chorea is concerned, with the addi- tional disadvantage of a bad cold, or actual rheumatism, or some other evil. TREATMENT. 717 And these latter cases are by no means uncommon. Nay, it may even be sus- pected that all cases would come into this category if care were not exercised more or less. The same remarks apply also to cold plunge baths, and to other forms of cold baths. With respect to hot baths and to ivarm iaths, the case is very different. A hot bath at bed-time has often seemed to me to have a marked calmative influ- ence. I am also disposed to think that a good part of the benefit ascribed by M. Baudelocque to sulphur baths (each bath contains about four ounces of sulphuret of potassium) is to be ascribed to the high temperature of the water, or, at any rate, to this in conjunction with the counter- irritation set up by the action of the sul- phuret upon the skin. The fact appears to be that Ijaths of one kind or other are not sufficiently recognized as a means of cure, not only in Chorea, but in many other cases of disease, by the orthodox practitioners of medicine. With baths, indeed, it is very much as it is with "movements" as a means of cure, and hydropathy, like kinesitherapy, has a lesson to teach, which medical men ought to set themselves to learn if they would be fully provided with the means by which to contend successfully against dis- ease. Electricity is another agent which re- quires a passing mention in this place, though all that can be said respecting it is, that as yet there appears to be little or no reason for placing any confidence in it as a means of treatment. Whether this will be always the case — whether there are not modes of using electricity which will have the effect of quieting choreic and analogous movements (so long, at any rate, as they are used) — remains to be seen. I suspect that there are such modes, and that they will be beneficial, and that too not a little, in the case in question, but I have not yet the facts to justify the expression of a belief on the subject. For the last seven years I have employed cod-liver oil in many cases of Chorea, and, so far as I can judge, I have good reason to be satisfied with the results. In adopt- ing this practice my main object was to restore nerve-tone by improving the nutri- tion of nerve-tissue. I remembered that fatty matter was an essential ingredient in nerve-tissue ; and, remembering this, I came easily to the conclusion that one natural way of attaining to the end in view was to take care that the food con- tained a sufficient amount of fatty and oily matter.' AVithout a due supply of these matters, I reasoned, the nerve-tissue must be of necessity starved — that, in fact, to withhold these matters, or to supply them in insufficient quantity, would be as great a mistake in cases where the object was to improve the nutrition of the nerves, as it would be to withhold lean meat in cases where the object was to get more muscle. I argued in this manner, and be the theory right or wrong I think, as I have said, I have no reason to be dissatisfied with the results of putting it in practice. For the last seven years also I have used phosphorus in the majority of cases of Chorea in Avhich I have used cod-liver oil, and for the same reason. I asked myself whether the fact that phosphorus is present in large quantity in the great nerve-centres, and that the amount of this ingredient seems to have some direct relation to the activity of the nervous functions, being as much as 2 per cent, in adult life, and below 1 per cent, in infants and idiots, might not show that phospho- rus is specially indicated as food for a weak nervous system — as much indicated, perhaps, as iron in cases where there is a deficiency of red-corpuscles in the blood ; and this question once put seemed to re- quire an answer in the affirmative. "In small doses," says Dr. Pereira, "phos- phorus excites the nervous, vascular, and excretory organs. It creates an agreeable feeling of warmth in the epigas- trium, increases the fulness and frequency of the pulse, augments the heat of the skin, heightens the mental activity and the muscular powers, and operates as a powerful sudorific and diuretic." In large doses, without doubt, phosphorus is a caustic poison ; in proper doses, it pro- duces the very changes that are to be desired in cases of Chorea and analogous forms of convulsive disorder. In proper doses and properly watched, it is quite innocent in its action, and may be very beneficial. Of this I am confident. The forms in which I first gave phosphorus in Chorea were the phosphorated oil of the Prussian Pharmacopceia and the ethereal tincture of the French Codex (forms con- taining 4 grains of phosphorus in the fluid ounce), but lately I have preferred the hypophosphites, especially the hypophos- phite of soda, for the simple reason that these salts, which were originally recom- mended by Dr. Churchill of Paris as spe- cifics in phthisis, are infinitely less nause- ous than the oil or tincture, and not less efficacious. I have given for some time from 5 to 8 grains, three times a day, of the hypophosphite of soda to children, in cases of Chorea, without any harm cer- tainly, and, as I think, with unmistak- able benefit, and I have not yet found any reason to change this practice for another. In an ordinary case of Chorea, the plan of treatment which I have now adopted as a rule for some time is to give cod-liver oil in conjunction with hypophosphite of soda, making the draught containing the latter salt the vehicle for the administra- tion of the cod-liver oil. With these medicines, according to circumstances, I 718 PARALYSIS AGITANS. have associated camphor or ammonia, one or both, adding the sesquicarbonate of ammonia to the draught containing the hypophosphite, and Oissolving the camphor in the cod-liver oil. 1 liave found that this latter solution is an excellent way of giv- ing the camphor, and also that the cam- phor masks the taste of the oil not a little, and makes the stomach more tolerant of it. I ha^'e not kept notes of all the cases which I have treated in this manner, but I think I am quite within bounds when I say that the number now amounts to upwards of sixty, and that the average duration of the treatment was under one month. I may also add that I have in three or four cases given arsenic along with hypo- phosphite of soda and cod-liver oil, and tliat the result, to say the least, was not such as to discourage a continuance of the practice. If there be any special sources of irrita- tion, as worms or carious teeth, these of course must be met and dealt with. If the agitation be so great that there is danger of the skin being excoriated, or of the patient falling out of bed, properly padded sides must be fixed to the bed- stead, or it may be expedient to encase the body and limbs of the patient in cot- ton-wool. If the affection be confined to certain muscles of the neck or elsewhere, it may be expedient to use hypotlermic injections of arsenic, as in the cases related in the text, to divide a nerve, as has just been done by Mr. Campbell De Morgan, or to use the actual cautery. If there be a morbid mental condition, as there too often is, moral means of treatment must not be neglected. In fact, each case of Chorea must be looked upon from a special as well as from a general point of view, and the success of the treatment will, in many instances, if not in all, depend upon the skill with which special means can be combined with those general means of which I have spoken, and upon which I have prosed at greater length than I ought to have done. PAEALYSIS AGITAN"S. By William Rutherfobd Sanders, M.D., F.R.C.P. Synonyms. — Paralysis tremens, trem- ula, jactitaus, palpitans ; Tremor artuum, T. coactus ; Scelotyrbe festinans, seu Fes- tinia (Sauvages); Synclonus tremor, S. ballismus (Mason Good) ; Schuttelahmung, Schiittelkrampf, Zittern ; Tremblement senile, Tremulence paralytique progres- sive ; Chorea senilis, Ch. festinans ; Pseu- do-chorea, Pseudo-paralysis agitans ; Dys- taxia agitans ; the Trembles, &c. ; the Shaking Palsy (Parkinson) . Definition. — Idiopathic Paralysis Agitans consists of involuntary tremulous or shaking motions of the limbs, head, or trunk of the body, which takes place even when the parts are supported and unem- ployed. The voluntary movements are preserved, but their vigor is lessened in the affected parts. In certain, usually advanced, cases, there is a disturbance of equilibrium ; most commonly a disposition to stoop, or bend the body forwards, and to pass, in locomotion, from a walking to a running pace. The senses and intellect are unimpaired. The definition includes these principal characters : 1st, The shaking or tremors, of a spasmodic kind, which occur even when the parts are not in use (Tremor coactus, palpitatio, nax^to;^ agitatio, jacti- tatio, quassus); 2d, The diminished mus- cular power (Paralysis, paresis, pseudo- paralysis); 3d, The disturloed equilibrium, shown usually in the tendency to stoop and to move forwards with accelerated speed (Scelotyrbe festinans, festinatio, procursus). Of these characters the clonic tremors or shaking are the most constant and distinctive. The paralysis, on the other hand, is of a peculiar kind. As here employed, the term does not mean cessation or interruption of volun- tary motion, which, on the contrary, per- sists ; but it is intended to designate both the imperfection of the movements, which results from the interference of the tremors, and also the impaired strength and the slowness of muscular action, which are usually observed in the tremulous parts. Some writers, objecting to call this condi- tion paralysis (a name apt to mislead), have spoken of it as "apparent but not real paralysis," or ''paresis," or " pseudo- paralysis," or "dystaxia." Lastly, the disturbance of equilibrium does not always occur : it is often late in appearing, and it serves chiefly to mark a special form or DEFINITION. 719 an advanced stage of the aflfection. Never- theless, in fully developed examples of Paralysis Agitans, all these symptoms, the tremors, paralysis, forward stoop, and accelerating walk, are associated together; as Parkinson expressed it, there is a com- ■bination of Tremor coactus and Scelotyrbe festinans. ' Historical Notice. — From the definition, as explained, it will be apparent that the older descriptions of Paralysis Agitans are to be sought less in the history of palsies than in that of spasmodic nervous diseases. In fact. Paralysis Agitans has been overlooked principally from being confounded, 1st, with tremors in general ; 2d, with chorea ; 3d, with cases of motor palsy (hemi- or paraplegia) complicated with spasmodic and tremulous move- ments. 1st. As a symptom, tremors early at- tract attention. They were briefly no- ticed by Hippocrates and Celsus, while by G-alen and succeeding writers their kinds, their causes, and their value as prognostic signs were fully discussed. At length, nosologists established the genus Tremor, dividing it into species, in some of which tremor was still regarded as a symptom merely, while in others it was recognized as a substantive or idiopathic disease. Accordingly, well-marked cases of simple Paralysis Agitans are found in many of the older authors,^ by whom they are sometimes alluded to, sometimes de- scribed with graphic details, in illustra- tion of the pathology of tremor or as ex- amples of a distinct species of disease. Less notice was taken of the disposition to stoop and hasten onwards. The earliest mention of this curious symptom is prob- ably made by Gaubius ; it was first par- ticularly described by Sauvages under the name of Scelotyrbe festiuans. But Sau- vages did not connect it with tremors ; he, indeed, had seen only two cases of it. It is certain that the combination of per- sistent tremors and hurrying gait had not been recognized, and no adequate de- scription of Paralysis Agitans existed previous to Parkinson's " Essay on the Shaking Palsy in 1817." His account still remains the standard authority. Suc- ceeding authors have, in general, simply quoted it, or have (especially French writers) overlooked the disease altogether. Accordingly, although Parkinson drew attention to the imperfection of our kaovvledge, the original contributions made since his time" have been few and fragmentary. A list of references will be found at the end of this article. ' Parkinson seems to consider the festina- tion as essential to Paralysis Agitans, but it cannot be so regarded. ' Sylvius, Bonet, Juncker, Van Swieten, Sauvages, &o. 2d. In regard to the confusion of Pa- ralysis Agitans with chorea, it must be remembered, that convulsive diseases have been imperfectly discriminated, ow- ing partly to the difficulty of then- pa- thology, partly to the superstitions with which they have been associated. The disease now commonly called chorea was not so named originally, nor was it con- founded with true St. Vitus's dance ; it was regarded merely as a kind of convul- sion (motus convulsivus) or species of epi- lepsy (epilepsia gesticulatoria), till near the end of the 17th century. ' About that period, Sydenham, in the brief description which fixes the characters of the disease, unfortunately named it " Chorea Sancti Viti," a misnomer which it has since commonly retained, with the effect of con- founding it with the dancing mania, from which it is quite distinct. ^ While older authors therefore may have described cases of Paralysis Agitans among the motus convulsivi extraordinarii (just as some authors have given definitions ap- plicable to it under the name hieranosos),^ it is only in recent times that Paralysis Agitans has been confounded with what is at present known as chorea. This con- fusion is due partly to a certain similarity in the diseases, partly to the unsettled state of medical nomenclature. Ordinary cases of the shaking malady are widely distinct from common chorea ; but cer- tain extreme forms occasion a violent ir- regularity of movement, resembling in a great degree the gesticulations of that disease ; so much so, that it has been proposed to regard Paralysis Agitans as a more intense form of chorea,^ and cases of Paralysis Agitans have been recorded under the title St. Vitus's dance.^ Some cases even exhibit a combination of Pa- ralysis Agitans and chorea.^ iSIoreover, while the common gesticulatory chorea is well known, there are other rarer forms, of irregular and uncontrollable spasmodic movements, as yet imperfectly studied and classified, to which the term chorea is usually applied : such are the rotatory or spinning-top chorea, the saltatio or leaping ague, malleatio, &c. In some ' Roth. 2 Authors distinguish the common chorea of Sydenham as chorea minor, the dancing mania as chorea major, choreomania, or tar- antismus. By chorea or St. Vitus's daiKv, however, Sydenham's disease is now always meant, the tarantism from its rarity being left out of account. 3 Linnasus, Gen. Morh., Upsal, 1763, p. 17, No. 144: " Hieranosos, Byting, Corporis agi- tatio, continua, indolens, convulsiva, cum sensibilitate." Also Vogel and Macbride. « Eisenmann, remark on Dr. Haas's case, in Canst. Jahrb. 1852, iii. 92. 5 Trousseau, case in 1843. See references. 5 Maclaclilan. PARALYSIS AGITANS. respects, therefore, it is not altogether | inappropriate to designate Paralysis Agi- : tans as a species of abnormal chorea ; hence some recent authors employ the terms chorea senilis and chorea festinans for Parkinson's disease. The objection to such names is, that they tend to con- found Paralysis Agitans with the ordinary St. Vitus 's dance, from which it is en- tirely different. 3d. Lastly, the term Paralysis Agitans or shaking palsy has been applied, both before Parkinson's essay and since, to cases of ordinary motor paralysis (hemi- and paraplegia) complicated with tremors — a complication not uncommon both in diseases of the brain, and especially in certain cases of chronic myelitis and of locomotor ataxia. Etymologieally the name of shaking palsy belongs perhaps to these, rather than to Parkinson's disease, but time has consecrated his use of the term. Parkinson's malady is Idioimthic Paralysis Agitans, in which the tremors or shaking are the chief and earliest symptom, and the paralysis entirely sub- ordinate and peculiar, true hemi- or paraplegia being rare complications : while, in the cerebral and spinal affections just referred to, the loss of motion (akine- sia) or sensation (anfcsthesia) is the main feature of disease, and the tremors and spasmodic agitations are only concomi- tants (i. e. the Paraljsis Agitans is Symp- Uimatic). Hence the latter class of cases should be styled, not Paralysis Agitans, but hemi- or paraplegia, or spinal or cerebral disease complicated with Paralysis Agitans : i. e. with spasmodic tremors. This distinction, which is essential for the accurate definition of Parkinson's dis- ease, has often been overlooked, and re- quires, therefore, to be specially insisted upon. In the following description of Paralysis Agitans, besides some allusion to tremors generally, it is proposed for the sake of distinctness to recognize certain subdivi- sions of the disease, which experience ac- cumulated since Parkinson's essay seems to require. Divisions. — Idiopathic Paralysis Agi- tans is divided into I. General (includ- ing the bilateral and unilateral), and II. Local. T. General Idiopathic Paralysis Agitans presents certain forms or varieties import- ant to distinguish, as regards prognosis and cure : — A. Senile forms. Paralysis Agitans senilis, occurring in advanced life, above fifty or sixty ; usually incurable and with fatal tendency from senile decay : divided into 1st, Simplex, and 2d, Festinaiis ot Pro- cursoria. Varieties, TJnilateralis or Hemi- plegicn and Betrograda. B. Non-senile forms, occurring under fifty, without fatal tendency, sometimes curable. 1st, Paralysis Agitans non-senilis, simplex '(?. e. sine festinatione), including also hysterical and reflex Paralysis Agi- tans, &c. 2d, Paralysis Agitans toxica, including, chietly, tremblement nietal- lique, mercvmal palsy, &c. The curable forms have been supposed to be Functional ; the incurable, Organic. It will be necessary to describe the senile forms in detail, as they are much the most frequent ; a shorter notice will suffice for the others. Description.— I. A. Idiopathic Paral- ysis Agitans senilis. 1st, simplex, when attended bj' the signs of senile decay only ; 2, festinans, or procursoria, &c., when the disturbance of equilibrium is also present. These two forms will be described together. Symptoms and Course. — Onset usually gradual ; course slow, progressive, liable to be arrested at different stages ; dura- tion protracted, associated with senile de- cay. Several stages may be recognized. 1st Stage. Commencement. — The first symptoms are usually so insidious that the patient cannot tell precisely when they began. A sense of weakness and a disposition to tremble is felt in some part, most frequently the hand or arm, some- times the leg or head. The tremors, at first slight and occasional, gradually in- crease ; and at an uncertain period, sel- dom less than a year, the corresponding parts of the opposite side, more rarety the other limb of the same side, become affect- ed. The tremors and muscular debility seldom extend beyond the arms during the first two j^ears, which period may be said to comprise the first stage. Except for the Inconvenience arising from the unsteadiness of the hand in writing or other manipulation, the patient would not consider himself the subject of dis- ease. At this period, probably, remedies might be applied with success. In a few cases, instead of the ordinary gradual ap- proach, the tremors have come on rapidl/ after a fright or exposure to cold. '2d Stage. Generalization of the Tremors. ^Some time after the hands and arms have been affected, one of the legs, usu- ally that on the side first attacked, begins to tremble and is more easily fatigued ; and in a few months the other leg be- comes similarly tremulous and weak. Walking becomes a task requiring con- siderable attention. The legs feel heavy as lead, and are not raised to the height or with the promptitude which the will directs, so that care is necessary to pre- vent frequent falls. At a later period, usually some years after, the tremors ex- tend to the head, and finally to the whole body. The tremors of the limbs are usu- ally in the direction of flexion and exten- sion, sometimes of rotation, sometimes of DESCKIPTION. 721 ab- and adduction (so that patients have had their knees padded to prevent them knocking together). In tlie head' and neck the movements are more commonly lateral (shaking negatively), then vertical (nodding). The lower jaw is affected with vertical, rarely lateral motions ; and the tongue is tremulous, impeding speech : in many cases, however, these parts are not affected till near the end of the disease. The larynx is little, if at all, affected. Deglutition does not suffer till near the close. The nmscles of the eyeballs and eyelids, and the facial muscles of expres- sion, are nearly always exempt from tre- mors.^ The thorax and trunk are later and less affected than the limbs, or head, or neck. Appearing chiefly during a gen- eral paroxysm of tremors, the spasmodic action of the respiratory muscles occa- sions a peculiar panting of the breathing and a jerking interruption of speech. As the tremors last, and become general over the body, they increase in intensity ; from mere vibrations they become violent con- vulsive agitations. The limbs are jerked to and fro as if by the action of springs or by rapid shocks of electricity. From the beginning, and throughout the whole course of the disease, mental emotion or agitation excites an attack of tremors, or greatly aggravates them ; rest and quietude diminish or stop them. In general, a slow, firm, voluntary act, or the grasp of a heavy body,' stops the tremors for a time, and any change of posture has the same effect, affording the patient con- siderable relief Parkinson mentions an artist, who, while his arm and hand were palpitating strongly, would seize his pen- cil, with the effect of instantly suspend- ing the tremors and allowing him to use it for a short period.'' On the contrary, when the limbs are quiescent, a voluntary movement usually starts the tremors, which continue for some time afterwards. The attacks of tremors are at first of short duration, and separated by intervals of complete immunity ; they become more severe and the intermissions shorter as the disease proceeds. In certain exam- ples the paroxysms have lasted so long as tea to forty minutes, and were followed by fatigue like that produced by violent mus- [' Erb and others assert that the head is seldom or never affected in Paralysis Agitans, although it is in cerebro-spinal sclerosis. See Erb on Multiple Sclerosis, Ziemssen's Cyclo- psdia, vol. xiii.— H.] ' In Oppolzer's remarkable case the tremors are reported to have extended to the muscles of the face ; also in a few other cases. . ' A patient we saw lately holds a smooth- 'ng-iron to keep his hand still ; another steadies it by seizing a chair. ' Lebert refers to a similar instance. VOL. I.— 46 cular exercise.' The tremors cease en- tirely during sleep. Parkinson does not seem to have noticed that frequently, in addition to the tre- mors, there occur tonic spasms (rigidity or contraction) of the muscles in the parts affected. The fingers or toes or the whole limb become rigidly ffexed or extended. These cramps last for some minutes, and return at intervals ; they are sometimes painful and followed by a sense of fatigue. They occur chiefly during the day, but sometimes in the night also. In a case recently observed by the writer startings of the limbs took place during sleep, in the form of powerful flexion of the knees, by which the legs were suddenly drawn up. On the relaxation of the spasms, the limbs were slowly let down to their pre- vious position without awakening the pa- tient. Local deformities also sometimes result. From the hands being kept constantly supported to stay the tremors, the fingers become dislocated backwards on the meta- carpals so as to form an angle with the back of the hand.^ Sometimes the dis- tortion is lateral ; in a case lately seen the fingers were bent obliquely to the radial side, owing probably to the clonic and tonic contractions being more power- ful in that direction. These deformities must not be confounded with the effects of rheumatism. [A not uncommon symptom is a sense of great heat of the body ; causing the patient to throw off the bedclothes, &c. This sensation is shown by the thermome- ter to be subjective only ; there being no real excess of temperature. — H.] 'M Stage. Disturbance of Equilibrmm. — The occurrence of this symptom is varia- ble : sometimes it appears early, while the legs are becoming tremulous ; some- times it is deferred for ten or twelve years or more after the tremors ; in many cases it is entirely absent (Paralysis Agitans simplex). It is therefore less a stage than a peculiar feature characteristic of one form, or of a special extension of the disease ; its presence should accordingly always be indicated by some additional term, such sls festina7is or proaursoria. Owing to deficient power in the extensor muscles of the back, the patient becomes less able to preserve the erect posture ; he bends forward while sitting, still more while standing. In walking, the centre of gravity being displaced forwards, while the legs can only be moved slowly, stiffly, and with some degree of spasmodic jerk- ins; agitation, he is in constant danger of falling ; he stumbles over small obstacles in his path, and by taking short hurried steps he is impelled from a walk to a run, 1 Trousseau, Clin. Med. Ibid. 722 PARALYSIS AGITANS. till he has difficulty in stopping himself. Persons in an early stage of this condition can sometimes march slowly with long measured strides, quite well ; but so soon as they resume their shuflEling gait, they Inust quicken their pace to avoid falling. There is no vertigo, as in cases of precipi- tancy from tumors or injuries of the cere- bral peduncles and adjoining parts. The forward running is the usual form of this curious symptom, which has not yet been much studied, but exceptional varieties occur. Thus Eomberg met with an oppo- site disturbance of balance. " Two pa- tients, aged sixty, felt a constant desire to walk or fall backwards, and therefore car- ried the head strongly bent forwards ; one of them in order to stand, separated his legs widely, at the same time cross- ing his arms on the back, with the view of offering some resistance to the over- powering tendency to move backwards" (Paralysis Agitans retrograda). Graves mentions a patient who had to be balanced to and fro before starting, and who, if arrested in his forward move- ment, immediately began to hurry back- wards and could not stop himself. No case is recorded of a disposition to fall or move sideways.' There is a less degree of this symptom in which the patient stoops and shuffles in his walk, but has not the true festination. 4:th Stage. Disease fully established. — When the tremors have become general, violent, and of frequent recurrence, the patient experiences great inconvenience, which increases with the progress of the disease. The limbs cannot execute the directions of the will in the common offices of life. The patient is unable to write or perform any manipulation : he cannot hold a book to read, and has the utmost difficulty or is quite unable to clothe or feed himself. Raising a glass of water to the lips is impossible ; the fluid is spilled and the glass knocked to and fro against the mouth. Patients deprived of assist- ance, in order to allay their thirst, have lapped up fluids with the tongue, like the lower animals. It is painful to witness the struggles which the patient makes to control the agitation of his body and eflect some desired movement ; the more he tries the more extravagant the jactitations become. To increase his distress, parox- ysms of tremors now often arise during rest ; indeed, at times, the tremors be- ' Sauvages relates of a painter, aged 50, that he was not only impelled forward in walking, but could not turn right or left till he stopped himself against an obstacle, sup- ported by which he turned his body gradually round and then hurried straight on anew. This is given as Scelotyrbe festinans, without any mention of tremors; but similar conditions have been observed in Paralysis Agitans. come almost constant, -with frequent aggravations. Commencing for instance in one arm, the wearisome agitation is borne until beyond suflerance, when by suddenly changing the posture it is for a time stopped in that limb, but commences generally in less than a minute in one of the legs or in the arm of the other side, often spreading over the whole bodv. Harassed by the tormenting round, tfie patient has recourse to walking, to which he is partial, both on account of the relief aflbrded by change of posture and because his attention is diverted from his unpleas- ant feelings by the care and exertion re- quired for its performance. But if the procursive tendency has appeared, this relief is denied. The propensity to lean forward becomes invincible. Forced to step on the toes and fore-part of the feet, while the upper part of the body is thrown forwards, he is irresistibly impelled to take quick and short steps, and to adopt unwillingly a running pace, in order to avoid falling on the face. ' On some days, however, the tremors are less severe ; and the patient is always relieved by intermis- sions during the day and complete cessa- tion of the tremors during the night. The disease, even at this stage, sometimes undergoes remissions for some weeks or months, during which the tremors greatly abate : unfortunately a relapse occurs and the disease resumes its progressive course. oth. Advanced and Final (Stafi^es.— Hith- erto the jactitations have been suspended at intervals during the day, and have ceased entirely at night. But in this stage tremors of the limbs occur even during sleep, and increase till they awaken the patient, often with much mental agitation and alarm. In addition, signs of failing strength and physical decay, which had previously appeared, rapidly increase. Unable to convey food to the mouth, the patient must be entirely fed by others. The bowels, previously torpid, require powerful stimulating medicine or mechan- ical aid for their relief. The trunk be- comes permanently bowed, and the whole muscular power fails. The patient walks w^ith great difficulty ; a stick no longer suffices ; he requires an attendant, who, walking backwards before him, prevents his falling forwards by the pressure of his hands against the fore-part of his shoul- ders. His words are scarcely intelligible, and the memory and intellect are weak- ened. The actions of the tongue and pharynx are so hindered by enfeebled action and perpetual agitation that the food can hardly be masticated or swal- lowed ; the saliva mixed with particles of food continually drains from the mouth. ' In the words of Trousseau, "II s'en va trotillant, sautlUant, — il est oblige dec(mrir,pmT ainsi dire, apres lui-meme." DESCRIPTION. IZ-d Finally, amid increasing general debility and diminished voluntary power, the tre- mors become more vehement, and seldom cease for a moment. When exhausted nature seizes a small portion of sleep, the motions become so violent as to shake the bed-hangings, and even the floor and Bashes of the room. The chin is bent down upon the sternum ; the power of articulation is lost ; the slops with which he is fed trickle continually from the mouth. The urine and feces are passed involuntarily ; bed-sores form ; and at the last constant sleepiness, and other marks of extreme exhaustion, usher in the fatal termination. The senile forms of the Paralysis Agi- tans, as just described after Parkinson, represent, it should be observed, the most aggravated examples of the disease. And the subject of it being advanced in years, the effects of senile decay are necessarily mixed up with the other symptoms. In- deed, tliis kind of Paralysis Agitans seems to induce and to terminate in general failure of the system. But the course of the senile disease is not always so deplor- able. Many cases of the simple or non- procursive form remain stationary for an indefinite period, and never reach the ultimate stages. ' A few exceptional cases have been cured. The procursive Paralysis Agitans also occasionally exhibits an ar- restment, or, at least, extreme protraction of its course. The fatal forms seldom occupy less than ten years. At the same lime, Parkinson's account, drawn directly from nature, represents, without exagger- ation, the slow, continual progress and the fatal results of the senile Paralysis Agitans in its- ftiU development. One very important fact, observed in nearly all cases of Paralysis Agitans, is that the cutaneous sensiljility is not af- fected, either in regard to pain, touch, or temperature. The sensory powers, in- deed, persist remarkably even amid the general failure of nervous energy in the later stages of the disease. The tlnilateral' or "Bemip?e(/ic" va- riety of Paralysis Agitans, first noticed ty Marshall Hall, presents no essential difference from the bilateral (paraplegic) ' Dr. Maolaohlan, out of a large number of instances among the inmates of Chelsea Hos- pital, found that the affection often had little or no influence in shortening life. None of his cases had occurred below 55, the majority between 65 and 70, yet in many the disease lasted upwards of 30 years. An in-pension- 8r, in his 107th year, had been affected since lie wag 60.— Page 213. ' "Uni-" and "bilateral" are preferable to "hemi-" and "paraplegic," being less apt to lead to confusion with ordinary motor pa- Wlysia. disease, just described. The limbs on one side are agitated with violent chronic tremors, while those on the opposite side are entirely unaffected, or exiiibit only a slight and occasional tendency to tremble. The affection is not less severe than the bilateral, into which it probably passes. Tliere is no complete case of tliis form, from beginning to end, on record. In one instance, lately under observation,' there was no disturbance of equilibrium, no festination, and it does not appear that this symptom has been met with in the unilateral disease. The progress is, pro- bably, the same as in the other senile forms. To sum up : Paralysis Agitans senilis occurs in advanced life, past fifty, usually past sixty years of age ; it is combined with and appears to hasten senile decay. Two forms of it are distinguished, the Simple and the Procursive (festinans) : it is usually very protracted, lasting ten years or more, and is, with rare excep- tions, incurable. We pass now to those forms of the dis- ease which occur earlier in life. I. B. Non-senile forms of Paralysis Agitans, occurring under fifty, without fatal tendency, and sometimes admitting of cure. They are much rarer than the senile forms of the disease. 1st. Paralysis Agitans simplex, non-seni- lis {sinefestiiiatione). — This form resembles the senile disease in regard to the tremors, differing chiefly by the absence of the signs of senile decay. The jactitations affect the same parts, the limbs, head, and trunk, exempting the muscles of the eye- ball, and usually also the facial muscles of expression.^ They come on in paroxysms excited by attempts at voluntary ruove- nients, or by mental emotion ; they sub- side or disappear during rest, and they cease entirely during sleep. In severe cases they are extremely violent. The limbs and the whole body quiver and shake convulsively in the most extrava- gant manner. The patient cannot stand without support ; in walking he jerks and staggers as if moved by broken springs, and is like to be pitched to the ground at every step. He cannot dress or feed him- self; if his limbs are approximated, they knock against each other ; and if his hand > Patient of Dr. Warburton Begbie, to whom the writer is indebted for an opportunity of examining it. 2 Marshall Hall mentions a male, aged 28, with Paralysis Agitans of right arm and leg, who presented a "peculiar rocking motion of the eyes, and a degree of stammering and de- fective articulation." Certainly, however, tremors of the ooulo-motor muscles are very rare in Paralysis Agitans; singularly so, since nystagmus by itself is not uncommon 724 PAEALYSrS AGITANS. is brought near the chest or the face, it strikes upon tliem in a series of quickly repeated blows. When the shaking arises unexpectedly, the patient may hurt him- self, knocking his head against a wall, &c. It is rare, however, for the tremors to exhibit such extreme vehemence ; more commonly they exist only to the extent of rendering the execution of regular movements impossible, interfering com- pletely with the patient's usefulness. It is further observed that, although some- times as severe, or more so, than in the senile forms, the tremors are less continu- ous and never occur during sleep, although they may come on as soon as the patient awakes or turns in bed. The special distinctions of the non-senile Paralysis Agitans are therefore : 1st. There is no disturbed equilibrium ; no disposition to fall or hasten forwards or backwards.' 2d. The diminution of voluntary muscular power is slight ; sometimes none is obser- vable. Tested by the grasp of the hand, by the dynamometer, or by the ability to lift weights or bear burdens, the muscular force is often found equal to the normal standard ; sometimes the shaking arm appears stronger than the sovmd one. Yet the patient himself usually complains of diminished strength, and he has less ability to sustain prolonged exertion. If the disease progresses, the muscular debility increases. This is an important sign, for increasing muscular weakness is of unfa- vorable prognosis. 3d. There is no fatal tendency. The affection is extremely ob- stinate, often incurable, but the general bodily health is not impaired, and the duration is indefinite if no complication supervene. A patient, lately seen, aged sixty-six, was first affected at twelve years of age ; the tremors have entirely unfitted him for labor during his whole life ; yet even now his appetite and bodily health are excellent. Similar cases are not very rare ; but, being regarded as ex- amples of incurable infirmity,* they were not brought Under the notice of the phy- sician, and probably suffer irremediably from neglect of care at the earliest stages. 4th. Occurring in middle life (twenty-flve to fifty), however formidable in appear- ance, it is susceptible of amelioration, and sometimes of cure. A case was cured by Elliotson by the use of carbonate of iron (1827), and several examples of recovery have been recorded under different meth- ods of treatment.' Others, however, have ' At least no case of non-senile Paralysis Agitans, accompanied by festination, is known to tlie writer. ' Often objects of obarity, or paupers in and out of workhouses. The disease, how- ever, affects the rich as well as the poor. ' Trousseau, case of St. Vitus's dance (liroperly Paralysis Agitans) in 1843; Russell resisted treatment altogether. To account for the fact that some cases are curable while others are not, it has been supposed that the former are functional and the lat- ter organic. To the slighter and more curable foi-ms of Paralysis Agitans belong the Hysterical Paralysis Agitans, which exhibits the usual tremors (sometimes an approach to the festination), and is accompanied by hysterical symptoms and usually some disorder of the general health. Though often obstinate, it is entirely free from danger, and is usually cured when the general hysterical condition is removed by judicious treatment. The Intermittent Paralysis Agitans, in which tremors of the limbs, lasting five to six minutes, recur twice or thrice in an hour, appears frequently to depend on intestinal worms in young subjects, or is a variety of the hysterical or reflex forms. It is curable.' Beflex Paralysis Agitans may depend upcta disordered primes vise, and be cured by appropriate remedies (Sauvages, Tre- mor a saburra). Perhaps derangements of other internal organs may exert a simi- lar effect ; as also external wounds and injuries. An interesting case, caused by the latter, was observed by Dr. Door, and related by Dr. Haas (1852). A healthy girl of nineteen received a splinter under the nail of her right thumb, on the extrac- tion of which violent pain, and soon after Paralj'sis Agitans, came on in the right leg, subsequently spreading to the right arm and the whole body. The tongue and speech became affected ; the general health suffered; the face had a stupid expression : and she dragged the legs in walking. She recovered completely. Lastly, it appears from the important cases described by Dr. Hennis Green (a few similar to which are mentioned in older authors) that nervous tremor of the nature of Paralysis Agitans may occur in children (age, eleven to thirteen), and is in them speedily curable. Of the three cases which he reports, two recovered in about a month ; the third died of pulmo- nary consumption, and no trace of lesion was found in the brain and spinal cord. The non-senile Paralysis Agitans is particularly apt to be mistaken for cho- rea ; it sometimes assumes the unilateral form. Reynolds ; Handfield Jones ; Sanders, case of dystaxia or Pseudo-paralysis Agitans. This patient, after a year, was able to return to light work, the tremors having nearly ceased. Dr. Alexander Turnbull, R. N., has recently communicated to the writer two cases which came on after ague at Panama — the one re- covered after a year, the other was still un- der treatment. ' See Gowry's case. CAUSES. 725 2d. Paralysis Agitans Toxica. — Various poisons occasion debility and tremors. Wlien tliese symptoms arise from the abuse of alcohol, tea, coffee, tobacco, or opium, they rarely occur except when the parts are used, and hence are simple tremors only; but if they take place also dm'ing repose, they belong to this sort of Paralysis Agitans. A strongly marked and very characteristic form of the cura- ble Paralysis Agitans is brought on by inhaling fumes of mercury, and, though less frequently, by certain other metallic poisons (tremor metallurgorum — tremble- ment mercuriel). This will be described elsewhere. (See Tremblement Metal- lique.) The other kinds of tremor mentioned by medical writers are either unimportant or symptomatic of other diseases ; they present an interest, as related pathologi- cally to the morbid condition probably existing in idiopathic Paralysis Agitans. Such are the tremors from bodily weak- ness and mental emotion : tremor senilis, which is evidently closely allied to and may pass into Paralysis Agitans senilis ; febrile tremors and rigors (attended by a sense of cold, which is never present in Paralysis Agitans), analogous probably to the toxic forms of Paralysis Agitans ; tremor or subsultus tendinum, which ex- hibits the same spasmodic jerking of the muscles as Paralysis Agitans ; lastly, the tremors in diseases of the brain and spinal cord (hydrocephalus, parasites in cere- brum, myelitis, ataxia, tumors, &c.) are symptomatic, and, as previously explain- ed, distinct from idiopathic Paralysis Agitans. II. Local Paralysis Agitans attacks a single part, most frequently the head and neck, or the arm, or the lower jaw, and remains limited to the region affected. The tremors occur occasionally, seldom constantly, during the day ; they cease at night; they are excited or aggravated by exertion or emotion. Usually free from danger, local Paralysis Agitans is re- garded, like the spasmodic tics, as an in- nrmity or bad habit rather than a disease. It is at the same time very obstinate, in fact usually incurable. It is important to distinguish the idiopathic Paralysis Agi- tans which continues local from that which is the precursor of the progressive general disease, or which may be symptomatic of a tumor or other lesion of the nerve centres. At first the distinction may be impossible ; but the history and course of the affection determines the diagnosis. Whenever the tremor has continued for some time unattended by any concurrent serious symptoms and strictly confined to one part, experience warrants the convic- tion that the morbid action has been ex- hausted in a circumscribed area, and that HO extension of the disease need be feared. It is, indeed, singular that after a few years the local exhibits uo tendency to pass into the general disease. A few remarkable cases have occurred of Paralysis Agitans restricted to the lower jaw and tongue ; in some distress- ing instances all remedies proved unavail- ing. The pathology has not been ascer- tained, and probably the severer cases were not idiopathic, but were symptomatic of some grave disease of the nerve centres. Of the latter kind an interesting ease is recorded recently by Leyden, in which Paralysis Agitans of the right arm was found associated with sarcoma in the left optic thalamus. The more serious symp- tomatic kinds are distinguished from the idiopathic by the more dangerous cha- racter of the symptoms, among which are the signs of centric nervous lesibn, such as motor and sensory paralysis, &c. In respect of pathology and treatment, the local resembles the general Paralysis Agi- tans. Causes. — These are frequently ob- scure, but it is probable that conditions productive of debility or atrophy of the motor nerve centres occasion the idio- pathic Paralysis Agitans. The results of experience are as follows : Predisposing Causes. — 1. Age is of primary importance, both in causing the disease and aggra- vating it. 2. Hereditary and parental in- fluence is indicated in some cases.' 3. The male sex is almost exclusively the subject of general Paralysis Agitans ; the hysterical forms and local tremors of the head being met with in the female. Ex- citing Cavses. — 1. Violent muscular exer- tion is a frequent cause, as also — 2. Inju- ries, especially falls ; also wounds, &c. 3. Excessive mental exertion, and parti- cularly — 4. Violent emotions, as terror or fright, which have sometimes produced the disease suddenly. 5. Venereal ex- cesses have been alleged. 6. Exposure to cold and wet, as lying on damp ground, especially when giving rise to — 7. Eheu- matism, which was noted by Parkinson, and has a decided causal relation to Para- lysis Agitans ; also— 8. Ague.^ In certain cases Paralysis Agitans appears to have followed— 9. Fever (typhoid and various exanthemata) and— 10. Syphilis. 11. In- testinal worms sometimes give rise to it in young subjects, occasionally modified ' Sauvages: " Mulier gravida, qusmaritum subito peremptum exhorruerat, genult filiiim tremore miserando correptum." Most knew a whole family in which it was hereditary. Lebert refers to females who, in successive generations, being otherwise in good health, presented tremors of the head at the climac- teric age. 2 Romberg, Maclachlan, Turnbull. JNo re- lation to gout has been alleged. 726 PARALYSIS AGITANS. into a periodical or intermittent type. 12. Disordered priinoe vi;e (tremor a saburra). 13. Suppressed itch will hardly now be admitted.' 14. Alcohol, opium, tobacco. 15. Certain poisons, particularly mercurial vapors, cause the Paralysis Agitans toxica. While these are the causes of the idiopathic disease, the symptomatic Paralysis Agi- taus, as already stated, may occur, com- bined with other characteristic signs of nervous disease, in various lesions and tumors, &c. , of the brain and spinal cord. Diagnosis. — Idiopathic Paralysis Agi- tans is sufficiently characterized to be of easy recognition ; but its relations to al- lied aflfections are important. 1st. It is distinguished from the other species of the class tremors, because in Paralysis Agi- tans the trembling occurs not only during action, but even when the parts are not in use and are supported (spasmodic, tremor coactus). Tremor senilis, which most resembles it, may pass into Paralysis Agitans, when the tremors which begin during action continue after it has ceased: the tremors usually at the same time in- crease in intensity from trembling to jac- titation. 2d. The different kinds of Para- lysis Agitans are distinguished: the simple senile form by occurring in advanced life, by its progressive course, association with general decay of the system, and fatal issue; the procursive (festinans) senile form presents in addition the disturbed balance in locomotion ; the simple non-senile form occurs in middle age or under, is often stationary in its progress, may be amelio- rated or cured, and is not accompanied by disordered equilibrium ; the hysterical, re- mittent, reflex forms, and that occurring in children, &c., are known by their special circumstances; the toxic Paralysis Agitans is recognized by the cause, and by the concomitant effects of the poison — in the mercurial tremors the tongue and mouth are usually and early attacked, which is not the case in ordinary Paralysis Agi- tans. 3d. The relations to common chorea, both of difference and resem- blance, are instructive. Chorea occurs chiefly in the young before puberty; Para- Ij'sis Agitans attacks the middle-aged, and especially the old. The gesticulations in chorea are jerking, irregular move- ments, changing frequently, and dissimi- lar on the two sides ; the tremors or jac- titations in Paralysis Agitans consist of to-and-fro oscillations of the part, due to the brief alternate action of antagonist muscles ; they continue long unchanged, and are usually the same on the two sides. Chorea specially attacks the female, Para- Ij'sis Agitans the male sex. With atten- tion, therefore, the diseases are not diffl- ' Mentioned by Canstatt. cult to distinguish. But their points of resemblance are striking. Both consist of involuntary, spasmodic movements, rapidly repeated, and not under the con- trol of the will, while the voluntary motor power persists in the affected parts, al- though it is often enfeebled, the debility sometimes amounting to paralysis.' Both are often caused by fright, and by rheu- matism (although no relation seems to exist between Paralysis Agitans and heart disease); in both, when fatal, no visible lesion may be discovered. On the other hand, chorea is nearly always curable in a comparatively short period ; while Para- lysis Agitans, although susceptible of cure in younger individuals, is a peculiarly ob- stinate disease, and is incurable in old persons, in whom it associates itself with senile decay. 4th. The irresistible move- ments forward or backward in Paralysis Agitans present great affinity to the like symptoms met with in "leaping ague," and certain forms of tarantism and ab- normal chorea, and which are also ob- served in connection with lesion of the cerebral peduncles or other parts of the encephalon.^ But these affections are not usually attended by tremors, and the his- tory and special concomitant symptoms are sufficiently distinctive. The differ- ence of Symptomatic from Idiopathic Paralysis Agitans must always be kept in view. 5th. The same remarks apply to the discrimination of idiopathic Paralysis Agitans from certain cases of locomotor ataxia and chronic myelitis, &c. — affec- tions which it often closely resembles in the progressive character of the symp- toms, and in the spasmodic nature of the movements. But these spinal diseases are, in addition to their clinical history, especially distinguished by the presence of decided motor, and mostly also of sen- sory paralysis ; while in idiopathic Para- lysis Agitans the sensibility is remarkably exempted, what is there called paralysis being only a failure of vigor. The diag- nosis is very important, and only difficult because the occurrence of tremors as a complication in various organic nervous diseases may mislead, if the difference of Symptomatic from Idiopathic Paralysis Agitans be not attended to. 6th. In a similar manner. Paralysis Agitans is dis- tinguished from beriberi, raphania, &c. ' Both are sometimes unilateral. 2 Marshall Hall remarks the similarity of certain symptoms in Paralysis Agitans to the effects observed by Serres in diseases of the tuber annulare and tubercula quadrigemina. The irresistible movements — forward, back- ward, lateral, whirling, rolling, somersault, &c. — in experimental lesions of the brain in animals (Fodera, Magendie, Flourens, &c.) have thrown much light on the subject. PATHOLOGY AND MORBID ANATOMY. 727 Complications. — These are rare in idiopathic Paralysis Agitaus ; the healtli usually continuing good till senile decay begins. Apoplexy, hemi- and paraplegia sometimes occur, but not often. Conmion chorea has, in some cases, been found associated with Paralysis Agitans ;' usu- ally, however, the disordered move- ments called chorea have been only exag- gerated examples of the shaking disease. On the other hand, as already remarked, symptomatic Paralysis Agitans may com- plicate many diseases of the brain and spinal cord. Pathology and Morbid Anatomy. — Tremors are generally admitted to be a sign of weakness in the nerve centres, and are ascribed to defective and interrupted discharge of nervous stimulus. But two kinds of tremors have been distinguished:^ first, simple or passive tremors, which oc- cur during a voluntary act, and cease witli it, being evidently due to want of power only (*po|iK){) ; secancl, spasmodic, clonic, or active tremors, which take place even during rest when the parts are supported and unemployed (TtaXfws, tremor coactus, palpitatio) : these are short, alternate, clonic convulsions of antagonist muscles, and imply some irritation in the motor nerve centres. Although these two kinds are allied and pass the one into the other, yet the distinction is important, and fur- nishes the ground of diagnosis ; the spas- modic, not the passive tremor being cha- racteristic of Paralysis Agitans. The dis- turbance of equilibrium is no doubt owing to an affection of a different part of the nervous system from the tremors, since these may exist, even generalized, with- out it. The cerebral or cerebellar pedun- cles or the pons Varolii, are most probably the seat of lesion. But while the locality is different, the association with tremors shows that the morbid action is probably the same in both. The general opinion is that the tremors are due to an affection of the spinal cord, the disturbed equilibrium to an extension of the morbid action within the cranium. Hence some wri- ters speak of Paralysis Agitans Spinalis, consisting of tremor and muscular de- bility, and Paralysis Agitans Cerehndis, in which the disturbance of equilibrium is superadded.^ There is no vertigo nor distortion of the eyeballs, as in lesion of the base of the eneephalon. The dis- turbed equilibrium seems due to weak- ness of one set of muscles (e. g., extensors), and perhaps spasmodic action of their antagonists (i. e., flexors). Morbid Anatomy, which formerly gave only negative, has lately afforded indica- ' Maclachlan, p. 216. ' Distinction first clearly drawn by Sylvius, previously indicated by Galen. ' Eemak. tions of positive results. The facts are as follows : — 1st. In many instances of idiopathic Paralysis Agitans no lesion of the cere bro-spinal axis can be discovered by our present means of investigation. In these cases, therefore, tlie disease may be re- garded asfunciional or dyyiamical; and it may be presumed to depend, (a) on im- paired generation of nerve energy, due to some unknown conditions ; (6) alteration of vascular supply, either congestion, or, as late researches on the pathology of con- vulsions suggest, anasniia, i. e., deficient or interrupted vascular supply ;' possibly also an cedematous condition of the nerve centres might cause the symptoms ; (c) molecular physical or chemical changes, which we may certainly assume in the toxic forms (mercurial tremors). The functional are especially the curable forms of the disease. 2d. In more inveterate, especially senile cases, Paralysis Agitans appears to de- pend on a discoverable lesion ; namely, an atrophic condition of the spinal cord, pons Varolii, crura, or medulla oblongata (atrophic or organic Paralysis Agitans). This atrophy has been found in several careful dissections, and it certainly coin- cides with and would explain the chief features of the disease — namely, its ob- stinacy or incurability, without immediate danger to life ; the progressive course ; the impaired strength and muscular de- bility (paralysis) ; the occurrence in old age, after violent exertion and emotion, under conditions of premature senility, &c. In addition to simple atrophy, with serous accumulations, autopsies have re- vealed in different parts of the spinal cord, medulla oblongata, and pons an in- durated condition (sclerosis), with patches of gray or gelatinous degeneration, due to the new formation of'connective tis- sue, which compresses and atrophies the proper nerve structures.^ Since a similar condition, involving extensively the pos- terior columns of the cord, is the chief lesion found in progressive locomotor ataxia (tabes dorsal is), some relation is established between it and Paralysis Agi- tans.2 It is curious that Parkinson (from the report of a case not seen by himself) drew attention to the induration and en- largement of the upper part of the me- dulla spinalis, oblongata, and pons, as the probable morbid condition in Paraly- sis Agitans, and supposed it might be due to simple inflammation, or rheumatic ' Marshall Hall, Kussmaul and Tenner, Brown-S6qnard, &c. 2 Bamberger, Skoda, Oppolzer, Lebert, &c. ' Also with tetanus, probably chorea, and with progressive paralysis of the Insane. See Rokitansky, Ueber Bindegewebs-Wuche- rung im Nervensysteme. Wien, 1857. Cru- veilhier, &c. 728 PARALYSIS AGITANS. or scrofulous affection of the nervous sub- stance or membranes. The sclerotic atrophy does not seem to be of inflamma- tory origin, although, according to Ro- kitansky, it is preceded by congestion. In the early stages, there may be softening instead of induration. Rheumatic and other morbid diatheses may probably dis- pose to it. Degeneration of the blood- vessels may possibly be connected with it.' The pathogenesis of atrophy of the nerve centres, however, has not yet been fully investigated ; and, although highly probable, it cannot yet be positively affirmed, that Paralysis Agitans depends upon atrophy, simple or sclerotic, of cer- tain parts of the cerebro-spinal axis. In regard to symptomatic I'aralysis Agitans, the tremors are ascribed to the atrophy of the nerve substance surrounding the tumor or other principal lesion. But whether the disease be functional or organic (atrophic) in its nature, it clearly affects the motor centres only, ex- empting the sensoiy and the intellectual ; and, further, the morbid state of the nerve centres implies not only diminished power, but some condition of spontaneous irritation, giving rise to the spasmodic jactitations even during rest. Probably the degenerative molecular changes in the nerve structures may occasion a dis- turbed equilibrium and consequent irregu- lar discharge of nerve stimulus. The morbid process is presumed to begin usu- ally in the cervical portion of the spinal cord, since the arms are apt to be first affected, and the disease presents the bi- lateral type. But the occurrence of the unilateral form, as well as the fact that the limbs are much earlier affected than the trunk, shows that the possibility of the cerebral centres of motion being sometimes attacked should not be over- looked. The disturbed equilibrium prob- ably ensues when the parts in the vicinity of the pons Varolii are involved, and the extension to the medulla oblongata is in- dicated by the impaired speech, degluti- tion, &c., which supervene in the ad- vanced stages of the disease. [Since this article was written, the distinction urged by Charcot has been generally accepted, between Paralysis Agitans and disseminated (multiple, cerebro-spinal) sclerosis. Of the two kinds of tremor above described, which may be called, the one passive and perma- nent, and the other volitional, the former ' In Skoda's ease the nerve elements were destroyed in some parts of the brain, the pons, and medulla, by embryonal connective tissne ; the vessels were obliterated; the muscles were in a state of fatty degeneration ; the neurilemma of the nerves of the upper ex- tremity was thickened. The thickened neu- rilemma has been observed in other cases. is peculiar to Paralysis Agitans ; the latter occurs in disseminated sclerosis. That is to say, in the first named disorder there is trembling at all times, whether the patient be moving or rechning, so long as he is awake. In the second dis- ease, tremor occurs only when some mus- cular action is attempted ; then the move- ment of the muscles used becomes irregu- lar, with a coarser tremulousness than in shaking palsy (see Multiple Sclerosis, under Induration, in this volume). Charcot analyzes' the morbid appear- ances of the cases above referred to, re- ported by Bamberger, Lebert, Skoda, Parkinson, and Oppolzer ; and beheves that some of them were examples of dis- seminated sclerosis, not of Paralysis Agi- tans. Yet, in Charcot's account of dis- seminated sclerosis, it is admitted that morbid anatomy has not made clear what location of disease explains the trembling which is one of its characteristic symp- toms. Erb,'' also, observes, that the two kinds of tremor, in some cases, "exist side by side." This pathologist, while preferring to regard such a combination as indicating the presence of two differ- ent diseases, rather than as evidence of the non-essentiality of the distinction be- tween them, adds: "We must wait for more accurate observations, however, he- Fig. 38. The writingr hand. Habitnal attitude of the hand at a Bomowhat advunced stage of Paralyyis Agita-ns. (Charcot.) fore passing finally on the correctness of this view." Fig. 39. Digital deformation, simulating that of primltiv» chronic articular rheumatism. (Charcot.) In three cases examined posi-mortem by Charcot,' the appearances common to all [' Lectures, &o., Lect. v.] [2 Ziemssen's Cyolopffidla, vol. iciii. Multi- ple Sclerosis.] [3 Jofifroy, Sooi^te de Biologie, 1871.] TREATMENT, 729 were the following : a, obliteration of the central canal of the spinal cord by pro- liferation of the epithelial elements which line the ependyma ; &, proliferation of the nuclei which surround the ependyma ; c, pigmentation of nerve-cells, most marked in Clarke's (posterior gray) columns. Two of the cases had also a multiplication of amyloid corpuscles ; one, a sclerosed patch on the posterior surface of the bul- bils rachidicus.' The language of Charcot appears to be still appropriate: "The special lesion of Paralysis Agitans re- mains to be discovered." — H.] Should future researches confirm the results above indicated, there would then exist a secure basis of morbid anatomy for the distinctions which authors have indicated clinically, of idiopathic Paraly- sis Agitans into functional and organic : the latter with, the former without, atrophy of the nerve centres ; the latter mostly incurable, the former admitting of cure. The Prognosis is unfavorable, but de- pends upon the age of the patient and the particular form of the disease. When fully established, idiopathic Paralysis Agitans is an obstinate,'' and in the aged, with rare exceptions, an incurable dis- ease. But, unless mixed with signs of senile decay. Paralysis Agitans does not endanger life, and its course is often in- definitely protracted. As a rule, it is ob- stinate in proportion to the age of the subject, and is fatal only in the old. The distinction of curable and incurable, functional and organic (atrophic), has been already sufficiently indicated. It need only be added that mere violence of the jactitations is no evidence of incura- bility ; slight tremors are frequently the most obstinate ;' it is the persistence of tremors during absence of voluntary effort, and especially during sleep, the oc- currence of disturbed equilibrium, and symptoms of senile decay which are of serious import. Disturbed equilibrium is apparently incurable in itself, as well as of bad augury for the disease generally. The supervention of convulsions, apo- [' Bulbe rachidien, fhe lower part of the medulla oblongata.] 2 "Morbus valde pertinax," Juncker. Com- paring it with apoplexy and motor palsy, &o. , lie says it is inferior to them in danger to life, but equals them in reference to treatment. ' Dr. Russell Reynolds, in a letter, June 1, 1865, says: "From what I have seen of a large number of cases, I am led to believe that there is a most important difference be- tween those oases in which there is trembling only and those in which there is clonic alter- nate spasm. In the latter the prognosis is very much more favorable than in the for- mer." The age of the patient and stage of the disease being, of course, taken into ac- count. plexy, motor or sensory paralysis, indi- cates more immediate danger to life. In the Eegistrar-General's Keports for England and Wales, from 185.5 to 18C3 inclusive, 205 deaths from Paralysis Agi- tans are recorded, 129 being males, and 76 females ; on an average about 14 males and 8 females annually. Of these 205, 189 were above 55 years of age ; nearly half, viz., 91, occurring at 65 years ; only 16 below 45 years, one death taking place at 20 years. It may be doubted, how- ever, whether the cases fatal below the age of 45 were true idiopathic Paralysis Agitans ; more probably they were exam- ples of spinal or cerebral disease accom- panied by tremors, i. e., by symptomatic Paralysis Agitans. Of the Modes of Termination, the prin- cipal in the senile disease is by general decay of the system. Sometimes life is cut short by the'intercurrence of the usual diseases of old age. Trousseau states that in three cases which he traced to the end the patients all died of pneumonia. The non-senile forms of Paralysis Agitans are not known to have any special mode of termination. Treatment. — The modes of treatment and remedies emploj'ed are numerous, but few have been attended with success. Allowance must be made for the form of the disease ; the senile being mostly in- curable, the non-senile obstinate, but sus- ceptible of relief or cure. The physician must keep in mind the propriety of ab- staining from remedies in inveterate cases, after a fair trial has been given to them : a fruitless perseverance would only injure the general health and excite false hopes. At the same time, general hygienic measures are always beneficial, and by their means alone, the symptoms may be alleviated, and life prolonged to advanced age. The methods of treatment are : — 1. Antiphlogistic. — This used to be com- monly practised on the supposition of the congestive or inflammatory nature of the affection of the spinal cord. In some cases, in an early stage, it seems to have done good ; purgatives, indeed, in judi- cious moderation, are useful in all cases, and they cure the forms depending on disordered primte vise (tremor a saburra). The means employed were : Venesection general or local, purgatives, diaphoretics, mercury; blisters, setons, cauteries actual and potential, moxas, &c. , to the spine ; frictions, stimulant embrocations, hot baths, &c. In the majority of cases, how- ever, this practice did no good or did posi- tive harm. The treatment now preferred, especially in chronic cases, is — 2. Tonic, general and nervine. Hygi- enic regimen, nutritious but not stimu- lating diet ; little wine ; rest or moderate 730 PARALYSIS AGITANS. exercise, light gymnastics. Excessive ex- ertion is injurious, and many cases of sim- ple Paralysis Agitans are aggravated by the patients when poor being compelled to work, or, when rich, endeavoring by forced exercise to overcome the debility in which they suppose their disease exists. Siibcarbonate of iron has been a noted remedy in consequence of Elliotson hav- ing cured cases by it in persons under 50; it failed in older patients. Quinine, zinc, arsenic, nitrate of silver, chloride of gold ; strychnine, which has apparently cured some, and failed in other cases ; ergot, said to have been beneficial ; iodine and bromide of potassium, balsams, oil of tur- pentine, sarsaparilla, quassia, colchicum, ifec. ; Iceland moss ; mineral-waters, sul- phurous or chalybeate ; sea or mountain air, the milk cure, &c. 3. Narcotics and Calmants. — Opium, helladmina, henbane (gss of Tinct. thrice daily, used successfully in functional Pa- ralysis Agitans by Dr." Handfield Jones) ; stramonium ; chloroform stops the tremors at the time, hut does not appear perma- nently beneficial ; ether, musk, camphor ; veratrin, externally or internally, reported successful in a case by Volz ; valerian and valerianate of zinc ; Calabar bean, tried without success by Dr. J. W. Ogle. 4. Baths have been much resorted to, sometimes with success, often without effect. AVarm sulphur baths, especially of liver of sulphur, has been specially recommended. Simple warm baths with cold douches (Romberg). Vapor baths, Russian baths, and baths of gelatine, fir- tops, mud, even animal baths, have been used in Germany. The water-cure, cold affusions; sea-bathing, which rendered one case stationary (Lebert); brine baths, ice baths, first tepid, gradually made colder. It should be remembered that some of these, especially the cold-water cure, are not free from danger, and require proper caution in old persons ; sometimes they aggravate the disease. 5. Electricity and Galvanism. — Partially successful in previous experience, elec- tricity was found to produce no improve- ment in four cases observed by Gull. The interrupted galvanic current appears also to have been of little service ; but the con- tinuous current recommended by Remak proved successful in his hands with a pa- tient aged 60, and others were benefited by it. In a man, aged 57, the disease, well marked though recent, was cured in this manner by Dr. Russell Reynolds. After five apphcations of Pulvermacher's chain of 120 Hnks, daily, for one hour, the spontaneous jactitations completely ceased ; the same treatment, continued every second day, completed the cure in about a month. In otlier instances, this means has not produced such favorable results, but it deserves a persevering trial in all cases. On the whole, good hygienic rules, at- tention to any special indications, gouty, rheumatic, &c. ; regulation of the primee vise ; the administration separately or combined of general and nervine tonics, and calmants, and the judicious use of the continuous galvanic current, are the measures chiefiy to be recommended. Depletion and counter-irritation are sel- dom required, and would in most cases be highly injurious. Time must in all cases be allowed, for the affection is ob- stinate. In the confirmed senile forms, we may be satisfied with arresting or mitigating, but must not expect to cure the disease. Beferences in chronological order. When marked °, the originals were not obtain- able. Hippocrates, Goan prognost. and Prorrhet., Ed. Kuhn, i. pp. 159, 161, 246, 288; Epidem. iii. § 3, 4th case, p. 298, &c. Celsus, lib. Hi. c. 27, and lib. i. c. 9. Galen, on Tremor, Palpitation, Convulsion, and Rigor, Ed. Kiihn, vii. 584 ; Scelotyrbe, Definitions, xix., 427, § 293. Orihasius {&.!>. 360), Ed. Bussemaker and Daremberg, iii. 209, On Trembling (from Galen). Paul ^gineta (6th or 7th century), Book iii. sect 21, On Trembling, Syd. Soo. transl. i. 407. Diemerhroeck (1652) Disp. de Paral. et Tremore. Tulpius, Obs. Med. i. 12, Tremor periodicus, 1672. Sylvius de la Bob, Op. Med., Ed. Alt. 1680; Prax. Med. 1. i. c. 42, p. 291 ; De Spirit. Animal, per nervos. motu laeso, § 5, and 25, Coactus Tremor, &c. Bonet, Sepul. Ed. Alt. 1700, 1. i. sect. 14. On Stupor, Torpor, Tremor, &c. Obs. 6—11, pp. 346-9. Jdnckee, Conspect. Med. 3 Ed. 1737, Tab. 115 ; De Tremore artuum, p. 886. Gaubius, Inst. Path. Med. 1758, Spasmus, § 751 ; Paralysis, § 757. Van Swieten, Com- ment. 2d Ed. 1749, ii. § 627, Tremcr febrilis; cases of Paralysis Agitans at p. 181, Vidi in hac urbe virum, &c. Sauvages, Nosol. Meth., Ed. ult. 1768, i. p. 557, § xiv. Tremor, and p. 590, 4 xxi. Scelotyrbe, festinans et insta- bilis. Linnceus, 1763, Gen. Morb. 144, Hiera- nosos. °Vogel, Bet. Gen. Morb. 1764, Hiera- nosos. Macbride, Theory and Pract. of Physic, 1772, pp. 558-9, Hieranosos. Sagar, Syst. Morb. Sympt. 1779, Tremor, pp. 430-2. Cd- len, Synops. Nosol. Meth. 1785, Gen. 43, Pa- ralysis-Tremor. KirUand, Comment, on Apop. and Parol. Affect. 1792, pp. 102 and 122. Heberden, Comment., Ed. Alt. 1807, c. 91, De Tremore, p. 371. Pakkinson, Essay on the Shaking Palsy (Paralysis Agitans), London, 1817. Art. Scelotyrbe in Diet, des Sc. M4d. t. 1. pp. 134, 1920. Co9ke, Nerv. Diseases, 1821, ii. p. 207. Masox Good, Study of Med. 2d. Ed. 1825, iv. Synclonus Tremor, p. 458, and Synol. Ballismus, p. 473. Elliotson, Med.-Chir. Trans, xiii. p. 240, 1827 ; Lancet, June 4, 1831, p. 290; Ryan's Lond. Med. and Surg. Journ. 1832, ii. 605 ; Lond. Med. Gaz. ATHETOSIS. 731 xi. p. 532, Jan. 1833 ; Prin. and Pract. of Med. by Rogers and Lee, 2d Ed. 1846, oh. xi. p. 689. Ceuveilhiek, An. Path. t. ii. 32, Lir., PI. 2, fig. 3, p. 19, 1829. Gowry, Case of Par. Agit. Intermittens (cured), Lancet, 1831, p. 651. Todd, in Forbes' Cyc. of Pract. Med. 1834, iii. 259, and Clin. Lect. 2d Ed., Led. 45, p. 764, &o. Most, Enoyc. d. Med. Prax. 1837, ii. 555. Gibson, on Spin. Irrit. case 5, Lancet, ii. 1838-9, p. 568. Romeekg, Nerr. Diseases, 1st Ed. 1840; 3d, 1857 ; Syd. Soc. transl. 1853, ii. 233. Makshall Hall, Dis. and Derange, of Nerv. Syst. 1841, p. 320. Thompson, Secale cornutum in Chorea, Par. Agit. &c. Lancet, Jan. 29, 1842, p. 616. Gkaves, Clin. Med. 1843, 1st Ed. p. 714 ; El- len Davis's case, &c. Cansiatt, Pathol, or Handb. der Med. Klinik, 3d Ed. Bd. iii., 1 Abth. pp. 444-5, 1843. ° Trousseau, Des. Pr6p. de Noix vom. dans la Danse de St. Guy, Journ. de M*d. par Beau, June, 1843, p. 161, reported as Par. Agit. in Canstatt's Jahrb. 1843, Bd. ii. p. 99, § 35. Watsoyi, Prin. and Pract. of Phys. Lect. 38, 1st Ed. 1843. Hen- His Green, cases of Nervous Tremor in Chil- dren, Prov. Med. Journ. No. 178, Lond. Feb. 24, 1844. °Volz, in Heidelb. Annal. xii. 2, 1846, reported in Schmidt's Jahrb. liii. 37. "V. Brunn, Chron. Zittern, in Caspars Wo- chensch. No. 40, rep. in Canstatt's Jahrb. 1846, ii. 70. ° Rudder, Chorea with Parox. of Scelotyrbe, Ann. Soc. MM. de Gand, 1848, ii. rep. in Canst. Jahrb. 1848, ii. 48. Roth. Hist, de la Musculation irresistible on Choree Anormale, Paris, 1850. ° Basedow, Stabili- tats-neurosen. Casp. Wochensch. No. 33, rep. in Canst. Jahrb. 1851, iii. 79. ° Seitz, Deutsche Klinik, No. 46, and ° Haas, Nassau Med. Jahrb. Hft. ix. rep. in Canst. Jahrb. 1852, iii. 92. Gull, Value of Electricity as a remedial agent, Guy's Hosp. Rep. 2 Ser. viii. 134-6. Paget, case of involuntary tendency to fall precipitately forwards, with remarks. Med. Times and Gaz. Feb. 24, 1855. °Bam- BERGEK, Beob. ub. Hirnkrank, in Verhand, d. phys. Med. Gaz. z. Wurtzb. Bd. vi. 283, rep. in Canst. Jahrb. 1855, iii. 73. Hasse, in Virch. Handb. d. Spec. Path. u. Ther. 1855, Bd. iv. 1 Abth. pp. 301 and 306-7. Russell Reymolds, Diag. of Dis. of Brain, &c. 1856, p. 16;i ; Case of Par. Agit. removed by continuous Galv. current. Lancet, Dec. 3, 1859, p. 588. Remak, Galvano th^rapie, Berlin, 1858, pp. 219, 248, 447. Copland's iled. Diet. 1858. CoHN, Beitrag. z. Lehre der P. Agit. Wien Wochensch. Nos. 18—26, rep. in Canst. Jahrb. 1860, iii. 73. ° Oppol- zek, remarkable case of P. Agit. with Autop- sy, Spital-Zeit. Nos. 17, 18, rep. in Canst. Jahrb. 1861, iii. 78; also quoted fully in Trousseau, Clin. Med. 2d Ed. ii. 219 ; also °Oi)poherm Wien. Med. Zeit. 1862, No. 52, rep. in Canst. Jahrb. 1863, iii. 39. ° Stofella, case of P. A. with Autopsy, Wien Wochensch. xvii. 37, 1861, rep. in Schm. Jahrb. 113, p. 39, and in Syd. Soc. Yearbook, 1862, p. 82. ° Skoda, in Wien. Med. Halle, iii. 13, 1862, rep. in Schm. Jahrb. 119, p. 294, and in Syd. Soc. Yearbook, 1863, p. 100. ° Alfred Louis, De la Tr^mulence paralytique progressive, Strasb. 1862, rep. in Canst. Jahrb. 1862, iii. 66. Lebert, Handb. d. Pract. Med. 1863, ii. 590. Maclachlan, Dis. and Infirm, of Ad- vanced Life, 1863, p. 212. Leyden, case of P. Agit. of right arm, with develop, of Sarco- ma in 1 Opt. Thai. Virch. Arch, xxix, p. 202, 1864. Handheld Jones, Functional Nerv. Disorders, 1864, 263. Topinard, De I'Ataxie, Loc. Prog., forme Paral. Agit. pp. 103, 114, 117, &c. Paris, 1864. Trousseau, Clin. M^d. 2d Ed. ii. 213. Sanders, case of Dystaxia or Pseudo-paral. Agitans with remarks, Ed. Med. Journ. May 1865, p. 987. J. W. Ogle, Calabar bean in Par. Agit., Med. Times and Gaz. 1865, ii. 256. [ATHETOSIS. By Henry Hartshorne, M.D. This term (from d9£Vo;, without fixed position) was first applied by Dr. Ham- mond, in 1871, to an affection of which he reported two cases in his worl? upon Diseases of the ifervous System. The characteris'ic symptom is a constant, in- voluntary, and more or less regular move- ment of the fingers or toes, on one side or both. As an occasional phenomenon, Charcot had noticed this in 1853, and Heisse in 1860. Charcot, however, regards it as a variety of chorea, following hemiplegia ; corre- sponding, therefore, in part, with what S. Weir'Mitchell has designated as post- parcdytic chorea. In some of the cases re- ported, however, no paralysis whatever has existed.' Oulmont published an account of his study of several cases in the Salpetriere.^ Other cases also have been reported ; among the latest of which are one in the [' London Med. Record, March 15th, 1879.] [2 :E;tude olinique sur I'Athfitose, Paris, 1878.] 732 writers' cramp. Bevue Med. Tr. et Etranglre, January, 1879, and another in the London Lancet, March 15, 1879. In the last-named instance, and at least once previously, post-mortem examination has been made. The following is the description given of the phenomena in the last case, which was under the care of Dr. Sturges, in the Westminster Hospital, London : — " The movements referred to were con- fined to the left side, and almost exclu- sively to the upper extremity. They were continuous and involuntary. When the hand was extended with the palm down- wards, the index and middle lingers were slowly and gradually flexed, the ungual phalanges being first bent, then the mid- dle, and finally the proximal. The thumb was also adducted, and either closed over the first phalanx of the index finger, or passed under the index and middle fingers, so that the ungual phalanx protruded be- tween the middle and ring fingers. The hand was then supinated, the fingers again extended and the thumb abducted. Pro- nation of the hand completed the cycle. This was tlie type of the movement, but it was subjected to some variation, and there was at times great irregularity. When the fingers were flexed consider- able force had to be exerted to extend Ihein, but the forcible extension did not increase the subsequent involuntary move- ments. Patient had always to keep his nails short, or they would indent the palm of the hand. He was able by a great effort to partly control the movement, but his power in this respect was very slight. On requesting him to close his hand, the fingers being at the time extended, he was unable to do so, and the effort, al- though directed exclusively to the left hand, often resulted in the unconscious closure of the right. The only time the hand was really quiet was during sleep. The movements were ordinarily so con- stant and so little under the control of the will that the patient was not able to use his left hand for any of the ordinary pur- poses of lifting ; even his food had to be cut up for him." In this case there had been two fits dur- ing infancy, followed by hemiplegia of the left side, which, however, disappeared be- fore the age of ten years, and did not return. The man died of phthisis in the hospital, and a careful autopsy was made. The whole right hemisphere of the brain was found to be distinctly smaller than the left. Atrophy of some of the convo- lutions had occurred, especially those of the frontal and parietal lobes. The whole of the gray substance of the right corpus striatum, and nearly all of its white sub- stance, was destroyed. The optic thala- mus, arteries and membranes of the brain, and the spinal cord, were healthy. Oulmont has dwelt especially upon what he conceives to be the important dif- ference between double or general Athe- , tosis, and that which is unilateral, hemi- athetosis. The latter, when there is motor hemiplegia, occurs nearly always on the paralyzed side. In the majority of cases, there is also hemiansesthesia of the same side. Permanent contraction, rigidity, atrophy, and laxity of the articular liga- ments, may exist, as post-hemiplegic sequelse, not necessarily connected with the Athetosis. This disorder is compared by Oulmont to hemichorea, and referred to a probable cerebral lesion, in the neigh- borhood of the fibres in front and outside of the sensory bundles at the lower part of the corona radiata (of Reil). Gowers and McLane Hamilton" refuse to admit that there is clinical or patho- logical reason for separating Athetosis from other symptomatic or secondary affections of disordered movement, chiefly hemiplegic in origin. Notwithstanding its occasional independence of paralysis (as above seen), its place in nosology, at present, appears to be rather that of a symptom than of a disease ] WRITEES' CRAMP. By J. Russell Reynolds, M.D., F.R.S. DBFrpnTiON. — A chronic disease, char- acterized by the occurrence of spasm when the attempt is made to execute spe- cial and complicated movements, the re- sult of previous education ; such spasm, not following muscular actions of the affected part when these special move- ments are not required. The term "Writers' Cramp" is bad in one respect, because the symptoms it de- [' Nervous Diseases, p. 92.] SYNONYMS — SYMPTOMS. 733 notes do not belong exclusively to the act of writing ; it is good, and therefore re- tained in this "■ System of Medicine," be- cause it points to the most frequent form in which the disease is exhibited, and be- cause it has already passed into general usage. A disease pathologically similar to Writers' Cramp may be found in the artist, and may prevent him from paint- ing in oil ; it may occur in the violinist or the pianist, and hinder the musical per- formances of either ; it may be met with in the seamstress, or the smith, or the milkmaid, and may limit or destroy their powers of work. Wherever it is found it shows the same general features, expressed in the definition, viz. a limitation by spasm of a particu- lar kind of movement, and of that movement only. Synonyms. — Scriveners' Palsy; Mogigraphie ; Schreibekrampf ; Crampe des Ecrivains ; Schuster- krampf ; Melkerkrampf. Syjsiptoms. — A slowly develop- ed difiiculty in executing a par- ticular movement, such as that of writing or playing on a musical instrument, other movements of the same limb being perfectly easy of performance. Usually the patient feels at first some undue weariness after long exertion, a stiffness of the fingers, or an un- steadiness and uncertainty of movement, all of which immedi- ately disappear on giving up the exertion. If writing, a man feels that his pen does not do what , he intended that it should ; that his handwriting looks unnatu- ral ; that he has to hold his pen more tightly than before, in order to keep it between his thumb and fingers ; that it starts from its place, and often is pushed, by his first finger, over the nail of his thumb, and that ne has some diffi- culty in getting it back to its place. A pianist makes blunders in striking chords, the fingers falling on keys they were in- tended to avoid : the violinist cannot con- trol the movements of his left hand, — or can do so only by a painful effort,— the fingers running together and feeling stiff: the seamstress cannot ply her needle, but pricks her fingers, and makes her stitching irregular. In one case, under my own care, the bricklayer could not use his trowel. At first the difficulty is slight, and may be overcome by strenuous effort ; but, after a little time, if the attempt to con- tmue or repeat the movement be persisted m, there is distinct cramp, jactitation, or tremor of the hand, and the particular performance is quite impossible. Other things may be done, but that one thing with regard to which the difficulty was first felt cannot be effected properly by any amount of exertion. A patient "may not be able to write, and yet may feel no difficulty in fingering either the piano- forte or the harp. The accompanying woodcut represents four different attempts made by one of my patients to write his name — Fig. 40. The moment that the attempt is given up the patient feels nothing abnormal ; but the moment that he tries again to per- form this special act the difticulty returns and increases. Sometimes the special symptoms are made worse by any exer- tion of tlie arm. The cramp-movements, at first limited to the thumb and fingers, are sometimes avoided by the writer who adopts me- chanical devices which leave them at rest, but make it possible to perform the act of writing by using only the muscles of the wrist and forearm ; as soon, however, as he has trained himself to write in this awkward manner, the muscles of the fore- arm take on a spasmodic movement, and he is no better off than before. In one case, which I have recently seen, the pa- tient could manage to write a few words by moving only "the muscles of his arm and trunk— his pen was directed by the 734 writers' cramp. muscles of his back and arm, the latter being pressed closely against his side ; but, after a few seconds, spasm occurred in these, the whole body was contracted, the head being drawn downwards to the right shoulder, and the trunk contorted so as to render it concave on the right side. In several cases that I have known the sufferers have taught themselves to write with their left hands, to do this with ease, rapidity, and neatness ; but, shortly after having acquired the art, the left hand has become afleoted in a similar manner, and its writing-power has been limited more rapidly than was that of the other limb. When the disease has existed for some time, the attempt to write often becomes painful; there is a feeling of "cramp," and much general distress, accompanied by spasmodic movements in the neck, and sometimes in the limbs not especially en- gaged in the effort ; and yet, apart from the attempt to write, there is no spasm and no inconvenience. After long persistence of the cramp there is sometimes feebleness in the gen- eral movements of the limb, — the grasp is not so firm as it used to be ; but such quasi-paralysis is the exception, and not the rule. In some cases the spasmodic movements have not been so closely limited, as they are in the majority, to the attempted per- formance of a special act ; those move- ments which require no fine adjustment may be performed with force and pro- priety, but others — needing delicate co- ordination — may be diflBcult or even im- possible. There has been tremor, or choreiform agitation of the limb, more or less persistent during the day, even when no voluntary effort is being made, but ceasing at night, during sleep, or after prolonged rest in one position. There are — in some individuals, but not in all— abnormal sensations in the affected limb ; and these may be noticed before any cramp appears. They may be in- creased by exertion, but do not entirely depend upon it. They are vague in cha- racter, such as a "feeling of weight," or of "tightness," "numbness," or "cold- ness ; " a pain, but more often a "some- thing not quite pain going up from the hand to the back." In some cases there has been actual anaesthesia of the fingers, and an " aching in the spine. "■ There is nothing peculiar to the disease now men- tioned in the sensations that I have heard described, when description was possible, except this, that the attempt to control the spasm augmented the distressing or uneasy feelings. In the majority of cases the special cramp exists by itself ; but in a few it is ' Solly, on Scriveners' Palsy; Lancet, Jan. 28, 1865. associated with other disturbances of the nervous system. Those which I have met with have been torticollis, occasional stra- bismus, stammering, and palpitation of the heart, with some distress about the cardiac region, over and above the mere fact of increased force or frequency of beat. The general health in some of the most typical cases has been excellent, and the physical strength equal to and even be- yond the average. In a few individuals there have been weakness, a "nervous temperament," and some ansEmia with impaired digestion and nutrition ; but in no one has there been witnessed any modification which is not consistent with, and frequently encountered in, other dis- eases. Etiology. — Age. Early life appears to be exempt ; I have not met ^\ith a single case in which the symptoms ap- peared before the age of thirty. Sex. The male sex is much more liable to suffer than the female. Occujjatimi. It is com- monly held that the disease is caused by excessive exertion, but there are reasons for doubting the correctness of this state- ment. Thousands of individuals write, work, milk, or play musical instruments to the highest degree that is possible, without suffering from the least inconve- nience of the kind now described ; and, on the other hand, many cases occur in which there has been no excessive strain upon the muscles in the performance of these special acts ; and, indeed, in some quite characteristic examples of the malady, there has been less than the usual amount of writing performed by gentlemen of the age and professions of my patients. It may then be convenient, but it is not scientific, to refer this form of cramp to over-exertion of a special kind. Worry of mind and anxiety have been present in many eases before the outbreak of the symptoms, but so they have been in many other forms of nervous disturb- ance quite different from this ; and in some persons affected with Writers' Cramp there has been nothing of the kind to which the patient or others could refer the symptoms. I have known the symptoms of Writers' Cramp to occur in one who had been much interested in their appearance in a friend. An injury to the wrm has been supposed, in some cases, to have originated the dis- ease. Diagnosis.— Scarcely anything need be added to the description already given. The special character of the difficulty is the diagnostic mark of true Writers' Cramp. A man may be unable to write from lead poisoning. But the presence of paralysis rather than spasm ; the singhng out of certain muscles not only for weak- ness, but for loss of nutrition and of irri- PROGNOSIS — PATHOLOGY. 735 lability to electricity in the induced form; the equal affection of the two upper ex- tremities, although, when sliglit, it may be shown more conspicuously in the hand which writes, and has been educated to perform other complex movements ; the presence of a blue line on the gums, and the general history of saturnine intoxica- tion, — are sufiicient to establish the diag- nosis. Wasting Palsy, which often commences jn the muscles of the thumb, may be known by its characteristic feature, "wasting," and needs ouly to be men- tioned in order to be distinguished from Writers' Cramp. In wasting palsy the loss of power is in direct proportion to the loss of nutrition ; in Writers' Cramp, it is the spasm which interferes with the par- ticular movement that is required. Local Paralysis. — A few weeks ago a gentleman was sent to me with supposed " Scriveners' Palsy. ' ' He had been read- ing and writing much, and on one even- ing sat reading for some hours "in a draught ;" his hand was weak, and on the following day he could not write. There was when I saw him nearly complete paralysis of the right hand and forearm, and the electric irritability was almost extinct, but in the course of a fortnight the power had returned, and the patient was well. The extent of the paralysis and the absence of spasm were the dis- tinctive marks. Several cases of this kind have come before me, and have been thought to be examples of Writers' Cramp ; but the fact of their having been mistaken for the latter is enough to put any one on his guard against a repetition of the error. PEOG]srosiS. — If the case be seen when the symptoms have existed for only a short time, relief may be confidently ex- pected, provided that rest can be given. If the symptoms have existed for many months, or if rest be impossible, the prog- nosis is extremely unfavorable. There is scarcely any malady which has resisted more obstinately all kinds of attempts — well-directed and ill-directed — which have been made for its cure. Many who were seriously threatened with Writers' Cramp are now free from the malady because they rested ; many who could not and did not rest, are now, in the present state of therapeutics, incurable. Bearing in mind what has been said with regard to the extension of the disease into other regions of the nervous system, some caution is required in stating the general prognosis of such cases, but, in the vast majority, it may be confidently expected that no such extension will occur. When there are signs of disease already present in other directions, such as strabismus, torticollis, weakness of the corresponding leg, and the like, the prog- nosis should be extremely guarded. _ Pathology. — The exact locality of disease, and the precise nature of the change which constitutes it, have not been yet demonstrated with regard to Writers' Cramp. Its closest clinical affinities are with stammering, spasmodic wry-neck, and histrionic spasm, or " mus- cular tic" of the face. Analogous mala- dies, but moving in a yet wider range, are sometimes encountered, such as cer- tain forms of rotatory movement, of chorea, and of locomotor ataxy ; and be- yond these there are anomalous cases, which every physician occasionally meets with, but does not know how to designate. One patient cannot make the attempt to walk without performing, or i-unning in danger of performing, sundry rotatory movements, which terminate in a fall : another, a hard-working clergyman, can only speak, though he has the voice of a Stentor, when on a level with his audience ; and this not from any fear, or shyness, or sham, but from definite aphonia. Some of the spasmodic movements induced in frogs by injury to the auditory nerve are of similar character ;' and the experiments of Magendie, Flourens, Longet, and Schiff afford further illustrations of analo- gous disturbances in the physiology of motion. In order to understand Writers' Cramp, it is necessary to remember what is, phy- siologically, involved in the education of the muscles to perform complicated acts, such as those of writing, speaking, or playing on musical instruments. The will does not pick out the muscles which are to be brought into play to hold a pen ; it simply directs itself to the result. The boy who plays at marbles directs his movements in the same manner, and with as much accuracy and nicety, as the professor of anatomy directs his when he is writing a description of the muscles of the hand. The combination or co-ordina- tion of muscular contractions is determined by the will, but is affected by another agency. Each is conscious of a wish to do a certain thing, and of a will to do it, but a knowledge of the mode in which the movement is brought about does not help, and may sometimes hinacr, its produc- tion. Experimental physiology and clin- ical pathology combine to teach us that a certain portion of the nervous system, the cerebellum, has the power of effecting the co-ordination that is required ; and they also unite in proving— what is often lost sight of— that this co-ordinating faculty is guided by sensations, and can act effl- I Brown-Sgquard, Lectures on the Physi- olo.^y and Pathology of the Central Nervous System, p. li)*. T36 writers' cramp. ciently only when they are normal in kind and intensity. The production of a movement such as writing is therefore a very complicated process, requiring for its efficient performance the integrity of a great number of different parts : viz. , that of the will and its immediate exponent in the cerebral hemispheres ; that of the nerve-fibres between it and the muscles, together with that of the ganglia which exist on certain nerve-trunks ; that of the muscles themselves ; that of the cerebel- lum, as the centre of co-ordination, also that of all the "sensory" nerve-fibres which place it in relation with the organs of special sense and with the muscles themselves ; and, lastly, integrity of the organs of sense, so that they, at the peri- pheral expansion of their special nerves, can. receive impressions in a normal man- ner. It must be remembered, also, that not only the fact but the degree of con- traction is under the control and guidance of the same organs or parts of organs. Failure in any one portion of this appa- ratus interferes with the production of the movement that is required ; and the kind of failure is determined by the locality of the lesion ; or, in other words, by the na- ture of the process or function which is lost or disturbed. If the contraction of a muscle be acutely painful, the man cannot write, the act would be impossible in Home cases of rheumatism ; if the muscle be wasted, it cannot be put into the same amount of contraction as in health ; if the skin have lost its sensitiveness, all fine movements are awkwardly performed, and the finest are rendered impossible ; they may be partially guided by the eye, but the guidance is defective for the most complicated acts ; if the motor nerve be damaged, the muscle is pro tanto palsied ; if the sensory nerves be injured, sensation is defective ; if the sense of muscular con- dition be in abeyance, the power to control either the kind or force of contraction is without its guide : but locally, i. e., so far as that limb is concerned, all other nerve, muscular, and sentient properties may be intact, and yet spasm or paralysis, or both, are present. If the will be deficient, and this from any cause, there is palsy, or irregular movement ; if the flbces coming between it and the nerve-trunks be in- jured, there is paralysis in the ordinary sense of the word ; if the cerebellum be diseased, there is loss of co-ordination, while power and sensation persist ; if the Spinal cord be injured, there may be, in relation to the nature and locality of the injury, almost any one of the conditions that have been enumerated. In true Writers' Cramp, the will, the co-ordinating power in all directions but in one, the motor power, the muscular nutrition and activity, as well as the sen- sorial faculties, are uninjured ; the indi- vidual is, or may be, " well" in all respects but one. A particular kind of movement is interfered with, by the occurrence of irregular and spasmodic, instead of regu- lar and co-ordinated, contractions. It must be carefully remembered that the malady is special; the muscles which can- not be made to write can be controlled so as to fasten the most tiresome buttons, carve the toughest of pheasants, or pull a heavy boat. The pianist cannot play on the pianoforte, but he can write as well as ever; the bricklayer cannot use his trowel, but he can do everything else that he wants to do ; and in order to understand this, we must revert to what is included in education, and what confers the dex- terity which comes of special practice. Many movements are "automatic;" we adopt them without education and with- out effort ; others are the result of labori- ous "practice." It would seem that the body is naturally endowed with certain paths or lines of nerve-action, along which all moves easily. The instinctive move- ments of the child or of the animal are examples of the mode in which, along these lines, impressions from without pass readily, and become converted into motor impulses, which are, in their turn, con- veyed to muscles, which contract, and so perform these instinctive acts. I3ut the process of education, so far as the per- formance of writing, playing, stitching, &c., is concerned, consisted in the fre- quent repetition, by an act of the will, of certain forced and complicated move- ments. The repetition makes them easy, until at length they are executed without effort, and almost unconsciously. It would seem that, by this education, new paths are forced, so that what was once difficult and required attention becomes day by day more easy, and at last "secondarily automatic." It cannot be doubted that some changes take place in the nutrition of the parts through which these lines of nerve-action run; and that their education involves structural alteration in the or- gans. The perfection with which compli- cated movements are performed in the lower animals appears to be associated with great keenness and remarkable de- velopment of the organs of sense ; and in man a similar relation may be observed. No man writes well who has not keen sight and a quick sense of touch ; no man plays well on the violin who has not an acute ear, and a delicate power of feeling in his fingers. In all instances of educated movement some "sense" is needed, and is an important element in the process by which the result is obtained. In the present state of science it is not possible to say, for every act, what part of the nervous system is especially engaged in this educational development ; but it seems probable that the association of CONVULSIONS. 737 movement is eflfected by ganglia which are common to fibres passing through 'dis- tinct but contiguous nerve-trunlss, and that it is owing to some nutrition-change in tliem — the result of persevering and forced effort — that the perfection of \nove- luent is produced ; associations at first caused by the will, are at last produced unconsciously. What happens, then, in such maladies as Writers' Cramp, is a perverted nutrition of these parts ; a worn-out activity, or a degeneration which may arise without over-exertion, and de- stroy all that had been previously achieved.' Neuromata have existed in the arms of some patients. The disease, as it has been shown, passes readily from one side of the body to the other ; and it must be carefully borne in mind that co- ordination of movement is a most complex process, requiring integrity of sensation as well as of motor nerve and of cerebel- lum. The real mischief may be some want of limiting and guiding influence ordinarily coming, through sensation, from external impressions. The spasm which occurs is very like that which !Mr. Lockhart Clarke describes as taking place in the legs of ataxic patients who cannot regulate the /orce of their muscular con- tractions. Treatment. — In an early stage abso- lute rest may do much ; in a later stage it may accomplish something; but I know of nothing else which can be called a therapeutic agent. I have tried every form of general and nervine tonic, of sed- ative, and of local application, but no one of them has been of the least specific value. I have used hypodermic injec- tions of morphia, atropine, and of arse- nic, and have found them incompetent to cure the disease. The hypodermic injec- tion of morphia appears sometimes to re- lieve the spasm for a certain period, and I have seen the writing become steadier within five minutes of the application, and increase in precision for half an hour, but the effect has then, or soon after- wards, passed away, and a frequent repe- tition of the process has been without any permanent result. It has, unfortunately, happened that several patients in whom I have used morphine hypodermically pre- sented an intolerance of that medicine. I have employed galvanism and electricity in all their forms, and have seen no good results. But in many cases perfect rest has removed the symptoms, and it alone seems worthy of being regarded as a means of cure. Mechanical contrivances for holding tlie pen may render occasional writing possi- ble, but they do not affect the disease ; and persistence in their use has been fol- lowed by an extension of the malady to the muscles of the forearm and arm. CO:^YULSTONS. By J. HuGHLiNtis Jackson, M.D., F.R.C.P. It cannot be kept too much in mind that Convulsion is a symptom, not a dis- ease. But it is the most striking member of the series of symptoms in which it oc- curs, and in many cases the only one about which we have definite knowledge. In other words, although we always be- lieve a Convulsion to be symptomatic, we too often know very little of the condition of the system of which it is one of the symptoms ; and this even after post-mor- tem examinations. Let us glance at the circumstances with which Convulsions may occur. Convulsions occur in association with ' Some of these points in the patliolo,o;y of Writers' Cramp have I'een ably treated by Mr. Solly, in the Lectures already referred to in the Lancet of 1865. VOL. I.— 47 organic changes in the nervous system of the most varied kinds ; for instance, with cerebral hemorrhage, and with intracra- nial tumors. They follow injuries to the head, either immediately or remotely : immediately (within a few hours), as when a blow leads to meningeal hemorrhage ; and remotely (after weeks or months), when diseased bone, the consequence of a blow, causes cerebral abscess. They Avill occur in a healthy but parturient woman after sevejie loss of blood. They occur with diseased kidney. They come on as indirect results of syphilis, as in cases of gummatous tumors in the hemisphere. In children they are often associated with rickets. Some beUeve that Convulsions may be the results of disturbances of parts of the body at a distance from the central nervous system, the result of ec- 738 CONVULSIONS. centric irritations, such as the irritation occurring witli dentition, or tlie irritation of worms. Finally, there are a large number of cases of convulsive seizures which (for want even of that approxima- tive knowledge we have of such causes of fits as are mentioned above) we are obliged to speak of as essential, eclamptic, epilep- tic, or epileptiform. AVhen we cousider further that the symptom occurs at all a^es and in many diseases, that there are many varieties in part of the body affected liy .spasm — it is unilateral or general — niany degrees in severity — there may be local spasm without lost of consciousness, or general convulsion with profound coma ■ — and in times of recurrence — there may be one fit a week, or fifty in a day — we are forced to the conclusion that we can only speak of Convulsion as a symptom. The only things we can safely alHrm of the symptom are certain truisms. It is the phenomenon of an occasional discharge of nerve tissue (no doubt of gray matter). It points not to destroying lesions, but to unstable nerve tissue — to "functional'' changes. But the most careful study of the symptom (the paroxysm) tells us nothing of the pathological process by which such changes of instability are brought about ; does not, for instance, enable us to say whether these changes are the result of "irritation," of tumors, of urtemia, or whether they are not mi- nute changes (epileptic) to the pathology of which we have no clue. But clinical study of the circumstances under which the symptom occurs^ tells us very much. Al- though it rarely leads us to a knowledge of the pathological condition of the ner- vous centres, it gives valuable information as to the treatment of the patient, and for the purposes of prognosis. There is a practical convenience in studying this symptom separately. Indeed, we are forced to this narrow study, as it is very often our only "way in" to a case; and its distinct consideration will not be hurt- ful if we use it as a point about which to group not only our positive knowledge for present action, but also, if such a phrase may be permitted, our positive ignorance for future research. I will try to show what meaning we can give to this symptom under various cir- cumstances ; how we should investigate the condition of our patient who presents it, and what we should try to do for him. It maj' be well to say that I have only to consider ei)ilcpsy so far as diag- nosis is concerned. It is justifiable to sacrifice some exactness to convenience by dividing the subject into (1) Convulsions in infants and young children, and (2) Convulsions in persons above seven years of age. Convulsions in Children. Convulsions may occur at any age, and this remark applies not only to general Convulsions but also to most kinds of con- vulsive movements. Still, Convulsion is par excellence the nervous symptom of in- fants and young children.' The tendency to Con^-ulsions gradually decreases with increasing years. The following quotation from West shows this: — " In proportion as the brain increases in size, and its struc- ture acquires perfection, and its higher functions become displayed. Convulsions grow less and less frequent, until, from the tenth to the fifteenth year, they cause less than three percent., and above fifteen less than one per cent, of the deaths from diseases of the nervous system." The first line in the accompanying table (Dr. West adds in a footnote) shows the pro- portion per cent, of deaths from diseases of the nervous system at different ages, to the deaths from all causes at the same ages in the metropolis ; and the second line the proportion borne by deaths from Convulsions, to deaths from diseases of the nervous system in general : — Under 1 year. From 1 to 3 yi'ars. From 3 to 5 years. Total under 5 yours. From .5 to 10 years. From 10 to 15 years. Total atove Ij years. 30-5 73-3 18-5 24-9 17-6 17-8 24-3 54-3 15-1 9-9 10-6 2-4 10-4 ■8 West says: "In a large proportion of cases of Convulsion in the infant. Convul- sions answer to delirium in the adult;" and Trousseau saj's that there are chil- dren who have Convulsions as easily as some have delirium or even dreams. We shall then, as a preliminary, speak briefly of the physiologicnl peculiarities of the child's nervous system. We may affirm of it two things. (1) It is unde- veloped. Besides the obvious fact that the infant has to acquire such movements as those of walking and talking, there is ' Meigs and Pepper write: "During the five years from 1S44 to 1848 inclusive, 1729 children under fifteen years of age died in this city (Philadelphia) of convulsions, whilst, during the same time, 1611 died of infantile cholera, 1060 of marasmus, 1041 of dropsy of the brain, and 772 of pneumonia, showing that eclampsia was the cause of a CONVULSIONS IN CHILiJREN. 739 evidence from the special nervous dis- eases of cliildren, tliat tlie parts of the young nervous system are not knit to- gether as closely as in the adult — incom- plete neurification analogous to incomplete ossification. The child is the subject of certain limited palsies and limited spasms which do not occur in the adult. Indeed, there is a form of talipes varus, Dr. Little tells us, which is always congenital. " In- fantile paralysis" never occurs in adults. After hemiplegia in childhood, a well- known contraction (spastic rigidity) often sets in which does not follow hemiplegia in adults (p. 742). And lastly, coming near to our immediate topic, spasm of the glottis is a convulsion of a certain limited region which is rarely met with after the age of three or four years. Then there are minor symptoms which are almost peculiar to children, e. g. carpo- piBdal contractions. As regards the last two symptoms, there are the significant exceptions that they occur in hysterical women. (2) The nervous system is developing. It is in a state of active change. Its nu- trition will be in considerable excess of its expenditure, whilst in adults the two will be more evenly balanced. For this reason the child's nervous tissue will naturally be more unstable than is that of the adult. It will more easily discharge from a slight cause, or, to use a common expression, it is more excitable. It is believed too that the equihbriumof the child's nervous sys- tem is more often upset by nerve-trans- mitted irritations than that of the adult is. Hence very severe convulsions are ascribed to irritation carried by the fifth nerve from the gums during dentition, or to the irri- tation of worms. The child's nervous system is even believed by some to be naturally so unstable that eccentric irrita- tions so very local as those just mentioned will produce a general convulsion in a healthy child, i. e. will determine a sudden and excessive discharge of nervous tissue which is only physiologically unstable. Others will qualify this opinion by the supposition that the nervous system, or some part of it, is pathologically unstable prior to the action on it of the transmitted irritation. Thus the late Dr. Hillier says (I italicize some words) : " It is very doubtful whether in a healthy child these causes can produce convulsions at all ; in & predisposed subject they no doubt often excite them." larger number of deaths than any other of the diseases just mentioned. It miTst be recollected, however, that a very large num- ber of these cases ought, beyond doubt, to have heeu returned under other titles, as many of them must have been a mere result of organic disease of the cerebro-spinal axis, and of other acute local or general diseases." The above are phj-siolooical differences. Disease finds the child's "nervous system undeveloped, and it finds it developing. But, so to speak, the attacking disease itself has peculiarities, at all events nega- tive peculiarities. A child is much less likely to suffer from gross lesions in the brain, such as hemorrhage, syphiloma, and other new growths ; he is less hkely to suffer from ursemia excepting from acute changes of the kidney, especially of scarlatinal origin ; or, putting it more simply, we usually discover no pathologi- cal changes in the nervous system of a child who has died of Convulsions. Wilks, speaking of diseases of children, says: '' We meet with a large nundjer of cases where the post-mortem appearances are absolutely nothing ; and where, indeed, we could scarcely expect to find it otherwise. We allude especially to cases of Convul- sions in children where no morbid changes are discovered ; and when we consider that a child may have several convulsive attacks and speedily recover, which only a degree more severe shall prove fatal, it is clear that no very great change could occur in an organ which would have per- fectly recovered itself had the fit been only one degree less in severity." Whilst it is true that, as a rule, no pathological changes are discoverable, we must not in- fer that pathological changes do not exist ; the probability is that there are minute changes. Nor must we infer from com- plete recovery from a convulsion, or a series of convulsions, that there are no pathological changes. Adults recover even from hemiplegia, which subsequent post-mortem examination shows to have been due to obvious although very limited destroying lesions — small clots, for in- stance. Therefore recovery from Convul- sions is no certain sign that there was no real impairment of structure. It is a sign only that no wide breaking up of structure has happened. There must certainly be local changes in those cases of Convulsions in which hemiplegia follows, however temporary it may be, since local S3'raptoms of necessity imply local lesions. Still this is only a necessary inference, as we rarely discover any changes even in these cases. Jv^ay, even in those rare cases where -sve find gross disease, a tumor for instance, we do not discover the minute and second- ary changes on which the discharge pro- ducing the Convulsion depends. We must not say that the tumor was the direct " cause" of the Convulsion, but that it led to secondary changes in nervous tissue on which the Convulsion depended, and these secondary changes are inferred, not de- monstrated. It is true that there are found at exami- nations after death from Convulsion abnor- mal quantities of serum and blood in the head, but these differences are quite as T40 CONVULSIONS. likely to be results of the fits as tlieir causes — the results of the sudden interfer- ence with respiration. Eftusion of serum and congestion of the brain have not been shown, either in adults or in children, to have much to do in producing sudden and Severe cerebral s3-mptoms of any kind. Of course those cases in which, possibly from obstruction to the vein of Galen, as by tumors of the vermiform process of the cerebellum, there is immense eifusion into the cerebral ventricles, are not in ques- tion. To resume, we know nothing of the causes of Convulsions in children in the Sense of knowing what the patliological changes are. This is so, however much we may narrow our consideration to groups of cases, either to those which occur singly and at intervals over a period of mouths or years, and which are often called epileptic, or to those in which the fits occur in considerable number for a limited period, and are often called eclamptic. After these general remarks on the symptom Convulsion as it occurs in chil- dren, we have to consider what meaning ^ye can give it in particular cases. Our task is twofold. We have first to note carefullj- the kind of paroxysm. For in- stance, is the Convulsion one-sided ? Is it followed by hemiplegia ? Secondly, to investigate the child's (jcncral hodih/ health. For instance, is he rickety ? Is tliere bronchitis ? Is there irritation from den- tition? Paroxysm. Convulsions occur in all degrees. The Convulsion may be a twitching or clench- ing of the hands only, or an occasional grim smile in sleep, or the spasm may be general and so severe that the child dies of the paroxysm, even of the first. At- tacks of slight occasional spasm, be it of one finger, have the same general signifi- cance as a severe convulsion has. They are both Convulsions, the proof being that, as in adults, we have very often first the local and quasi-trivial spasm, and later, a general convulsion. Each of them is a sign that there is an abnormal discharge of the nervous system or of some part of it. But the effect of the severe and of the slight discharges is different. We have to consider very carefully not only the "cause" of the convulsion, but also what effect single and repeated paroxysms pro- duce on the child. The slight and partial fits do no harm, or little harm, for they do not spread to the respiratory muscles, and thus, as it were, they do not retaliate on the nervous system which "began it" by congestion of the brain, and they are too slight to exhaust the child by abnormal exercise of the nuiscles convulsed. Fur- ther, it is Usually held that fits so sligiit and so partial point to slight and usually to transient causes, and that they often disappear when we obviate some condition of ill-health, such as wrong feeding and diarrhoea, or when we lance gums swollen during the eruption of teeth. But even granting that these sliglit sym])toms sig- nify that the nervous .system is bi t slightly disturbed, or that they usually directly re- sult from some removable condition, and that the seizure does little harm to the patient, they still demand serious con- sideration, for two reasons. In the first place, we think ill of that nervous S3-stem which is upset ever so little by .slight causes, such as over-eating, and we ha^■e anxieties that if the child be afterwards exposed to severer exciting causes, such as fright, exhausting diarrhoea, &c., very severe convulsions may occur. Another reason for careful attention to slight spasms is, that they may not disappear under treatment, or that they disappear for a time only, and that they are often the premonitory symptoms of severer con- vulsions, the paroxysms of which v:ill do much harm to the child by interfering witli respiration and, when frequently re- peated, by exhausting him. Therefore, although in strictness these slight symp- toms are themselves miniature convul- sions, it is convenient to consider them, along with other sj'mptoms, as warnings. But it must be remarked that, like an adult, a child may be suddenly attacked by a severe convulsion in the midst of what seems to be perfect health. He may die in the first fit, or we may see him soon after the seizure playing about as if no- thing unusual had happened. Premoxitoey Symptoms.— It is pro- per to mention, to begin with, that Trous- seau states that there are no premonitory symptoms. "Nothing," he says, "fore- tells the invasion of the attack ; and, for my part, I have never ol strved the pre- monitory signs spoken of by Brachet, and repeated after him by others." Most au- thors, however, admit that there usually are warning symptoms. There are often symptoms before there is any local twitch- ing, such as peevishness, want of sleep, and sleepiness. These symptoms show tliat the child's nervous system is suffer- ing, but they cannot, of course, be taken as evidence that the illness is one in which the symptom Convulsion will be the sole or even the most striking event. In the child, as in the adult, want of sleep is associated with drowsiness. Adult patients will sometimes say what very young patients are not likely to tell us. that they always feel sleepy and never sleep soundly. Children who are about to have Convulsions will sleep with their PEEMOXITORY SYMPTOMS. 741 eyes partly open ; their mouths will twitch; they will start in their sleep, grind their teeth, and may have ni^lit terrors. In the day they are dull, heavy, aud peevish. When any twitching occui-s on one side of the face or in one limb, or in both limbs of (me side, however slight the cause, let us say over-eating, which secras to excite it, we fear the nervous system is seriously implicated, and that severe convulsions are setting in. When the slight symptoms occur during waking, especially if now and then a vacant look points to some loss of consciousness, how- ever transient it may be, we fear severe convulsions are at hand. I may here quote, as a summary of the occasionally insidious march of the symptoms, what Churchill says of fits of dentition: "I have frequently observed a sort of grada- tion from simple irritation and restless- ness to starting, surprise, wildness of look, partial or local convulsive move- ments, and, lastly, general convulsions." Having spoken of partial or slight fits and incidentally of premonitory symp- toms, we now come to consider varieties of severer convulsions. It is not denied that we may have any kind of occasional spasms in children, but we choose three types. It is a very important matter to note the variety of Convulsions, especially for prognosis : 1. Laryngismus Stridulus ; 2. Unilateral Convulsions ; 3. General Convulsions. Laryngismus Stridulus. — A certain kind of Convulsion is called laryngismus stri- dulus because the muscles of the larynx being attacked by spasm, a noise results during inspiration from narrowing of the glottis. It is not a laryngeal disease, al- though one of its names, "false croup," seems to imply that it is. There is no continued fever in laryngismus. It is Convulsion affecting the muscles of res- piration. Dr. Gee, in a most able article, very rich in clinical observations (Con- vulsions in Children, St. Bartholomew's Hospital Reports, vol. ill. ), remarks : "In laryngismus (convulsion interne) we have a disease closely allied to epileptiform convulsion. Out of fifty cases of laryn- gismus of which I have notes, nineteen had had eclamptic fits. " Niemeyer treats of it under the head of iNTervous Diseases of the Larynx (Spasm of the Muscles of the Glottis). The larynx is found to be quite normal post-mortem. The obtru- sive symptom, the crowing noise, is due to spasm of the glottis, but in many^ cases the muscles of the chest and abdomen, as well as those of the larynx, become in- volved. The alliance of the laryngeal spasm — the local convulsion — with general con- vulsion is further shown by the fact that Qot infrequently the child has first laryn- gismus and then general convulsion. Oc- casionally we lind in the intervals of the fits tonic spasm of the hands and feet— carpi )-pcdal contractions. Yet it has certain peculiarities beyond those of limitation of range of the siusm. Age is one of the most important of tlle^o. Dr. West compares attacks of laryngisnm-i to h^-sterical attacks, and remarks that both occur when pnice^ses of development are active. Out of thirty-seven cuhcs of laryngismus, thirty-one, he tells us, oc- curred betwixt tlie ages of six nmuths and two years. Vogel' says, " Tiie age at which the disease occurs, tluctuati s be- tween one-half and three years ; that is to say, it makes its appearance with tne eruption of the first tooth, and disappear, with that of the last." Niemeyer sa;is that spasm of the glottis occurs alm(,>,t exclusively during childhood, and espe- cially in the first year of life. It is mo,-t frequent during the period of the first dentition. He makes a remark which is of considerable interest in connection with the one quoted from West : " Among adults none but hysterical persons sutler from spasm of the glottis, and those only exceptionally." Mackenzie, in his work, " Nervo-muscular Affections of the Larynx," treats of lar3mgismus under the head of Spasm of the Adductors of the Vocal Cords, and says that hysterical cases (in adults) are by no means infre- quent. The observation of these cases is of very great interest, because in the adult the condition of the vocal cords in the attack can be seen, and we may plau- sibly infer that the condition of the glottis is similar in the laryngoscopy of children. Mackenzie writes of adults : "With the laryngoscope the vocal cords can be seen on inspiration to be spasmodically ap- proximated. They may separate widely ; but, instead of remaining apart for a few seconds, they are instantly and spasmodi- cally adducted to the median line, or even beyond it, that is, against one another." Another peculiarity is, that boys are much oftcner the subjects of this disease than girls, "a fact almost all authors admit" tVocel). Of Gee's (op. cit.) forty-eight cases, thirtv-four were males. Mackenzie (op. cit.) says, "Tlie greater liability of the male sex, which occurs in other laryn- geal diseases, holds good here." The most striking feature of the disease is the crowing noise the child makes. This noise often begins insidiously, but there is great difference in this respect. The crowing noise is most frequently ol> served when the child awakes from sleep, and is very often noticed for the first time I A Practical Treatise on Diseases of Chil- dren. By Alfred Vogel, M.D. (Translated by H. Raphael, W.D.) Appleton & Co., New York. 742 CONVULSIONS. in the night. After several attacks of the crowing, whicli is generally at first occa- sional, and produces little inconvenience, very often exciting no alarm in the child's friends, a severe paroxysm may come on. A slight crowing noise may become al- most continuous in the child's ordinary respiratory movements, and a severe at- tack may come on in the midst of this warning. The convulsion may be, it is believed, at first no more than spasm of the laryngeal muscles — a laryngeal con- vulsion ; but in many cases the whole system of respiration is involved in the spasm, and sometimes the limbs — the convulsion becomes general. The severe attack is paroxysmal, and while the pa- roxysm is on, respiration is much impeded — sometimes indeed being quite, for a short time, suspended, as in severe con- vulsion in the adult. At the climax the face is flushed, the eyeballs start, the veins of the neck are distended, and the face wears an aspect of exquisite distress. The sign that this stage of danger is pass- ing is a crowing or whistling noise made by air entering the now only narrowed glottic aperture. As before said, general convulsion may supervene. In the inter- vals, as in the other forms of Convulsion, if the attacks be not frequent, the child may be quite well, or only fatigued and peevish. If they are frequent (and they may occur thirty times a day), the child may be exceedingly exhausted, almost comatose. Occasionally, although this is a rare occurrence, the child may die in an attack, even in the first attack, just as now and then an adult may die in an epi- leptic attack. Nay, according to Nie- meyer, in rare cases spams of the glottis in hysterical adults produces death by suffocation. Without underrating the importance of studying particular convulsive seizures, due to spasm of certain groups of muscles which have especially important duties, we must, as regards treatment, consider the more general question of the state of the child's health or nervous system, which permits occasional spasm of mus- cles anywhere, whether these be of the limbs, of the thorax, or of the larynx. The inference is that the causes which give rise to larj'ngismus are essentially similar to those which give rise to other varieties of Convulsion. (See p. 744.) It is convenient, however, to say a few words here on causation. The general belief is that this form of Convulsion is oftener than other varieties of Convulsion determined by the irritation of dentition, a belief which the facts as to age seem to justify. I say "seem," be- cause the eruptions of the teeth are no doubt to be considered as marks of stages of development of the whole system, just as the occurrence of menstruation is later in life. Further, there is another fact of very great importance never to be lost sight of, viz., that, as Jenner, Elsasser, and Gee have pointed out, children the subjects of laryngismus are usually, almost always, rickety. Forty-eight out of Gee's fifty cases were unquestionably rickety, and in the two exceptional cases there was laryngeal catarrh. We must at least modify the inference as to the influence of dentition, and say that the irritation of dentition produces laryngismus in rickety children. In none of Gee's cases (op. cit.) was there any reason to believe that the teeth bore any part in the causation of the fits. In ac- cordance with these facts and opinions, whilst we must certainly endeavor to re- move every source of eccentric irritation, we must also treat the child for rickets as well. "Laryngismus, when treated as if wholly dependent on the rickets, even if it be not so in fact, ceases to be a serious disease" (Gee). Laryngismus has been attributed to en- largement of the thymus, but this view is not now entertained, one very good rea- son being that post-mortem examinations show that in many instances there is no enlargement of this organ. Moreover, in cases where a large thymus has been found there has been no laryngismus. Unilateral Convulsions and Hemiplegia. — The Convulsions are limited to one side, or they affect one side first and chiefly. In such a fit, if it be severe, the face, arm, and leg of one side are in spasm; the head and both eyes turn to the same side, and next the chest becomes fixed. When se- verer still, the other side of the body be- comes affected in the same way as the first, but to a less extent ; the spasm may return to the side first affected. In this class of fits the spasm may be, for a while, very limited, e. g. a few jerks of the head to one side, or to spasm of one side, or it may be sometimes limited, and may at other times affect the whole of one side, or spread over the whole body. When the spasm is very limited, to the arm for instance, or even, when slight in degree, to one side of the body, there may be no loss of consciousness' The sources of danger to life from the paroxysm in this and in other forms of Convulsion are either that the spasm may fix the respira- tory muscles, or that the'frequency of the attacks may severely exhaust the child. It is important to note this kind of Con- vulsion, because it is the one which is often followed by hemiplegia. We shall therefore anticipate what has to be said of the sequelae of fits so far as this symp- tom is concerned. We should always carefully examine the child's limbs, after as well as during a fit ; and when the fits of this kind are i\-equent, we may find the PREMONITORY SYMPTOMS. 743 arm find leg of one side paralyzed. If, however the child be deeply insensible, we may not be able to determine this, just as we cannot determine the existence of hemiplegia in some cases of cerebral he- morrhage in adults so long as the patient is very deeply comatose. A\'e may first liud out that the patient is paralyzed when he is recovering from the "status epilepticus." I believe hemiplegia is common, but the palsy usually passes oil' quickly. This is precisely what occurs so often in adults. We frequently see uni- lateral convulsions, or more strictly con- vulsions beginning unilaterally, in adults, followed by transient hemiplegia — the epileptic hemiplegia of Dr. Todd. How- ever, the palsy in children sometimes does not pass off ; and if it remains for many days after convulsions have ceased, and if, above all, it remains so long after but one severe convulsion in a child otherwise seemingly healthy, it is very likely to be permanent. The palsy may be only a little weakness, or there may be complete im- mobiUty. In most cases the leg at all events recovers so far that the child can walk. As the cliild grows up, the condi- tion is often a mixture of palsy and spasm. There is either "contracture'' or " spastic rigidity" of the hand and foot— the foot suffering very much less than the arm. More rarely the fixce suf- fers too in the same way. As the cliild grows up the paralyzed parts are smaller than those of the other side, the bones as well as the soft parts ; the scapula is fre- quently strikingly smaller on the para- lyzed side. The condition is not like that of limbs affected by infantile palsy. The muscles respond to the interrupted cur- rent, and when there is much spastic rigidity, the arm, although shorter than the sound limb, may be thicker. Here we may say a few words as to the cause of this symptom. In the first place, unless the child's ner- vous system is altogetli'-r different from that of the adult, the .s3-mptom points to disease of the opposite side of the brain. (Vide infra on Convulsions in Adults.) But such a symptom does not of course point to any particular pathological change. ' It is rare to find atrophy of the optic nerves in hemiplegic children, and ' I have made an autopsy on the body of a young woman, twenty-two years of age, who had been hemiplegic in tlie left side, after one series of fits, since the age of about three years, and subject to frequent convulsions from the age of five or six. The right cere- bral hemisphere was much smaller than the left, and the left arm and leg were smaller than the right arm and leg. I found, how- ever, no disease beyond what the unilateral atrophy implies. I have to thank my friend Mr. Norton for permission to see this patient. this IS some evidence that there is no gross lesKiu, sucli as tumor, tubercle, &c. Ihc changes are probably minute. The causation of the symiitom cannot be clearly discussed. But this issue may be raised : Is it the result of the very same changes which caused the Convulsion, or is it the result of damage to the brain in the parox- ysm, e. ;/. to excessive congi'slion, or even rupture of vessels from sudden stoppage of respiration? I have uo doubt it is owing to the first cause. 1. Because the i rule is that tlie spasm has been on the side afterwards paralyzed, or has begun on that side and affected it chietlv. -2. Because in the epileptic hemiplegia of I adults, in whom we do sometimts find gross clianges, syphiloma for instance, we find the disease in the cerebral hemisphere opposite the side of the body, first con- vulsed and afterwards paralyzed. To this may be added the argument that general congestion of the brain is not likely to lead to so local a s^-mptom—to paralysis of one side of the b(jdy. Tiie fact that the hemiplegia is often transient does not show tliat there have been no local changes, because in adults, hemiple- gia, after a convulsion, is often transient, I even wlien there is organic disease of the brain, — syphiloma for instance. The Conmdsions are general. — It is not meant that the Convulsion affects both sides together, nor both sides quite equal- ly, but that both sides are nearly equally affected, and nearly at the same time. The chief point here is to consider the condition of the thorax in the parox3'sm. A long stoppage of respiration is the worst symptom w€ can witness, and when a child dies in a fit he is no doubt killed by the prolonged fixation of liis thorax. In some of these cases the limbs seem to be comparatively little aftected, although all four are somewhat affected. The older the child, the more the limbs and the less the chest suffer. These fits vary much in degree of severity. If slight, the child may, as in other varieties of Convul- sions, seem quite well shortly after. If severe he may remain exhausted and ap- pear dull only ; if very severe, he lies in deep coma. The frequency of the fits modifies his condition. He may have a second fit before he has recovered from the effects of the first, or as the nurse will sav, "in and out of fits all day long." The child may have an attack and never suffer again. He may die in his first fit. It is not very uncommon for a fit to occur in a child who is seemingly quite well. He is suddenly convulsed, and may as soon as the fit is over go to play again as if nothing unusual had happened. It is to be insisted on that, however well a child may seem before and after a convul- sion, we 'cannot be sure that he will not iU CONVULSTOXS. have more. lie probably will. Xext day or next week ho lias another, and then perhaps thirty in the day. From a rapid succession he surtl-rs iu two ways : 1. The respiratory function is much in- terfered with, and it is suddenly interfered with. 2. There is very great exhaustion from the severe muscular "exercise," and want of sleep. These things will be par- ticularly referred to under "Treatment." SEQUELiE. — The chief sequelas may with great looseness be arranged as, (1) Paralysis; (-J) Amaurosis; (3) Defects of iSpcech and Disorders of Mind; (4) Squint- ing; (5) Paralysis of cranial nerves. Tiiere are of course other defects after Con- vulsion : loss of smell, loss of hearing, and unsteadiness of gait. These, however, are less common ; they have different sig- niticance, being more accidental than the other delects 1 have named, and often de- pend on organic disease. (1) Now children are subject to two kinds of paralysis, one of which almost deserves the name of essential, and is well enough recognized when called In- fantile Palsy. The other, which will oc- cur at any age, namely hemiplegia, is the form of paralysis which most frequently follows Convulsion, and has been already considered. (2) Amaurosis will be con- sidered elsewhere : it is a rare sequel of Convulsion in children. If we find double optic neuritis, or double optic atrophy, we fear there is a gross intracranial lesion, such as tumor, a lump of tubercle, &c. Kecovery from a condition very like that occurring from meningitis does not con- tra-indicate the existence of gross organic disease, if there has been double optic neuritis. Atrophy of the optic nerves occurs with fits owing to chronic hydro- cephalus. Under any circumstances we can do nothing for Amaurosis from atro- phy of the optic nerves. (3) With loss of speech we maj^ take in mental defects, because in children the two things often go together. (Deaf-mutism is not consid- ered here. If deafness occurs from any cause before speech has been acquired, mutism is the result.) After attacks of Convulsion, children are liable to lose their speech, and this loss occurs without any notable lack of power in the articu- latory muscles. The proof of this is that the child eats and swallows well, ar excellence, cases of essential Convulsions (eclampsy). •'Now, of sixty-one eclamptic children, fifty-six were rickety. Saying this I fear that I shall incur the charge of exaggera- tion. It is necessary to explain that my experience is wholly derived from the children of the poor." He tries to show, and I think he shows conclusively, " that the existence of a constitution leading to rickets is the most important fact in the kind of Convulsion [that depending on the general condition of the child] in ques- tion." And even when no other causes are obvious, we must not infer that the relation between teething and Convul- sions is one solely of irritation transmitted from the gum to some part of the child's nervous system. The coming through of a tooth must be thought of as an outward mark of a certain constitutional progress In development, as the occurrence of men- struation is later in life. It is far better to acknowledge that very often we cannot find out what causes a tit than to put it down to an orthodox cause for the want of a more real one.' When diarrhoea is severe the child is often emaciated, and the fit is more likely to be due to exhaustion than to eccentric irritation starting from the intestinal amal. We should not adopt routine efforts at clearing out the bowels to get rid of " undigested irritating" matters. In most of these cases the child has been improperly fed, and careful dieting is of very much more moment than immediate treatment of the diarrhoea by drugs. A ' "Much eclat has lately been made in Eng- land and France with the scarification of the gums. Some recommend a crucial incision ; others, the removal of the whole cap which covers the head of the tooth. But, as an ad- monition, it is premised in all the reports and laudation, that the tooth has to be very near eruption, otherwise the scarification will be of no benefit. I have frequently performed this operation, but have always found that the lancinated wounds of an inflamed mucous membrane heal very badly, and ulcerate for along time; that the nervous symptoms con- tinue notwithstanding, till ultimately artifi- cial or spontaneous diarrhoea supervenes. Indeed, if we have to wait until the tooth is 'very near' breaking through, then the pro- cess is in fact near its end, and any other simple remedy is as efficacious as this, which is attended by a considerable amount of pain." (Vogel, Raphael's Trans, p. 107.) child is at once overworked and underfed when it has to take into its stomach large niasses of food which it cannot proporiy digest. We must certainly not consider the most violent convulsion in a child who is thin or who has exhausting diarrhoea as a result of " congested brain." There may be stagnation of blood in the head, the result of the paroxysm, but not any "active" process requiring antiphlogistic treatment. We do not know what the intracranial changes are which cause fits, and we have no" evidence that cerebral congestion occurs before the attacks. We have plenty of proof, from disease and from experiments on animals, that Con- vulsions will follow antemia ; but as in these instances the anaiuiia is sudden, per- haps the facts are not quite to the point. We have, however, chnical evidence that they occur in feeble children and in the course of exhausting diseases. 8ince the days when antiphlogistic measures were so freely resorted to in children's dis- orders, "we have learned," Vogel says (op. cit. p. 385), "that pale anamic chil- dren are as liable to be attacked by Con- vulsions as robust and plethoric ones." Beyond question the violence of fits and their /regweiit repetition are not the clinical signs of active changes in the head. Heat of skin and vomiting, headache, and irre- gular pulse are the real signs of acute changes in the head — encephalitis and meningitis. But since the brain may be- come much congested as a consequence of the fits when they are severe and fre- quently repeated, it is intelligible that some advantage may follow the applica- tion of leeches by a reduction of the con- gestion, although there is no inflammatory process to relieve. I say again that severe and repeated Convulsions are not the signs which should make us deplete gene- rally, apply blisters, or give purgatives largely. Treatment of this sort is admit- tedly a most fatal mistake in those cases where the fit is but one sign of starvation, as it undoubtedly is in many cases of diar- rhcea, and in cases of wrong feeding. (4.) It does occasionally happen that a child is attacked by Convulsions when in apparently good health. But before con- cluding tliat a child is in good health we must, I repeat, consider very carefully whether or not there are signs of rickets, and we "must bear in mind that active rickets and the preservation of a large amount of fat are by no means incompat- ible." (Gee, op. cit.) These are the cases in which it is plaus- ible that the convulsion is the result of some temporary cause, such as over-eat- ing ; of some removable cause, such as the irritation of teeth during dentition ; or of some sudden excessive mental disturbance, such as fright. I consider it very doulrtful whether any of these so-called "causes" 748 CONVULSIONS. induce fits in children whose nervous sys- tems are healthy beforehand. But it is very likely that tliey are exciting causes when it is not healthy. I have twice made autopsies on children who have died in fits after a meal, and in each case the stomach was full of food. In one case the ciiild had had lits before, but none for three months before the fatal seizure ; in the other the fit which the child died in was the first. If then we find that a child has had a fit soon after a meal which we have good reason to believe was large — say a basinful of soup — we should give an emetic. If we find that a tooth is coming through, we may justifiably lance the gum. But when we have done this we must bear in mind that a nervous system which has given way from such temporary and comparativelj' slight exciting causes, will be very likely to fail again when again tried by indiscretion in feeding or by eruption of teeth later in the dentition period. Indeed, we must, I think, con- clude that the nervous system of a child cannot be healthy if a slight and tempo- rary cause produces a convulsion, however healthy the child may look. AVe often find that the fits recur when we have done all we can to remove supposed sources of irritation. There are great differences of opinion with regard to the influence of den- tal irritation. Vogel says (op. cit. p. 387): "Eclampsia, originating from dental irri- tation, belongs to the serious forms, and often leaves behind it partial paralysis and imbecility." Meigs and Pepper, in their most valuable work on Diseases of Children, say: "As a general rule, the convulsions which depend solely on the process of dentition are slight, and last but a short time. In all the instances that we have seen in which this was the only cause to be detected, the attack was of this nature." (5.) "We will now consider cases in which Convulsion attacks healthy children without obvious cause of any kind, and cases in which they continue when we have removed all temporary sources of irritation. Once more having regard to the important researches of Elsasser, Jen- ner, and Gee, I would urge the considera- tion whether in these cases the "healthy" child is not rickety, although often slightly so. It is to be remarked that a child may suffer fits from blows on the head, and occasionally we see patients who have Convulsions after severe blows, followed by indentation of the skull. These cases it is not my task to consider. We are sometimes told by the friends of our httle patients that palsy or convulsion followed an injury, but on inquiry we find there is not a shadow of evidence of a blow or a fall having occurred. The friends suppose very naturally that a fit must have a cause, and if their child has a convulsion in the midst of seeming good health, they infer that the child has had a fall. When we find a child the subject of Convulsions for which we discover no cause, or infer none from the condition of the teeth, bowels, and general health, we think of the terms eclampsia and essential. I do not, however, use these terms, for I know no means of distinguishing betwixt an epileptic fit in a child and an eclamptic fit. The practical point is this, and it is occa- sionally put to us by the child's friends : Is it epilepsy ? I take this to mean : Is the illness one which will quickly, in days or weeks, run a course to death or to per- manent recovery, or will the child recover from the fit or series of fits, but be hable to occasional attacks of convulsions for j'ears or for life ? Tliis seems to me to be the practical question. Now, when we see a child in his first fit, we certainly can- not tell, whatever the age may be. The paroxysm is the same in all cases of gen- eral Convulsion. There seems to be great unanimity among authors that the eclamp- tic fit is quite like that of epilepsy. Nie- meyer speaks of eclampsia as acute epi- lepsy. Vogel says it is impossible to distinguish the paroxysm of eclampsia from that of epilepsy. Then epilepsy will occur at any age. Vogel (op. cit. p. 411) states that Beau found, out of two hundred and eleven epileptics, that the disease was congenital in seventeen cases, and that it occurred from birth to the age of six vears in twenty-two cases. Nevertheless, "^ogel saj'S, "Young children in general rarely suffer from true epilepsy, as we might ex- pect, if the more frequent eclampsia be regarded as a distinct disease." And he adds : " Eclampsia is easily distinguished from the disease under consideration (epi- lepsy), by the fact that it almost always occurs at the breaking out of an acute affection only ; that the general condition of the patient, after the termination of the Convulsions is not restoi-ed : and that it is often fatal, while epileptic attacks are almost always devoid of danger." I sub- mit that at the best we can only deal in probabilities. The older the child the more seemingly causeless the fits, the slower the succession — say a fit every other day, or fits scattered at irregular intervals of days or weeks — and perhaps we may say the less rickety the child the more likely are the fits to be epileptic, i. e. the more likely is the child to continue for years or for life subject to fits. But I am convinced that we can give a prognosis in no case with anything like certainty. I do not exempt cases where a child has had one fit during the eruption of a tooth or during an exanthem. We can only say, even in these cases, that the child is very unlikely to suffer again. If the child be PROGNOSIS — TREATMENT. 749 partially hemiplegic after a seizure, he is very likely to sutler from Couvulsions later in life. Epileptic fits in adults not rarely date from Convulsions in infancy. The con- nection is shown ni>w and then by strag- gling fits at intervals of months or years, or by uninterrupted continuity of attacks at fairly regular periods. I have no facts, and I knovf of none on record, to show how many children keep well after get- ting through an illness with severe Con- vufsions, but I am certain that attacks in infancy — from one which attracted little attention, " we thought, ' ' says the mother, "it was only the teeth," to a whole batch —are occasionally followed by epileptic fits near the age of seven, fourteen, or twenty. In reference to this question, it is im- portant to ask if the child's near relatives have had nervous symptoms. Every med- ical man can relate instances of fits, or of other symptoms of cerebral disease in dif- ferent members of one family. I ~have had under my care a girl of eleven years of age, who has had fits from the age of six months. Her sister, three years of age, had had them from the age of one week : another sister, aged ten, from the age of four years ; and a fourth, also a girl aged eight, from six years. Instances sn strildng are rare. The fact that seve- ral of the child's relatives have had hemi- plegia or Convulsions from emboUsm, clot, syphilis, &c., has no bearing whatever on tii3 question. If the child's brother, or si4er, or mother had Convulsions in childhood, the evidence is perhaps stronger ; but I confess that I have very little faith in the hereditariness of such siimptoms as epilepsy or Convulsions. Tue occurrence of Convulsions in several of one family may be because they all suffer from rickets. We may believe that a " nervous temperament" is transmitted, but if so, there will be a predispositi')n to many nervous affections, and not to one symptom only. At the best it is very difficult to obtain certainty as to heredi- tariness, as Convulsi(ras arc so very com- mon in children, and occur, it is presum- a jle, from numerous pathological pro- cesses. Peogkosis. The prognosis of a symptom with so uncertain a meaning must, of course, be very uncertain, and much has been inci- dentally said on prognosis. Here may be excluded from consideration the attacks which precede or occur in the course of acute disease. The writers of other arti- cles will speak of seizures so occurring. Wlien a child has had a fit, and appears td be in good health again, the question as to the cause of the fits, with a view to forecast the cliild's future, becomes again urgent. If there is clear evidence of some source of irritation, and we have got rid of it, we may hope the child will keep well ; but I have already spoken of the uncertainty of our hopes in this respect. By far the most important question in prognosis is whether or not the child is likely to get through an attack or a series of attacks of acute Couvulsions with life. In the first place, a single attack may be fatal, but this is a rare event. AViiks re- lates two striking instances of rapid death with Convulsions. One was a small, deh- cate child, six weeks old, who was seized suddenly with diarrhcea and Convulsions, and died in a few hours. The other pa- tient was a child four years old, strong and healthy, who died soon after being brought to the hospital. In neither case was anything wrong found with the brain; but in the child four years old the stomach was distended with food. I have men- tioned two cases of a like kind. Such cases, however, are rare. The consider- ation of less acute seizures is more im- portant. We have no generalizations, and can only deal in generalities. The younger the child, the more likely is the result to be fatal. The more frequent or \'iolent the seizures, the more profound the coma ; and the worse the state of health in which the fits began, the more likely is the child to succumb. To con- sider the manner in which fits are likely to bring about death, is the important matter.'' This will be considered with the treatment, to which I now come. Treatment. It would not be correct, as I have re- marked, to speak of any purely rational treatment of a single symptom, as it means things very dift(2rent. Our treat- ment is nearly altogether empirical. And, of course, we" exclude entirely from pres- ent consideration cases in which Convul- sion occurs in such diseases as scarlet fever, menindtis, &c. Even an empirical treatment of 'Convulsion would not be jus- tifiable in these instances. Our thoughts or treatment go hand-in-hand with our investiarations into the cause. Principles of treatment apjjly to Convulsions of all degrees, from rolling of the eyes to com- plete seizures. If we find the child in a fit, we can do little durins the paroxysm. "We should see that every part of its dress is loosened, that it has a plentiful supply of pure air, and we should direct that it be laid down and kept quiet. Vogel says that by sprinkling the face and exposed chest with cold water, we may suecoed in in- ducing deep spasmodic inspiration, by 750 CONVULSIONS. which the danger of suffocation at least is lessened. Then as to general treatment, in the intervals of the paroxysms. I begin with what may be called attention to imme- diate circumstances. We undress the child, and it is possible we may find that a pin or a needle is sticking in some part of the body, even in the child's head, penetrating the brain. A needle has been found in the liver of a child who died of Convulsion (see Trousseau's Clin- ical Medicine, vol. i. p. 343, Bazire's translation). Trousseau believes that blisters and mustard plasters are often the causes of fatal Convulsions. If we find that the fit came on after eating, we should give an emetic of ipe- cacuanha. If a gum be swollen and tense, we may properly use the lancet. We should inquire after the state of the child's bowels ; if they are constipated, we should give a purgative. But none of these things must be done as matter of routine. The presence of diarrhoea, es- pecially, with tenesmus and expulsion of little but mucus, may show that there is irritating matter in the intestinal canal, and it is then proper to give a dose of cas- tor oil. This must be, however, only to make a starting-point for careful dieting. The presence of abdominal pain and con- stipation in robust children may lead to the suspicion of retained feces. Diar- rhcea, which is — paradoxical as it may seem at first glance — sometimes a sign of constipation, would not prevent the mod- erate administration of purgatives or enemata. Por a child at the breast, an enema of an ounce of warm water or of thin gruel may be administered ; at one year, two ounces. Very likely the diar- rhcea is due to wrong feeding, and to diet the child would then be the most impor- tant thing to attend to. When the mo- tions are very frequent, and if the child be thin and weak, we may try to check the diarrhoea by astringents, if proper dieting does not arrest it. Warm baths are frequently used, and, when there is no great heat of skin, and no thoracic complication, the child may be put in a bath at the temperature of about 96° Fahr. for from five to ten min- utes. Under any circumstances the feet and legs may be immersed in warm water. Then mustard plasters — a mixture of mustard and flour — may be applied to the calves of the legs for five, ten, or fifteen minutes. When we have done all that immediate investigation prompts ; when we have attended to the bowels, lanced the gums, ordered proper food, the Convulsions may persist, and may even increase in num- ber and in severity. We are thus urged to do something more. There is in attacks of Convulsion a ten- dency to (1) death by exhaustion, from the frequency of the fits and want of sleep ; (2) death from asphyxia, from sud- den and prolonged fixing of the chest walls, and from slow congestion of the lungs. The latter is often rather a way of dying than a cause of death. Adults die from convulsive seizures in each of these two days. 1. If the child were much exhausted by frequent fits, or if he were weak to begin with ; if he were thin, if he had long had diarrlioea, we should look most carefully to his support : we should prescribe beef- tea or juice of meat in abundance. Is or should we hesitate to give stimulants. The circumstances that would guide me most on tills point would be the great fre- quency of other abnormal muscular ac- tions. The main object in treatment of disor- dered function of the brain in general, e. g. sleeplessness, delirium, and frequent, slight Convulsions, is to produce sleep, and to accomplish this we should give nu- triment Mberally ; and if this fails, stimu- lants freely. I have already spoken of the importance of recognizing that violent or frequent Convulsions do not depend on inflammatory changes. If the beef-tea or juice of meat were vomited, I should give "milk with a little ice, and inject the tea and the juice. Affusion with cold water has been ad- vised, but this I should not adopt unless the child was robust. Of course I speak of cases in which there is no general fever, and no sign of inflammation of the membranes. A thin, delicate child I should keep warm. Vogel, however, says that affusions of the head with cold water, performed every hour or two, are useful against all Convulsions in children (op. ci"t. p. 107). Then as to drugs. Antispasmodics have been given, but I think the best an- tispasmodics are nutrients and stinmlants when these can be taken and digested. It is of course comparatively easy to get drugs into the stomach, but they may be vomited. It may then be desirable to give an enema of asafcetida, e. g. 20 to 30 minims of the tincture in an ounce of warm milk. In all cases — Convulsions in exanthematic and other acute diseases excepted— I should give bromide of po- tassium in large doses, by enemata, if necessary, if the fits were frequent, or if they continued several days. A mixture containing hyoscyamus, two or three drops for the age of six weeks, may be given with peppermint water. The great point, however, is, I repeat, to get the child to sleep, and to do this it is_, I think, justifi- able, simple nutrients failing, to give stim- ulants freely. I should, however, be most wishful to give as much nutriment and as little stimulant as possible. Nor, of TREATMENT. 751 course, should I give M'ine because a child had a fit, but only when the child was feeble to begin with, or was exhausted by the frequency of the attack, wearied too from imperfect sleep, and perhaps starv- ing because the friends had not given enough nutriment before we were called. I should not give stimulants if the ther- mometer showed a great increase of tem- perature. Supposing nutrients and stim- ulants and the drugs mentioned were taken and retained, and failed to stop the Convulsions and to procure sleep, I should then venture to give narcotics. In no case should I prescribe narcotics except when I had ascertained that the child had previously taken nutrients and stimulants, or unless the child was fairly vigorous to start with. In m case, at any age, would I give opiates, when there was great ex- citement without vigoi". It is as hurtful to give opium at this extreme, as in the condition of brain which occurs with gen- eral febrile states, and which condition is supposed to be due to congestion. Nor wo aid I give the narcotic more than once in twelve hours, and then I should give a decided dose. e. g. a quarter of a grain of Dover's powder under the age of three mouths ; half a grain to a year, and a grain to a year and a half. Chloroform has been used by Sir Jamss Simpson, and, when the above ascending series of reme- dies—nutrients, stimulants, bromide of potassium, and opiates — have failed, this may be tried. Dr. West says : " In cases where depletion is inadmissible, where the Convulsions are not obviously due to or- ganic disease of the brain, while they are both severe in their character and are re- turning with frequency, the inhalation of chloroform sometimes altogeth'T arrests them." It is also, he sa3's, of service in Convulsions of a more chronic kind. He tells us, however, that its effects are eva- nescent ; he adds, that he has never seen mischief from its use. " It requires the constant presence in the house of some one competent to administer it. " [It is a matter of universal testimony that ether is safer for inhalation than chloroform. Ether has been largely employed in Ame- rica in the treatment of Convulsions. The remarks just made concerning the admin- istration of chloroform apply equally well to it.-H.] 2. Now I come to speak of the cases where the severity of the individual fits threatens death by asphyxia, or when from the breathing we fear the blood is largely delayed in the lungs. When Con- vulsions occur in robust children, bleed- ing is sometimes advised for them. It is i a remedy which has been urged by many writers, but does not seem to me — I speak very respectfully — to be likely to be of use ; but I have never tried it in any form, either by leeches or otherwise. For I have no faith whatever that Convulsions depend on any increase of nutritive changes that we can arrest by taking blood. There is in children's Con\'ul- sions no certain evidence as to the patho- logical condition of nervous organs. It is. however, often evident enough in robust adults, as when epileptiform seiz- ures follow on blows, and on tearing up of tlie brain by mechanical injury, or the irritation of tumor, that bleeding could do no good— no good by acting on the cere- bral circulation. "But it \TOuld, I think, be good practice to relieve the venous sys- tem when, after repeated fits, the circula- tion is becoming embarrassed by great congestion of the'lungs. Death seems, in these cases, to result from pulmonary con- gestion. Indeed, I think we neglect to bleed as often as we ought to do, on the principle Markham has laid down. I should be entirely guided by evidence from the color of the Ups and the state of respiration, and not by the heat of skin or by shivering. However, difficulty of the respiration so great as these signs imply would mark the advance of a fatal issue, and our treatment could only, I fear, be expected to delay it : when I did deplete, it would be by leeches only. I have just spoken on the supposition that the fits are frequent and are running a rapid course, and are tending towards death by exhaustion or by asphyxia ; but if the fits come on at intervals, as once every day, or once a week, and if from in- ability to discover what they really did mean, i. e. if unassociated with debility, irritation of teeth, &c., we were obliged to class them as epileptic or essential, I should adopt the same treatment as for epilepsy in the adult, supposing of course all general indications fulfilled. I should give bromide of potassium, a quarter of a grain under six weeks, half a grain under three months, a grain above, and a grain additional for every year. Indeed, the bromide is a most useful drug in chronic convulsions from any cause, and in most cases — excepting temporary and acute states like uraemia — I should prescribe it when other remedies failed, whatever was the state of the child. Since, however, there is manifestly an association of Con- vulsions with rickets in very many cases, it is well to treat the child for this condi- tion in all chronic cases. I shall therefore conclude what I have to say on the treat- ment of Convulsions by the following quo- tation from a paper on rickets, by Gee (St. Bartholomew's Hospital Reports, vol. iv. p. 79) :_" Trecctnient. This must be radi- cal. And in cod-liver oil we possess a pharmaceutical agent worthy of a place beside iron, Peruvian bark, and mercury. We ought to lose no time over the symp- toms of rickets ; slight catarrh, diarrhoea, paleness, a tendency to fits, these will all 752 CONVULSIONS. disappear under cod-liver oil. Give ex- pectorants, purgatives, styptics, and the rickets will increase under our eyes ; nay, occasionally it will even develop de novo while a child is being treated for coughs, deranged bowels, and other apparently simple disorders." Convulsions in Adults. It is a matter of exceeding great diffi- culty to write on the su*bject of Convulsion in the adult. We may arrange Convul- sions as they are local or general, as they are acute or chronic, as they depend on acute states, such as uraemia, on organic disease, such as tumor, or on changes which we infer to be functional. I shall follow the course adopted in treating of Convulsions in Children. I shall speak first of the varieties of the paroxysm, and then of the causes of the seizures. There are no doubt innumerable varie- ties of paroxysm, but for clinical purposes we may arrange most of them in one of two classes. Class I. The Convulsion begins uni- laterally, and begins deliberately. In this kind of seizures consciousness is not al- ways lost, and when it is, it is lost after the spasm has begun. Class II. The fit begins either without any warning or by a very vague one, such as a strange feeling in the head (" giddi- ness," "swimming," &c.), or by a sensa- tion at or near to the epigastrium which is variously called "sinking," "faint- ness, " "sickness," "fear," and some- times by children "stomach-ache." In these cases the spasm is more contempo- raneous, i. c, it affects the two sides of the body more nearly at the same time, and it affect -i them more equally. In this class of cases loss of consciousness is the first symptom, ■which occurs very quickly after the first warning. It is not pretended that there is an absolute distinction, for in the first class the spasm, in severe cases, spreads all over the body. In the second class it is not usually, probably never is, strictly equal on the two sides. Nor is it strictly contemporaneous; one side almost always, if not always, suffers not only viore but sooner than tlie other. Moreover we often do not witness the fit, and we may be un- able to learn how it began and how it affected the patient. Fits of the first class are almost always chronic. Those of the second also are mostly chronic (epi- leptic), but frequently acute ; they may be symptoms of urcemia, cerebral hemor- rhage, &c. In handling the subject clini- cally we must arbitrarily put in the second class cases in which we can only learn that the patient has had a severe convul- sion. In strictness, Class II. is merely a grouping of cases which agree in that Convulsion is the most prominent symp- tom. AVe must make a provisional ar- rangement for clinical purposes, and the above distinction is at least convenient in practice. The paroxj'^sms of the first class only need be described at length. These fits are far simpler than those of the second class. The patient can tell us more about them ; we can, when present at a fit, ob- tain a clearer idea of what takes place, because the progress of the Convulsion is more deliberate than that of the second class. It is for this reason that I speak at most length on the "causes" of Con- vulsion, after describing the peculiarities of the paroxysm and its sequelse in this class. Class I. The Convulsion begins Unilaterally. Onset. — The patient or his friends tell us that he is subject to fits beginning by "working" in the hand, or in the face, or in the leg ; sometimes there is a local sen- sation, often named an aura, before there is visible movement. The rule is, that in these cases the spasm starts in the very same place in each seizure. For instance, one patient's fits will always begin in his right index finger, another patient's always in his right great toe. The excep- tions occur chiefly in cases of syphilitic disease of the brain. Taking a large num- ber of cases, there is an order of frequency of onset to be stated. The spasm begins most frequently in the hand (usually in the index finger and the thumb), less often in the side of the lace and tongue, and rarel}' in the foot. Burige (Fits partial or general). — In the severest fit the spasm first spreads over the side it begins in, then extends to the trunk, and then to the face, arm, and leq of the other side. It is important to ob- serve that the spasm may stop at any stage. There are all degrees, from a slight twitching of one finger to general and severe convulsion. In other words, these fits may be partial or general. More- over, the same patient may on one occa- sion have a fit limited to the hand or arm, during which he is quite conscious, and on another occasion the spasm may spread all over his body ; he will then become insensible and may bite his tongue. The importance of studying the partial fits is that sometimes they occur for months before a severe fit. A few minutes' steady cramp — not " live blood," tremor, fidgets, or irregular jerks of a choreal kind — on one side of the face, in one hand, or in one foot, demand almost as serious consideration in prognosis as a severe fit does ; for a patient who has such CONVULSIONS IN ADULTS. 753 local spasm will probably suffer from severe convulsions. Ligature. — These are the cases of " epi- lepsy" in which the fit may often be stopped by tying something round the limb above the part in which the spasm begins (or in which some abnormal sensa- tion (aura) appears), by unclenching the closing hand, or by briskly rubbing it. As Brown-Sequard has insisted, such pro- cedures are as successful in cases of or- ganic disease of the brain, syphiloma for instance, as in cases where there is no evidence of such kind of disease. The patient or his friends may often arrest the progress of fits of this kind. We hoar patients remark to this effect, " If I can get the hand open, I have no fit." I am convinced from what I have seen in Brown-Sequard's practice that a garter of blister above the part in which the fit begins will keep off fits of this kind. Dr. Buzzard has recently written an import- ant paper on this method of treatment in the ■' Practitioner" for October, 1868. In a few, but in very few cases, there is his- tory of injury to the part in which the spasm begins. Duration nf the Attacks. — The duration of the attack varies much. It may last even ten minutes, but in such cases the spasm is long in spreading to the muscles of the thorax. Consciousness. — These are the cases of Convulsion in which there is often no loss of consciousness whatever. The patient does not lose his consciousness when the fit is partial ; the whole of one side may be involved in spasm without any insensi- bility, but the rule is that consciousness is lost at an earlier stage. For instance, when the fit begins in the hand, con- sciousness i'S usually lost when the spasm has largely involved the face, and when the head begins to turn. When it starts from the foot, consciousness is usually lost when the spasm or abnormal sensation reaches the body. There are in these seizures all- degrees of impairment of con- sciousness, if such a plirase be permis- sible. The patient may assert that in some of his attacks he is conscious, but may qualify his statement by adding that he does not know people about him or where he is ; at another time he may be profoundly comatose. Affections of Speech (Epileptic Aphasia).^ —In certain of these seizures the patient loses his speech without losing his con- sciousness. This is not to be confounded withpetii mal. It most often occurs when ' "There is a peculiar class of cases of epileptic hemiplegia, in which the exciting cause of the epileptic fit at the same time damages or greatly injures voluntary power and speech." (Todd, "Nervous Diseases," lect. XT.) VOL. L— 48 the fit begins on the right side of the /ace and tongue. Occasionally there is only disorder of speech. Temporary loss or defect of speech is often observed even in cases where the spasm is limited to the right cheek and tongue. The patient may consult us because he occasionally sud- denly loses his speech for a few minutes ; for instance, he goes to a shop, and on trying to give an order finds that he can- not talk, or he talks so badly that he is supposed to be drunk. We mostly hear that there is local spasm of the right cheek at the same time. (We rarely get any facts about writing in this condition ;. this part of the subject is too complex for consideration here.) It is hard to de- scribe the defect of speech which some- times follows these seizures. The defect is not, I think, quite like the defects of speech which are the result of small de- stroying lesions such as small clots, lim- ited softening from embolism, &c. There is very much hesitation ; the patient slurs his words and mumbles. I use the word defect, because there is never, so far as I have observed, permanent loss of speech (complete inability to utter words) after a convulsion beginning by deliberate spasm in the face or hand. If an adult does not talk at all for several days after a "fit," especially if he expresses himself quite well in writing, we should suspect malin- gering. If there be loss of voice with or without loss of speech after a "fit," pre- tence or hysteria is almost certain. Epileptic Hemiplegia. — These are the cases of Convulsion in which there is so often hemiplegia — epileptic hemiplegia of Dr. Todd. Sometimes hemiplegia follows such seizures, and sometimes it does not. The presumption is that when the spasm is very severe — severe in degree that is, not necessarily, although usually exten- sive in range also — there is palsy. Thus much, however, is certain, that a patient who has fits of this kind (at all events when the spasm begins in the hand) can never be considered safe from hemiplegia. In very many cases the palsy is trifling, such a " numbness," for instance, as pre- vents the patient picking up a pin, although he may strike the table pretty strongly ; occasionally there is perfect' paralysis. The palsy always affects the side m which the fit begins ; and when there is complete hemiplegia, the hemi- plegia is quite like that produced bv plug- ging of the middle cerebral artery. '^Vhen, however, the spasm is limited in range, the consequent palsy is limited in range. If the arm only be affected by severe spasm, the arm only is palsied when the ' I use the words "perfect" and "imper- fect" to express degrees of loss of power, and the words "complete" and "incomplete" to express differences in range of the paralysis. 754 CONVULSIONS. fit is over ; if the leg only, the patient drags it, but uses his arm well. Thus it happens that we may have complete palsy of the arm following a convulsion in which there had been no loss of consciousness whatever. Whether the palsy be com- plete in range or perfect in degree, it passes off in the vast majority ot' cases, and according to the degree of palsy, in hours, days, or weeks — perhaps, however, leaving a little numbness— the patient may aftervvards speak of his "weak side." Unfortunately, since the patient will doubtless continue subject to convulsive seizures of a like kind, we shall be obliged to admit that he will probably have the palsy again. Indeed he may have an- other fit even before the palsy from the former one has had time to pass off. More rarely hemiplegia is the first symp- tom, and Convulsion of the kind I de- scribe occurs after or during recovery. The Convulsion affects first and chiefly the side paralyzed. Since this order of events usually happens in cases where there is valvular disease of the heart, I suppose there is in these cases embolism of some part of the district of the middle cerebral artery. Freqimncy. — In this class of cases the fits vary in frequency. They are, I think, more irregular in this respect than chronic convulsions of other kinds. The patient may have one a week, one a month, or he may have thirty or forty, nay literally hundreds, in a iew days. When the fits are very frequent, the patient is usually, if not always, hemiplegic and deeply comatose. There is the "status epilep- ticus." It will be observed that in the paroxysms the spasm still affects first and more strongly the side already paralyzed. The signs of danger in the status epilep- ticus are not so much the number of fits or the degree of palsy — the frequency of the fits, of course, adds much to the gravity of the case — as increase of tem- perature, abnormal respiration, and irreg- ular pulse. Causation. — A convulsion implies dis- charge of unstable gray matter. We have then three directions of investigation in these cases : (a) the seat of the changes in gray matter ; (6) the pathological pro- cesses by which these changes are brought about ; (c) the circumstances which favor the discharge (exciting causes). (a) Seat of Lesion. — The probability is that in many cases we should discover no lesion post mortem. Although we must admit that gray matter is in an abnormal condition (because it discharges on slight provocation, and because it discharges abundantly), we must admit also that this abnormality does not involve any great alteration of structure. If it were much altered, even disorderly functions would not be possible. We are therefore not likely to discover the changes in the gray cells to which exaggeration of their normal function — to store up and expend force — is due. Niemeyer (op. cit.) says, '' Experience teaches that the lesions from which abnormally active impulses pro- ceed are insusceptible of anatomical de- monstration.'" Since increase of func- tion, even in disease, implies increased nutrition, we infer that the gray cells affected in Convulsions store up force in large quantity, and reach a high degree of tension. Further, since they discharge on slight provocation — possibly even m periodical normal changes in "the body, when by continuous nutrition a certain degree of tension is reached — we must suppose they are in a state of highly un- stable equilibrium. Instability, in this article, is made to include two things- high tension and very unstable equilib- rium. But admitting that we cannot, or have not, yet discovered the change which permits this duplex condition, we have ground for inference as to the position of the changes of instability. In some cases we discover gross changes. (For convenience we shall suppose the gross change to be, as it often is, a syphi- litic nodule.) The gross change affects the cerebral hemisphere^ opposite the side of the body in which the spasm sets in. Moreover, in all the autopsies I have seen the disease has been in the region sup- pUed by the Sylvian artery, and has af- fected convolutions — parts rich in gray matter. But the nodule we find is of course not the direct cause of the seizure ^the seizure is the result of a discharge of gray matter, and the nodule is an over- growth of connective tissue. In other words, the changes in gray matter on which the Convulsions depend are sec- ondary to the nodule. Now, at least two views may be held as to the seat of these secondary changes. The view generally adopted is that they are in the medulla ' "ITie proximate cause of convulsions is an abnormal increase in the nutritive changes of the nervous centres." (Russell Reynolds "On Epilepsy.") 2 Wilks savs ( ' ' Pathology of Nervous Dis- eases," Guy's Hospital Reports, 1866) "that the morbid conditions which we find to give rise to epileptiform convulsions are remarka- bly uniform. They all point to the presence of local irritation of the surface [of the brain ] . " Speaking of a case of epileptic con- vulsions in a patient who had tumor in the pons Varolii — a case which had been sup- posed to confirm Schroder van der Kolk's "supposition that the cause of epilepsy is seated in this part" — he says, "I have no hesitation in saying that for one such case fifty might he found in which the marked changes producing these symptoms occupy the surface [of the brain]," CAUSATION. 755 oblongata; and that tliey arc the result of an "irritation" starting from the nodule, or rather from its neighborhood. Another view is, that the gray matter changed is near the tumor itself, or in its vascular territory at least. Arguments in favor of the latter view are, chiefly, first, that the muscles first and most aflfected in the seizures are those most and longest af- fected in hemiplegia due to the disease of the corpus striatum ; secondly, that the epileptic hemiplegia, when complete, is quite like that which results from plug- ging of the middle cerebral artery. Other reasons could be given. The occurrence of temporary defect of speech in certain of the seizures {vide p. 753) is of some value in localizing. It may, however, be said that disease of certain convolutions often causes no symptoms at all, and therefore that when Convulsions occur along with, they cannot depend on, changes in the convolutions. The word disease is, however, here used vaguely. It is true, as every surgeon knows, that much of the convolutions may be destroyed without the supervention of symptoms. The patient can do without certain parts of his brain, but if much of its gray matter be very im- stable, he must have symptoms, for it will discharge strongly, and of necessity put muscles in disorderly movement. It may be asked. How is it, if the patient can do without the part which discharges, that there is sometimes hemiplegia ? The explanation is admittedly speculative. The hemiplegia comes on after the parox- ysm. Suppose the fit to begin by dis- charge of unstable gray matter in a cer- tain convolution, the violent impulse thus originated will probably dischai-ge lower and yet related centres of healthy gray matter. At all events, the nerve fibres to the muscles, and the muscles them- selves, are suddenly in excessive function. I suppose, then, that the hemiplegia re- mains until the normal conditions of these suddenly overworked parts have been slowly restored by nutrition. Wilks (op. cit.J says the paralysis follows by "an in- hibitory action. " As my plan, however, is chiefly clini- cal, I have discussed the question of position very briefly. It suffices for the discussion of the next question to admit, as we must, that there are changes of gray matter in some part of the nervous system. (6) The Pathological Process. — The changes of instability may no doubt be brought about in many ways ; but we shall limit ourselves to these questions : 'Are the changes the secondary results of gross organic disease — tumor, for in- stance—or are they minute changes, often inferable, rarely, if ever, discoverable ?" If there are symptoms pointing to gross organic disease, we fear that the patient will die of that disease ; if there are not, our fears are of a difterent kind, viz., that he will be subject to fits for years or for hfe, or, as it is often said, will be an epi- leptic. The first question then is. Is there gross organic disease ? If for no other reason than to econo- mize space, it is well to consider first the symptoms which show that there is grofs organic disease of any kind ; and next, to consider the evidence by which we infer its ]Dartioular nature— whether, for in- stance, it be syphilitic or not. IJefore beginning our task, it may be well to point out that certain symptoms which young practitioners sometimes rely on are not to be relied on, either for or against the diagnosis of gross organic disease. Tongue-biting is of no value in the diagnosis of the cause of any kind of con- vulsion : it is only a sign of severe con- vulsion. It occurs in cases of the first class described, if the fit be general and severe, and does not occur if the fit be partial and sUght. It occurs in severe fits from uraemia, cerebral hemorrhage, tu- mor, &c. Kor does the condition of the pupils during the fit furnish any evidence in diagnosis. Yery great inequality of the pupils after the fit would point to or- ganic disease. In these cases there may be, as has been remarked, no loss of con- sciousness when the fit is limited in range. It was said by the late Dr. Bright that absence of insensibility in convulsive seiz- ures is some evidence that the lesion is organic. With very great deference, I must say I cannot accept this view. If we were to judge by post-mortem evidence alone, we might draw the conclusion ; but we see patients who have convulsion without loss of consciousness, who not only show no signs of organic disease, but who, except for their seizures, seem to be in good health. Post-mortem exami- nations, in cases where there has been no evidence of organic disease, are very rarely had. I have not yet seen one. The fact that the fit is partial, let us say limited to the arm, the transitoriness of epileptic hemiplegia, the absence of fits for mouths, do not negative the existence of gross organic disease. It is to be especiall}' in- sisted on that quick recovery from epi- leptic hemiplegia is of no value whatever in negativing organic disease, tumor for instance. The signs I have mentioned are of no value for or against the diag- nosis of gross oi'ganic disease in this class of convulsions. The evidence which warrants the diag- nosis of gross organic disease in cases of Convulsion is of a different kind. We have carefully to distinguish betwixt the symptoms which are owing to local de- struction of the nervous system and those owing to changes diffused in nervous masses about the destroying agent— the 756 CONVULSIONS. results of the irritation it excites. For instauce, a certain form of hemiplegia is owing to the destruction of fibres and cells of the corpus striatum by, let us in- stance, a clot. This symptom is special to the part injured ; injury to no other part produces it. Again, it is primary, for it comes on at once, from destruction of nerve fibres there seated. But, next, the patient suffers headache ; his temper- ature rises, his pulse and his respiration become irregular. Such symptoms may be called general, because they do not point to disease in any one part of the encephalon, and they may be called sec- ondary because they do not come on at once, but are indirect results of the irri- tation of the clot as a foreign body — of a local encephalitis. Hence we see that whilst the nature of the lesion matters little or nothing so far as the production of such special and primary symptom as hemiplegia is concerned — it suffices that nerve-fibres in the corpus striatum are by awj means destroyed — it matters very much with regard to the general or sec- ondary symptoms. The encephalitis in cases of clot is often a rapid process, but the same distinction is to be made in cases of tumors, syphiloma, abscess, and other Icinds of gross organic disease. But it frequently happens that tumors, syphi- litic disease, &c., occur in regions of the brain — in the cerebrum and cerebellum — large parts of which may be destroyed without the production of any special symptoms — without hemiplegia or obvious mental defect. In other words, the pa- tient does not suffer because the tumor has destroyed a certain part of his brain. He begins to suffer when a local encepha- litis is excited by the destroying agent. And as this encephalitis does not always occur, he may have no symptom what- ever from cerebral tumor. What is the evidence which shows a patient the subject of a convulsion to have OToss organic disease within the cra- nium ? The sj'mptoms which show there is organic disease within the cranium, not in these cases only, but in any cases — in cases of palsies of cranial nerves, hemi- plegia, &c. — are such as severe headache, urgent vomiting, and double optic neuritis. The pain in the~head has no value in diag- nosis if it be the temporary sequel of a severe fit, or of a series of fits. We must be satisfied that the patient's "headache" is really pain, and not "confusion," "gid- diness," "weight on the top of the head," &c. Nor can we lay stress on it as evi- dence unless it be intense, and unless it has lasted for some days or weeks. We can sometimes judge of its intensity by the patient's manner and by his expressions. He gives up work ; he may remark, " it is not a common headache." He is said by his Mends to " rave," and sometimes it is reported that he "knocks his head against the wall." The headache is of more value in diagnosis if it occurs in un- usual places. If it be at the back of the head shooting forward, or on one side — I do not refer to nodes nor to neuralgic pain extending into the face- — gross disease is likely. The vomiting is urgent, it i.«* pur- poseless and capricious sometimes, for in- stance, occurring only at night or in the morning. The vomit is frothy "like phlegm," the patients sometimes say; and if there be very much retching, as there usually is, it is greenish or yellowish. The tongue may be quite clean, and the appe- tite may be good. Vomiting is not al- ways present. When symptoms so well marked have lasted for several weeks, we suspect that the convulsion is the result of gross disease. We may, I think, be quite certain if there is also paralysis of the whole of any one motor cranial nerve. If there be double optic neuritis as well, or its usual sequel, double optic atrophy, we may be almost absolutely certain. Let us suppose we have satisfied our- selves that there is a gross lesion of some kind, we have now to find out what is its particular nature. We may, I believe, exclude clot in nervous centres as a cause of clu7onic seizures of this kind. No doubt effusion of blood on the surface of the brain would produce fits of this kind, and in all cases we should inquire carefully for history of injury to the head, and seek for evidence of clironic renal disease, the two chief conditions under which meningeal hemorrhage occurs. I have only twice known albuminuria to occur with fits of this variety, and there is, I think, no war- rant for the supposition that uraemia has anything to do with their causation. It is true that Convulsions called ursemic— after scarlet fever, for instance — are often unilateral, but as f^r as I know these seizures do not begin by a very deliberate spasm in one side. When they do, their real nature may be inferred by examining the patient's heart, urine, &c. The gross organic disease may no doubt be of many kinds, but practically the point we wish to determine is. Is it syphi- litic, or is it some other kind of new growth ? It is needless to mention that when other symptoms of syphilis are pre- sent, such as nodes, the diagnosis of syphilis is almost certain, and needless to urge in all cases of this kind a very care- ful investigation for evidences of syphilis, such as scars on the skin, holes in the palate, white marks on the tongue. It is only necessary to speak of cases in which such decisive evidence is not to be had. In the first place the gross disease is fre- quently syphilitic. It is so with the very rarest exceptions when there is also double optic neuritis. It is next to certain that there is syphilitic disease if the patient CAUSATIOJr. 757 has Convulsions of this kind along with complete palsy of the whole of any motor cranial nerve ; for one great diagnostic mark of syphilis is that it produces random associations of symptoms. The evidence is clearer if the motor cranial nerve para- lyzed be on the same side as that on which the Convulsion begins; and on which there may be epileptic liemiplegia, because we are sure then that there are two lesions. (The facial paralysis, which is part of epileptic hemiplegia., is not of course in- cluded in the exp*.':,ssion palsy of a motor cranial nerve, because it is not owing to disease of a nerve trunk. ) If there is palsy of any nerve trunk, e. g. of the radial, palsy of one leg, or paraplegia, the great probability is that these symptoms and the Convulsions are owing to syphilis. Still there may be some other kind of new growth, but this is very rare in cases of Convulsion of the class described, and rarer still when the Convulsion is attended by any of the other symptoms mentioned in the preceding paragraph. In some cases the recovery of the patient from local palsy, let us say of the third nerve, by iodide of potassium will make the diag- nosis pretty certain. In other cases the length of time, e. g. many months or several years, the symptoms had lasted, would point to syphilis. There can be no doubt that we should treat for syphilis. Fits of this kind occasionally follow blows on the head. In these cases we should carefully inquire for evidence of syphilis, as syphilitic disease of the brain is frequently "lighted up" by injuries. In some cases there is a depression of the skull on the side opposite the side of the body in which the fit begins. Suppose now that there is no evidence of gross organic disease of any kind. In the vast majority of cases we can get no fiirther, we can only infer that there are not gross changes in the brain, and as a corollary that the patient will not soon die, but will continue subject to fits. In a few cases there will be found evidence which will warrant the supposition that the plugging of small arteries of the Syl- vian region ts the cause of tlie pathological change.' It is certain that patients, the ' The inference is not that each fit or each series of fits depends on separate pluggings. It is true that sadden plugging of the middle cerebral artery, or perhaps of some large branch, may lead to a severe convulsion in a patient whose nervous system was previously healthy, but in these cases there is persistent hemiplegia after a fit. If a smaller branch be plugged and perhaps slowly occluded, the hemiplegia passes off or diminishes greatly, and, as before said (p. 753), occasionally the patients become subject to convulsion begin- ning in some part of the region previously paralyzed. The hemiplegia depends on de- striiction of nerve fibres, the occasional spasm subjects of valvular disease, have seizures of this kind after or during recovery from hemiplegia. Yet although I have made post-mortem examinations of patients, the subjects of valvular disease, who have had Convulsions, I have had no post-mortem examination of one whom I knew to have had fits of the kind described. My sup- position is that patients who have "epi- leptic fits" from intracranial aneurism suffer really from local embolism, and that when the aneurism is of the middle cere- bral artery, or of some large branch of this vessel, the seizures will be of the first class. It is, however, held by some that the fit depends on irritation by the aneurism. Mr. Callender (St. Bartholomew's Hos- pital Reports, vol. iii. 1867) has made the very important observation that the "epi- leptic attacks belong to aneurism of the middle cerebral artery." (c) Exciting Causes of the Paroxysm. — Some patients who are subject to fits of this kind are otherwise in very good health. Such cases are sometimes sup- posed to be owing to some very general cause. A patient who in the midst of good liealth has had a severe convulsion is naturally most anxious that his fit should be attributed to some very general and removable cause, and will dwell much on such facts as that he had taken some- thing that had disagreed with him, or that he was in a close room, or will say that he was "bilious," or worried by anxiety the day it happened. Dyspepsia, over- work, fright, and the like, may be admit- ted to be factors in causation. I cannot, however, conceive that any such general conditions can alone produce fits which time after time begin in one hand and even in the very same finger even for months and years. In other words, I cannot conceive that they alone can de- termine the discharge of healthy nervous tissue in some particular locality. I class them as exciting causes, believing that there is some central change as well. Whatever view may be held, there is for therapeutical purposes a complete agree- ment that we should try to remove all such causes. ^Xe may find that the pa- tient is dyspeptic. It is, I think, quite certain that in some cases the paroxysm frequently C07nes on when the patient is flatulent. So, although we may differ as depends on instability of gray matter. It is evident enough that plugging will lead to destruction (softening even to diflluence) of fibres and cells, but it is not sufficiently borne in mind that plugging of small vessels may lead also to increased quantity of blood be- yond the plug, and thus to altered nutrition and instability. At autopsies on patients who have died of or with plugging of the middle cerebral artery, whilst we find soften- ing of part of the corpus striatum, we find also at the periphery "red softening." 758 CONVULSIONS. to the way in which d3'spepsia is connected with the seizure, there is no question that to treat the dyspepsia by careful dietary and by medicine is a matter of the very greatest importance. (See Dr. Paget, of L'ambridtje : Lectures on Gastric Epilepsy, Lancet, 1868.) These seizures, like other convulsive attacks, and other nervous symptoms, sometimes follow fright. The first fit of a series evidently depending on organic disease may follow fright so closely that we are driven to believe there is some re- lation betwixt the two things. I imagine that the fright merely determines the pa- roxysm which some other cause would afterwards determine. There is nervous tissue in a state of highly unstable equi- librium, which will surely discharge soon from some provocation, and now and then fright is that provocation. As no special point of treatment is involved, and as the discussion of such causes belongs rather to epilepsy, nothing further need be said here. As to local irritation by worms, teeth, &c., all that need be said here is that we should try to remove these sources of irri- tation. Then possibly the part of the nervous system diseased, ceasing to be worried by such eccentric irritations, may cease to discharge. Class II.' Let us now suppose the patient's fit to be one of the second class. These cases cannot be considered on the same plan as those of Class I. ; the paroxysms are too sudden, and the conditions under which they occur are too numerous and complex. In chronic cases of this class the same reasoning as to position, nature of change, and exciting cause will to a very great extent apply. We shall include in this class those cases of which we obtain no history of the mode of onset of the fit. For instance, we find the patient coma- tose, and we only learn that he has had a convulsion. It is then that the question arises, Is the fit epileptic ? This is the great question when we see a patient in or soon after his first convulsion. But since we may find him hemiplegic, it will be best to use the expression epileptiform, and modify the question thus, Does the fit depend on a state of the brain or sys- tem which is such that the patient will recover from the fit in all probability to suffer similarly again and again for months or years, or is it owing to such causes as cerebral hemorrhage, tumors, ursemia, &c., which will soon lead to a fatal result? In the first place, the phenomena of the convulsion — it does not begin by deliberate See page 752. aura in one limb — the nature of the pa- roxysm, stertor, coma, tongue-biting, fur- nish no reliable evidence. Cases of apo- plexy from cerebral hemorrhage are now and then diagnosed as cases of epilepsy, because the apoplectic condition was ush- ered in by a fit of an ' 'epileptic character. ' ' It is to be insisted on that neither the kind of convulsion nor its repetition are signs serving in the diagnosis of the nature of the lesion. Neither enables us to say whether the fit is epileptic or not. Nev- ertheless it is freely admitted that in most cases we are right in the prediction we make. Although it is difficult to make a diagnosis, it is easy to guess. If we are called to a young man who has had a se- vere fit and who is not paralyzed after it, and if we find that he has recovered or is recovering consciousness, we shall be right in the great majority of cases if we say, without any further medical exami- nation, that the fit is one of epilepsy, and not one of ursemia, cerebral hemorrhage, &c. But it is not necessary even to see the patients to make diagnoses which shall be generally right. And when we hear that a patient has been long subject to fits, from each of which he quickly re- covered, or if we hear that he has had attacks of petii mal only before the con- vulsion, we shall be right in nearly all the cases when we make the diagnosis of epi- lepsy. But even under these circum- stances the practitioner will be wrong now and then. For instance, there may be chronic renal disease, notwithstanding the patient has had fits of an "epileptic character" months before. Again, the former fits may have been due to aneu- rism of one of the larger cerebral vessels, and the fit we are called to may be owing to rupture of that aneurism. The former fits may have been owing to tumor, and the one we are called to may be the result of fatal hemorrhage from that tumor. These are rare cases, but we are sure to meet with them now and then. If we do not consider these rare possibilities, we may make very painful blunders. I repeat that a routine diagnosis of epi- lepsy in young people who have a convul- sion will rarely be wrong, because such Convulsions are nearly always epileptic. And those who do not examine the urine unless the patient be dropsical, and who content themselves by saying in cases of death by Convulsion that the patient "died of an epileptic fit," and make no post-mortem examination, will not be aware that this diagnosis is sometimes grossly wrong. In what follows, in order to encounter fully the difficulties of diagnosis which actually do occur, and because I have only to do with the most commonly occurring seizures (epileptic) in diagnosis, I will suppose that we are called to a person in CEREBRAL ANEURISM. 759 his first fit, or first series of fits, and only incidentally notice what bearing on our diagnosis the fact of the previous occur- rence of fits has. There is no position more embarrassing than that we are in when called to a patient in his first fit. As before said, it is easy to be generally right. We will consider some of the recognized causes of Convulsion, or, it may be safer to say, the known conditions under which they arise. It will be well first to remark however, that when we are called to a patient who has " died in a fit," we must ask if the patient were eating when the fit came on. Dr. Lalor has written a valuable monograph on death by choking in epileptic attacks, and I could relate a case in which I feel convinced that death was thus caused, although the larynx was not examined post mortem. Renal Disease {Urcemia). — In all cases of Convulsion we must examine the urine, however young the patient may be, and however healthy he may look, and not- withstanding that he has had fits de- scribed as epileptic on previous occasions. This examination is still necessary when the patient has recovered consciousness by the time we reach him. None of the above circumstances negative urtemia, nor is the quick repetition of fits of value in diagnosis. The fact that the patient has had no dropsy does not influence us. We must, I repeat, examine the urine. If it be smoky ; if there be scarlet fever in other members of tiie patient's family ; above all, if the patient be the subject of scarlet fever, we conclude almost with cer- tainty that there is urcemia. I say almost, because now and then Convulsions in scarlet fever are followed by a liability to Convulsions for life. As we sometimes say, "some cases of epilepsy date from scarlet fever;" occasionally they leave persistent hemiplegia. It is hard to be- lieve that there can have been uraemia only in these cases. Since endocarditis occurs now and then in scarlet fever, and since plugging of the middle cerebral ar- tery will cause Convulsions, it is as likely that there is embolism as ursemia. Cerehral Hemorrhage. — The mere pres- ence of albumen, however, does not lead us to declare that there is urcemia. In a patient past middle age there may be cerebral hemorrhage. If there be hemi- plegia with deep and continuing coma, we diagnose hemorrhage, and we do this not- withstanding that the patient is young — say twenty — and notwithstanding that he was " quite well before the fit. " If there he no hemiplegia, and if the patient be young, the inference is very strong that there is uraemia, and not clot. But, as will be mentioned in the article on Apo- plexy, a general convulsion followed by deep coma and universal powerlessness, in a patient whose urine is albuminous, may be owing either to very large hemor- rhage into the cerebrum, into the lateral ventricles, or into the pons Varolii, or it may be owing to urcemia. We cannot rely on stertor, kind of coma, repetition of convulsion, or increase of temperature, although rapidly increasing stertor, rap- idly deepening coma, are signs in favor of the diagnosis of hemorrhage. It is the ingravescence of these symptoms, after the convulsion, which favors hemorrhage. We will now suppose that there is no albuminuria.' Cerebral Aneurism. — Dr. John W. Ogle and Dr. Murchison have pointed out that epilepsy (i. e. fits at intervals, like those usually called epileptic) occurs in patients the subjects of aneurism of large cerebral arteries. Such aneurisms will occur in young people, and therefore the question of age has no bearing on diagnosis. There is nothing special, so far as has yet been determined, in the kind of convulsion ; there are, indeed, no symptoms which are characteristic of cerebral aneurism. There may be no symptoms at all, or none sufficient to send the patient to a doctor, until the fatal ones from rupture of the aneurism. We cannot therefore be cer- tain whether a patient's fits are the re- sults of cerebral aneurism or not. If, ex- cluding albuminuria, syphilis, and other causes to be afterwards mentioned, we have reason to believe that there are vegetations on the heart's valves, we may surmise that the fits are owing to cerebral aneurism or (vide sup>ra) to local embolism in connection therewith.^ We can occasionally diagnose that a fatal seizure is owing to rupture of a cere- bral aneurism, and this is an important matter in a medico-legal point of view. If a young patient has had Convulsions now and then for months or years, and if after one severe fit he is more profoundly comatose than usual, with great stertor, and if he continues so for some hours, rupture of a cerebral aneurism is proba- ble. It is all the more hkely if the patient has been hemiplegic. If the patient dies in the fit in a few minutes or in half an hour, we are more certain, because we know that it requires a large and, what is more important, a sudden hemorrhage to kill quickly.' We are more sure still if ' Occasionally when there is chronic renal disease, we discover no albumen in the urine, and it is said that occasionally, after a severe convulsion, albumen appears in the urine in consequence of that convulsion. I do not see how we can avoid mistakes in these cases. ' See Dr. Grull on Cerebral Aneurisms, Guy's Hosp. Rep., vol. v. (3d series). 3 It is not, of course, said that rupture of aneurism of the large cerebral vessels always kills suddenly or quickly, nor always by Convulsion. Rupture leads to death slowly. 760 CONVULSrOXS. the patient is known to be the subject of valvular disease of the heart, or if he has had rheumatic fever. Dr. J. W. Ogle and Dr. Church have shown, and my ex- perience bears out their conclusions, that aneurism of the larger cerebral vessels frequently occurs along with vegetations on the heart's valves. Endxjlism. — Embolism of the middle cerebral artery sometimes, although rare- ly, produces severe convulsions. It is followed by hemiplegia. The modes of onset of symptoms trom plugging vary much. They sometimes come on sud- denly and sometimes deliberately, accord- ing, the presumption is, as the vessel is slowly or suddenly plugged. Again, the degree of the symptoms varies. There may be no loss of consciousness, and the hemiplegia may be transitory. This is so when the branch occluded is small. If a patient the subject of valvular disease becomes hemiplegic after a severe convul- sion, it is considered to be almost certain that there is sudden plugging of the main trunk or of a large branch of the middle cerebral artery : it is not quite certain. The convulsion and consequent hemiple- gia may be owing to rupture of a large aneurism of this vessel. Aneurism of the middle cerebral artery usually ruptures so that the blood is poured out external to the brain, and the patient dies quickly because the blood gets out in large quan- tity, and, what is more important, with great rapidity. But occasionally it rup- tures so as to 6rcf(fc up the motor tract, corpus striatum, nor thalamus, and will then, so to speak, imitate common cere- bral hemorrhage. If then a patient, espe- cially a young patient whom we know to be the subject of valvular disease of the heart, becomes hemiplegic after a convul- sion, we must take this rarer possibility into consideration. If the coma be very deep, if it deepens, or, generally speaking, if the patient quickly gets worse, rupture of an aneur- ism is at least as likely as embolism. "With all our care we shall be wrong now and then, as patients sometimes die in a few days in an apoplectic manner, from plugging of the middle cerebral artery. (See also Art. Softening. ) Tumors. —If the patient, especially if he be a young and healthy-looking man, have had for weeks or months severe pain in the head, vomiting, &c., there being no albuminuria, — above all, if there be also double optic neuritis, — a tumor of the brain is probable. Although headache is one of the symptoms of cerebral aneurism, cerebral aneurisms rarely if ever cause in- tense and persistent headache. if the rupture of the aneurism is small, or if the blood, as when the aneurism ig far in the Sylvian fissure, can only get out slowly. I Here I must refer to the evidence stated ' in more detail (p. 758). But in this con- ' nection one further fact is to be mentioned, viz., that a patient may have occasional convulsions for weeks or months from the " irritation of a tumor," and may die after one severe convulsion, or several quickly recurring convulsions, due to large hemorrhage from that tumor. If, then, we find a patient whom we infer to be the subject of cerebral tumor who has been seized with convulsions much more severe than usual, and if he becomes un- usually deeply comatose, and if the coma deepens, especially if there be no further convulsion, we fear large hemorrhage from the tumor.' Syphilis.^ As before said, if the con- vulsion be of the first class, and if there be signs of organic disease, there is usually syphiloma of the brain : but if the con- vulsion be general, or if we know nothing of its mode of onset, we must infer from the evidence of present syphilis. If there be such demonstrative evidence as nodes, &c., or a clear history of recent syphilitic changes in any part of the body, our diagnosis is practically certain. If there is not such evidence, we may judge from the history of a random succession of nervous symptoms, such as palsy of a cranial nerve, followed by hemiplegia or paraplegia, or from the previous disor- derly association of nervous symptoms, showing several lesions, e. g. palsy of the third or fifth, or portio dura with hemi- plegia of the same side. When, however, such symptoms are of recent date, they may be still rarely owing to tumor. "We must, however, "always in these cases treat for syphilis. Abscess. — Again, it is possible that there may be cerebral abscess. If we are to ignore this possibility altogether, we shall very rarely err, as cerebral abscess is very rare. I have, however, more than once been consulted for Convulsion which turned out to be owing to cerebral ab- scess. There are no certain points in diagnosis except the presence of bone dis- ease in some part of the cranial wall, most often the bones of the ear, occasionally at the vertex. If the only evidence there is be that the patient a week or month ago received a severe blow on the head, the fit may be owing to syphilitic disease oi' the surface of the brain. It probably is, if the fit begins deliberately, and if there be epileptic hemiplegia. Syphilitic dis- ease of the brain not infrequently follows blows on the head. If, however, there be no evidence of syphilis, no palsy of any cranial nerve — excepting amaurosis from ' Of course it is not to be implied that hemorrhage from cerebral tumor necessarily leads to Convulsions, any more than ordinary cerebral hemorrhage does. TREATMEXT OF CONVULSIONS IN ADULTS. 761 double optic neuritis, whicli is scarcely to be called palsy of a cranial nerve, — if we find that there is a "putty" tumor on the scalp, abscess is probable, and very pro- bable if there be hemiplegia after the Convulsions. Occasionally, as is well known, a patient sutfers from cerebral abscess without any symptoms at all, or any obvious symptoms. Occasionally after a period of latency it breaks into the lateral ventricle : then the symptoms are quite like those of hemorrhage into the lateral ventricles, and we can only make the diagnosis of what has occurred from evidence of blows, disease of the bones of the ear, of the nose, &c. If there be no history, and if we find no evidence of disease of bone, we cannot make a diag- nosis. Epilepsy. — Supposing now that we can negative the above causes, we conclude that the patient has had an epileptic fit. By this we mean that he has had a con- vulsion which does not depend on an organic lesion, or on an acute state like uraemia, or on a sudden quasi-accident like hemorrhage. We infer that he will quickly get into his usual health, but that he will in all probability have fits of a like kind again and again for years. We say probably, because now and then he does not suffer again, and it not infrequently happens that after the first fit or the first series of fits he has an interval of good health for many months. Death in Convulsions. Now and then, however, a patient dies in a convulsion, and we discover nothing post mortem which we can suppose to have been the cause of the fit. Of course there is something overlooked, and we should always search every organ of the body with great care in these cases. When the pa- tient is known to have had fits of a like kind before, we may say that he died in an epileptic fit ; but when it is his first fit, this nomenclature does not conceal the bald fact that a patient seemingly healthy has a convulsion the cause of which we cannot make out, even after post-mortem examination. He dies in it, we surmise, because it has been unusually severe, res- piration, and probably the heart's action, having been suspended too long for re- covery. The point that chiefly concerns us here is that such modes of deatli are well recognized, and do not indicate either violence or the administration of poison. Treatment of Convulsions in Adults. Obviously enough, treatment will vary so much in different cases that most of what has to be said will be found in the articles Urcemia, Cerebral Hemorrhage, Embolism, and Epilepsy. Indeed, I wish only to say a word on the treatment of Convulsions due to syphilis. In these cases we treat for syphilis, but in chronic cashes, at least, this treatment is not of so great service, so far as removing the symp- toms goes, as from superficial considera- tions we should expect. The bromide of potassium is of more service than the iodide in keeping off fits. [Puerixral eclampsia is not alluded to in this article. Its full discussion belongs to works on Gynaecology. A few words, however, upon it may not be inappro- priate here. Convulsions diiriny pregnancy may be either ursemic, reflex, or apoplectic. Pres- sure of the distended uterus upon the re- nal veins may interfere with the normal condition and action of the kidneys. Of this state of thinos albuminuria is an ad- monitory sign. When it amounts to such a degree as to produce marked uraemia, Convulsions may follow. If parturition be safely accomplished, the Convulsions disappear with the uraemia. In women having excito-motor irrita- bility greatly developed, there may be, in the absence of uraemia. Convulsions from irritation of the gravid uterus, act- ing reflexly. Here, also, delivery results in the cessation of the tendency to eclamp- sia. A plethoric state exists during preg- nancy in some women, predisposing to cerebral congestion.' Either before, dur- ing, or after delivery, one concomitant of this condition may be Convulsions; whose prognosis is always very serious. A fatal termination is least apt to occur in the utero-reflex cases ; it is most frequent in the apoplectic. Signs of this form are, deep flushing of the face, distension of the vessels of the neck and head, full, some- times slow, pulse, and stertorous respira- tion. Treatment. — If, during pregnancy, a woman known to have good viscor of sys- tem, with a full pulse, warm skin gene- rally, and hot head, is attacked with Con- vulsions, it is good practice to draw blood from the arm. About ten ounces will usually be enough ; if the pulse be quickly reduced, less will do. An enema of cas- tor oil, soap, and warm water may be ad- ministered. A large sinapism should be appUed to the back, and cold water to the liead. If the convulsion be prolonged, the [' The opinion of Cazeaux and Traube, that, instead of plethora, there is hydrsemia in such cases, is not likely to be correct. That of Frank, Munk, and others, that the symptoms are due to high arterial tension, has more to sustain it. This may explain the symptomatology of many cases. — H.] 762 EPILEPSY, patient may be placed in a warm bath. After this, sliould further treatment be called for, inhalation of ether or chloro- form may be suitable as a last resort. When the convulsions are evidently utero-reflex, not uroemic, nor accompanied by apoplectiform congestion of the brain, bleeding is out of place. Sinapisms to the back and limbs, and the warm bath, will be proper, and the use of ether or chloro- form by inhalation may be earlier resorted to. Nitrite of amyl (a few drops, by in- halation) has been employed in some such cases with benefit. When the convul- sions show a tendency to repetition, bro- mide of potassium may be used, or hy- drate of chloral may be given in twenty or thirty-grain doses ; or morphia may be administered by hypodermic injection. Either of these remedies will require close watching of their effects upon the patient. — H.] EPILEPSY. By J. Russell Reynolds, M.D., F.R.S. Definition. — Epilepsy is a chronic disease of which the characteristic symp- tom is a sudden trouble or loss of con- sciousness, this change being occasional and temporary, sometimes unattended by any evident muscular contraction, some- times accompanied by partial spasm, and sometimes by general convulsion. The two elements probably present in every case of Epilepsy are diminution of intelligence and excess of muscular con- traction ; and these two elements may exist in almost every variety of combina- tion, and be developed to any degree of intensity. The latter element is not al- ways seen to exist; there may be no spasm of the facial muscles, not the slightest change in the expression of countenance ; or the face may become dull in aspect, or pale in color, but consciousness is, for the moment, in absolute abeyance. There are reasons for thinking, as will be shown hereafter, that this loss of consciousness depends upon spasm affecting the vessels of the pia mater, but such spasm is hid- den from our eyes. The former element, loss of consciousness, is that which is essential to our idea of Epilepsy ; without its occurrence, no convulsion, however severe, should be regarded as epileptic ; •when it does occur, as a paroxysmal event, and with a chronic history, the case is one of Epilepsy, although no other symptom may be present. There are two classes of errors into which authors have fallen with regard to the use of the word Epilepsy. The older mistake was to apply the term to every case in which there were convulsions ap- pearing in a certain form, called "epilep- tic," " epileptoid, " or "epileptiform;" the modern error is to use the word to denote a paroxysmal— i. e. occasional and sudden — loss or diminution not only of consciousness but of any function of any organ ; or, indeed, sometimes to denote anything, or any condition, which occurs in a paroxysmal manner. The former led to the association, under one name, of diseases differing so widely from each other as tumor of the brain, Bright's dis- ease of the kidney, intestinal entozoa, lead poisoning, and almost every form of malady : the latter might lead to the placing in one common group, and calling by one common name, such diseases as amaurosis from dyspepsia, stammering, deafness, paralysis, or asthma. The for- mer tendency led to the production of such words as renal epilepsy, sympto- matic and sympathetic epilepsy, toxfemic epilepsy, and the like : the latter has con- duced to the coinage of such terms as epi- lepsy of the retina, acoustic epilepsy, and so forth. There is, I think, a radical and very mischievous mistake in both of these modes of using words; the error is similar in the two, as far as regards its principle, but it differs in the detail of its develop- ment. The older authors exaggerated the importance of the form of a group of symptoms — convulsive — occurring in a number of organs, and common to many widely different diseases ; the modern have exalted into undue prominence the pathological significance of one element out of this group of symptoms — viz., ar- rest of function — which single element may occur in many diverse organs of the body. By such a term as " renal epilepsy" was meant a disease resembling Epilepsy in its outward form, but dependent upon, not an unhealthy condition of the nervous centres, but on an irritation of the kidney, or an altered blood-state which kidney- CAUSES OF EPILEPSY. 763 disease might have determined : by such words as " retioal epilepsy" something very diflferent is intended, viz., a malady showing itself only in the retina, in which a change takes place, supposed to be analogous, in its intimate pathology, to that occurring in the brain in Epilepsy. In the one Epilepsy merely means con- vulsion ; in the other it merely means ar- rest of function; and the objection I enter- tain to such use of terms is based upon the fact that, however widely different individual cases of Epilepsy may be, they do yet belong to and constitute a group which has a definite clinical history, and has had it for some hundreds of years. If good reason can be shown for getting rid of the word "epilepsy," I should rejoice to lose it from our nosology; but so long as the word is retained at all it should have a definite and intelligible meaning. Eenal asthma would be a term as patho- logically correct as "renal epilepsy;" dyspnoea of the fingers as justifiable as the expression " epilepsy of the retina." Syijonyms. — No useful end would be served by enumerating all the names by which this disease has T)een described, in- asmuch as many of them have fallen into complete disuse. The most important are the following : — Epilepsy (English) ; I'Epilepsie (French) ; Fallsucht (German) ; Mai Caduco (Ita- lian) ; Epileptica passio, Morbus sacer, M. comitialis (Latin) ; 'Emajy^^t'o, 'En;a^4"{ (Greek). Natural Histoby. — 1. General Peevalektce of the Disease. — Epi- lepsy is spoken of as a very common affec- tion. Niemeyer states that in every thousand individuals there are to be found six epileptics.' Such statement cannot, I think, be true with regard to Epilepsy in this country ; for among 1820 invalids, whose cases were recorded by myself as out-patients of the Westminster Hospital, there were only seven epileptics; and but thirty-four whose diseases could by any possibility be confounded with Epilepsy. It must be observed further, that Niemeyer is speaking of individuals generally, and that the results of my own examination at the Westminster Hospital are obtained from a small class of indivi- duals, viz., those who are ill. The proportion of true Epilepsy to other diseases of the nervous system has been found to be about 7 per cent. 2. Causes of Epilepsy.— (a) Predis- posing Catises. — Hereditary taint has been found to exist in rather less than one- third of those cases which have fallen ' Niemeyer, Handbuch der speciellen Pa- thologie, p. 637. under my care, and have been carefully examined on this point.' It is not in- tended by this statement to affirm that true Epilepsy has existed in the parents of one-third of the cases ; but that some disease of the nervous system, more or less closely allied to that under considera- tion, has been present in either the parents, the grandparents, the aunts, uncles, brothers, or sisters ; that there has been a family proclivity to nervous disorder, in one case showing itself by idiotcy, in another by mania, in a third by convulsions, and so forth. I have found only 12 per cent, of epileptics giving a dis- tinct history of Epilepsy in other members of their families ; a number which is very near to that stated by Dr. Sievekin^, and not far removed from that given by M. Delasiauve. It has been said that the disease is more frequently transmitted on the fathers' than on the mothers' side,'' but the re- verse of this proposition has been found to obtain in cases examined bv myself. Of 130 epileptics, I found 80, or 61-06 per cent., who asserted the entire absence from their families of any predisposition to nervous disease ; and 8 individuals, or 6"10 per cent., who were in some uncer- tainty as to the health of important rela- tives. These patients were derived from all classes of society; and I have no means of determining the question, on a scale sufficiently large to be satisfactory, whether Epilepsy is more commonly found to be hereditary in the upper, the middle, or the lower classes. Several ele- ments of doubt enter into the solution of this question, the most important of which is the greater difficulty that is encountered in obtaining accurately the facts which belong to the latter. Hospital patients often know but little of their antecedent or even collateral relations. Among the upper classes there is not rarely a studious concealment of what are regarded as pre- judicial family conditions. The middle classes are not only more accurate than the former, but more free than the latter; and, judging from what I have gathered • In a careful paper by Messrs. Leech and Fox, in vol. i. of the Manchester Medical and Surgical Reports, p. 198, the proportion_ of those epileptics in whom hereditary taint was traceable was somewhat higher, viz., 36-8 per cent. These observers compare with each other epileptics and non-epileptics, and, having obtained particulars with regard to the health of a large number of the relatives of each group, show that the relatives of epi- leptic patients were found to suffer from "some form of nervous disease" in larger proportion than were those of non-epileptic individuals. ! Esquirol. Des Maladies Mentales, tom. i. p. 406. 764 EPILEPSY. from them, as they shade off on either side — above them and below — I should be of opinion that hereditary taint is more frequently discoverable in the better con- ditions of life than in the pop»er. It is not intended that there are absolutely a larger number of hereditary epileptics among the former than the latter ; but that, of an equal number of epileptics in the two extremes of society, a larger pro- portion will furnish evidence of hereditary taint among the rich than among those who are in want. This is probably due to the fact that the latter class are ex- posed more frequently and more severely than are the former to the most active de- termining causes of the disease, viz., anxiety, alarm, and want. With regard to the hereditary transmission of Epilepsy, as indeed with regard to the causation of all diseases by supposed hereditary taint, it must be remembered that, inasmuch as the large majority of cases owe their malady to other causes than inherited tendency, a certain number of those whose parents exhibit a like affection to their own may have become morbid inde- pendently of any hereditary taint. It is well known that many of the children of epileptic parentage are free from the dis- ease, and it is quite clear that many epi- leptics, descended from epileptic stock, have been exposed to causes of the malady which would, of themselves, have been held sufHcient to have induced the malady independently of any constitutional taint. It is, therefore, of practical importance not to assume too readily the operation of this cause, and hence to neglect an exami- nation into other conditions. In the largest and most correct sense of the word, the etiology of Epilepsy is advanced but little by the discovery of hereditary taint; the causation may be thus thrown back- wards, but it is not explained. Sex. — Little that is of value can be shown with regard to the influence of sex as a predisposing cause of Epilepsy. Practically, the two sexes appear to be about equally affected ; and the different statements that have been made by va- rious authors — some of whom represent the male sex, others the female sex, as the more liable to the disease — may prob- ably be accounted for by other circum- stances than that supposed, viz. a special sexual predisposition. The relative num- ber of female epileptics who are out-pa- tients of hospitals may be determined by the hours at which the physicians make their visits, or by other conditions which have to do with the social position of the applicants, and which may render it easy, difficult, or almost impossible for either the one or the other sex to attend. Similar degrees of fallacy, although different in kind, may influence the re- sults obtained from private practice. The facts of a physician's age, and single or married condition, for example, might exert an influence upon the relative num- bers of his male and female patients too great to be counterbalanced by proclivity to Epilepsy inherent in either sex. Again, the statistics gathered from asy- lums are liable to disturbing causes so far as etiology is concerned. In proportion to the amount of disease a larger number of males than females find their way into public asylums. The reason for this is obvious, viz. that men are prevented from doing their special work in the world by an amount of disease which need not deter women from performing their do- mestic duties. Yet further, the statistics furnished on this point by some authors are complicated by limitations as to age, and by the fact of more or less clearly pronounced insanity of mind. Little, then, that is definite can be stated on the influence of sex, as a predis- ponent to Epilepsy ; and it seems to me to be the wisest course at present to leave the question open for further investigation. Age. — The influence of age in the pro- duction of Epilepsy is strongly marked. This is shown in the following short table of cases collected by myself : — Age at commencement. Males. Females. Total. Under 10 years ... 10 9 19 Between 10 and 20 years 66 40 106 Between 20 and 45 years 25 20 45 Over 45 years .... 1 1 2 102 70 172 The most important fact to be recog- nized in the above summary is the great frequency with which Epilepsy com- mences between 10 and 20 years of age — i. e. at a period of life embracing the pro- cesses of the second dentition and of the establishment of puberty ; and, without going much further into detail, it may be stated in addition, that by far the larger number of the group showed their first symptoms of the disease between the ages of 13 and 17 years, inclusive. Eur- ther, that there is a comparative immu- nity from the commencement of the dis- ease between 25 and 35, the greater pro- portion of cases forming the third group having been seized by the disease at or about the age of 40.' • For further information on these points the reader is referred to Hasse, in Virchow's Handbuch, Ister Abth. 4ter Bd. p. 264; Reynolds on Epilepsy, p. 126; Leuret, Archiv. G6n. de M6d. 4me S6rie, 1843, t. 11. ; Sieve- king, Med.-Chir. Trans., vol. xl. p. 158; Herpin, Du Pronostic, &o., p. 332, Leech and Fox, in Manchester Medical and Surgical Re- ports, p. 199. It is, however, to be remem- bered that in the case of some of the authors referred to care has not been taken to separate Epilepsy from other convulsive diseases. CAUSES OF EPILEPSY. 765 When there Is a marked hereditary taint as a predisposing cause of Epilepsy, the disease is found to develop itself some- what earlier than under other circum- stances. The difference, however, is not so great as that which is to be observed in regard of some other maladies which are held to be hereditary. The difference may be fairly represented in the following table : — Non- Hereditary, hereditary. Commencing underset. 15 83-33 46-15 above " 16-66 53-82 It has appeared, further, that when Epilepsy is hereditary it shows itself at an earlier age among girls than among boys. The difference is not great, and Messrs. Leech and Fox have arrived at an oppo- site result.' (6) Accidental or Exciting Causes. — Pa- tients and their friends often exhibit a very great anxiety to refer the outbreak of Epilepsy to some external condition, which they may speak of as its cause ; and, in doing so, they occasionally attach undue importance to trivial circumstances. There is a natural reluctance to admit the presence of constitutional or hereditary taint, and an eagerness to find excuses for the poor sufferer, in the fact of his having been exposed to some extraordi- nary disturbance from without. In this way we may in some measure account for the wideness of the range of conditions to which the production of Epilepsy has been referred. It is so ditflcult to conceive that a disease having such strongly marked features as those of the epileptic paroxysm can lurk in an apparently healthy frame — that all the essential conditions of so terrible a malady may be present and yet give no sign— that many find an explana- tion of the outburst in some externally disturbing cause which they can appre- ciate, and ignore the operation of those internal conditions which had hitherto escaped their notice, or had been regarded from a different point of view. It is important to classify the causes to which Epilepsy has been referred, and I have done so by distributing them into four groups : placing in the first, those which operated through the mind or the emotions, such as fright, grief, worry, and the like ; in the second, those which acted through the reflective centre, such as ec- centric irritations ; in the third, those which produced their effect through changes in the general health, such as those which maybe occasioned by preg- nancy, by acute specific, or other dis- eases ; and in the fourth, those which may be regarded as acting physically, such as insolation, mechanical injury, and the like. It is difficult to determine into ' Op. cit. p. 202. which category of causation some cases should be placed ; as, for example, those in which the fits have been referred to either falls or blows, inasmuch as it is possible that such accidents may have operated through the mind by alarm or fear, rather than through the body by the merely physical process of concussion or laceration. I have placed such cases in those groups to which they had been as- signed by the patients or their friends at the time that the disease began. The following table exhibit.s the relative frequency of the several kinds of causes to which I have referred :— Nature of Cause. Numter of Cases. I. — Psychical ; such as fright, grief, worry, overwork 29 II.— Eccentric irritation ; den- tition, indigestion, ve- nereal excesses, dysen- tery, &c 16 III. — Greneral organic changes; fatigue, pregnancy, mis- carriages, rheumatic fe- ver, scarlet fever, diph- theria, pneumonia . . 9 IV. — Physicalinfluences; blows on head, falls, insola- tion, outs 9' 63 Besides these sixty-three cases, I have the records of sixty-one cases in which no cause could be assigned ; the patients or their friends either asserting their absolute inability to make any reasonable conjec- ture on the matter, or hazarding some explanation which was utterly nonsensical. It is important to know that of these sixty- one, there were forty-three individuals who, after examination and cross-exami- nation, and suggestion, could give neither to themselves nor to me any clue to the solution of the mystery. Of 124 cases, there- fore, sixty-three, rather more than the half, supposed that they could explain the causation of their malady ; forty-three, or 34 per cent., asserted their utter inabihty to do so ; while twenty-nine, or 2S per cent., referred their attacks to mental or emotional disturbance. The frequency with which mental or emotional disturbance has been shown to be the cause of Epilepsy is such that it requires some further notice. The most common conditions that I have witnessed are those of continued anxiety and pro- longed rather than intense alarm. I have in a very few instances found that an over-strain of the mental powers has been followed by Epilepsy, but in almost every one of these cases there has been consid- erable anxiety, as well, and it, I believe, ' Messrs. Leech and Fox found a much larger proportion of cases falling under this category. Op. cit. p. 206. 766 EPILEPSY. has been the more efficient factor of the malady. Women and girls have much more Irequently than either men or boys referred their attacks to emotional dis- turbances ; the proportion being 36 per cent, of females, and 13 per cent, of males. The period at which the first attack has occurred after an individual has received some great mental shock varies widely ; the fit may take place at the moment of alarm, or it may follow after an interval of hours, days, or weeks. With regard to eccentric irritations, it must be remembered that in the list given above cases of "convulsions" are not enumerated. Both the first and the second dentition, and even the cutting of the " wisdom teeth," may be attended by convulsions, which in the large majority of cases disappear as soon as the source of annoyance has been removed. In a few rare cases, however, the processes referred to have appeared to cause genu- ine Epilepsy, and it is to these rare cases that reference is made. It is curious to know that in not more than half of the cases of Epilepsy can it be ascertained that "fits" have occurred during infancy; and it is a still more interesting fact that epileptic women appear to exhibit no high degree of proclivity to puerperal convul- sions. Dr. Tyler Smith states that puer- peral convulsions occurred only twice in fifty-three deliveries of fifteen epileptic women ;' and so far as my own experience extends, it is exceedingly rare, and indeed almost unknown, for epileptic women to suffer from their attacks during or imme- diately after labor. Among the second group of causes ap- pears one to which, I believe, far too great an amount of importance has been attach- ed, viz. excessive veneryor masturbation. It is very common to hear suspicions ex- pressed upon this point ; much more com- mon, I think, than to hear any such statement of facts as should prove that Epilepsy and masturbation have any spe- cial character or frequency of relation to one another. The one is a tolerably pre- valent disease, the other a very widely distributed vice. There are multitudes of epileptics with regard to whom no such suspicion could evf r be entertained ; and there are, it is to be feared, much larger multitudes of masturbators who have never become epileptic. When, therefore, we find the two elements combined in the same individual, it is necessary to observe some caution in our attempt to interpret their relations. It is, I believe, sufficiently well proved to be regarded as a fact that the vice referred to is liable to induce various disturbances in the health, and that the major part of these is brought about by, and is exhibited in, the altered 1 Lancet, 1849, vol. xxiv. p. 644. functions of the nervous system ; but what it appears to me is yet wanting in proof is the special relationship of Epilepsy to this particular wickedness or weakness. Again and again it has occurred to me to see cases of vague and various nervous de- rangements which might be fairly inferred to be the result of masturbation ; but it has in only an exceedingly small number of cases of Epilepsy been possible for me to establish the existence of such relation. There can, I think, be no doubt what- ever as to the existence of an intimate asso- ciation between various forms of nervous malady and either various abnormal con- ditions of the sexual organs, or unnatural circumstances attending upon their exer- cise ; but, as yet, the nature of that asso- ciation is, I believe, and as undoubtedly, unexplained. Sometimes sexual excess, and sometimes the reverse ; now great emotional involvement, and now the en- tire absence of all sympathy ; at one time exuberant enjoyment, and at another dis- appointment or disgust, are conditions met with in epileptics, and in all forms of many sorts of disease ; but, so far as I know, neither one of those conditions is more frequent than another in the history of epileptics. I have known cases in which morbid libidinousness occurred in epileptics, but only long after the develop- ment of the disease ; and on the other hand I have met with cases where the sexual propensity had become diminished, or even extinct, after the occurrence of the attacks, and this without any pre- vious excess in its gratification. In endeavoring to determine this ques- tion, which is of considerable etiological interest, it would be undesirable to omit notice of the striking eflects which have been observed to follow the administra- tion of bromide of potassium in cases of Epilepsy. It cannot be doubted that this medicine is highly valuable in diminish- ing the number of attacks ;' and the only point of interest to us now is to ascer- tain whether its modus vperandi is such that it either countenances or discoun- tenances the prevalent belief with re- gard to the etiological question under consideration. When this medicine was first introduced by Sir Charles Locock,^ it was recommended as being of especial service in those cases of Epilepsy in women in which the attacks occurred only during the menstrual period ; and since that time it has been very generally received that bromide of potassium possesses strong antaphrodisiac properties, and that its ' See p. 780 on Treatment, Dr. S. W. Duckworth Williams' Paper "On the Efficacy of the Bromide of Potassium in Epilepsy and certain Psychical Affections," also a paper by the editor in "The Practitioner." 8 See Lancet, May 20, 1857, vol. i. p. 528. SYMPTOMS. 76T utility in Epilepsy is to be accounted for by its special action upon the generative organs. From the very first 1 saw rea- son to doubt this mode of explanation,' and much enlarged experience has, from my own mind, removed all doubt what- ever upon the point, and produced a set- tled conviction that bromide of potassium, when given in such doses as to be of ser- vice in Epilepsy — viz. from 10 to 30 grains either three or four times daily — exerts no recognizable influence upon either the sexual propensity or power. It is not asserted that doses might not be given so large as to exert such influence, but that Ti'here decidedly remedial effiacts have been produced in Epilepsy, their produc- tion has not been attended by any change in the generative functions. Dr. Duck- worth Williams^ says: "I have tried it (KBr) in every variety of uterine affec- tion that has come within my reach, in- cluding nymphomania, satyriasis, mer jr- rhagia, amenorrhrea, dysmenorrhwa, &c. &c., but without perceiving the least bene- fit accrue." Dr. Williams' mentions cases in which the patients, in spite of their taking the medicine, "persisted in their bad habits, and their sensuality became if possible more confirmed" (p. 17) ; and his experience on this matter is in entire accordance with the results of my own observations. "We cannot, therefore, sup- port the prevalent creed in regard of one mode in which Epilepsy is produced by facts gathered from the treatment of that disease by bromide of potassium. To what degree the view to which I refer is supported by the oljservations of Mr. Baker Brown,' must depend partly upon the therapeutic results' of this mode of treatment, and partly upon the inter- pretation which must be given to the alleged facts. On the former point the evidence is unsatisfactory, being gathered from a small and too exclusive selection of cases ;* on the latter point some mis- conception is possible. Considered etio- logic.ally, we want to know the proportion of cases in which the particular cause to vrhich Mr. Brown refers had been in ope- ration, but upon this point we are not furnished with any evidence whatever, inasmuch as in all the cases he records not only was irritation of the pudendal nerves believed to exist, but a certain kind of operation was performed. It would, I think, be pushing much too far the infer- ence to be drawn from Mr. Brown's little book, to assert that his opinion is that mi-y case of Epilepsy is produced in the manner described. What we want to ' See Author, on Epilepsy, p. 332. ° Loo. ant. oit. p. 16. ' On Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females * See Treatment, p. 781. know is the number of cases of Epilepsy in which Mr. Brown entertained no such suspicion, and, still further, the number of cases in which, having entertained it and acted upon it, the result was unsatis- factory. As to the interpretation of the facts that are stated, there is this to be borne in mind, that so far as I can under- stand Mr. Brown's theory, it is not that in such cases there have been of necessity immodest wishes, excessive sensuality, or irregular practices, but that there has been a morbid condition of irritability of a certain nerve, and that this has been taken away by the removal of the peri- pheral termination of the nerve. Eefer- ring for future consideration the question of the therapeutic propriety or desirability of the operation of clitoridectomy,' all that is necessary to say now is that — in the absence of any definite statement of Mr. Brown upon the question of propor- tion as described above — my own expe- rience would lead me to believe that the cause he refers to is of very rare and very exceptional occurrence. In another work^ I took some pains to show how extremely rare it was to meet with a case of Epilepsy in which no causative conditions could be discovered. Although in one person we might find no predisposing cause, and in another no ex- citing cause, in only one-eighth of the cases was there an absence of both. In seven-eighths, either one, two, three, or more causative conditions of disturbance were present and were recognized. The proportion, therefore, of cases of Epilepsy in which the causation of the disease is placed beyond explanation by our present knowledge of pathology is not greater than that which we meet with in many other chronic diseases, and is far less than that which is admitted to exist in several. There is some mystery in the causation of almost all diseases ; and I do not think that it is greater in the case of Epilepsy than in that of many others with regard to which we think ourselves on easy terms with the science of pathology. 3. Symptoms.— It will be convenient to consider those which occur in, and con- stitute a paroxysm of Epilepsy, separately from such as may be observed during the intervals of attack. We have, therefore, to describe, first — The Paroxysmal Symptoms, or features of the attaclc. In most characteristic cases of Epilepsy there is an entire loss of con- sciousness in conjunction with a peculiar series of involuntary muscular move- ments ; but, on the one side of these typ- ical cases, we see epileptics in whom the loss of consciousness is alone obvious. ' See p. 781. 2 Aiithor, on Epilepsy, p. 2G1 768 EPILEPSY. and, on the other, individuals exliibiting certain higlily marlvcd spasmodic plie- nomena, and only very slight or even im- perceptible obscuration of the mind. It is necessary, therefore, to classif}' cases, in order to render description possible, and it is proposed to do so by dividing them into four groups, which may be thus distinguished : First, those in which there is loss of consciousness without evident spasm ; second, those in which such loss of consciousness is accompanied by local spasmodic movement ; third, those in whicli it is attended by general tonic and clonic convulsion, following a particular order ; and fourth, those in which general or partial convulsion occurs without com- plete loss of consciousness. The first and second forms may be termed "epilepsia mitior," or "le petit mal;" the third form "epilepsia gravior," or "le haut mal;" and the fourth "epilepsia abor- tiva," or irregular Epilepsy. (a) Epilepsia Mitior^ or ^''Le Petit Mal," without evident Spasm. — All that occurs and can be positively attested in cases of this description is a sudden, temporary, but absolute arrest of both perception and volition. The individual so attacked loses consciousness for two, three, or more seconds ; and may after that or a longer period resume his sentence or em- ployment perfectly unaware that any tiling abnormal has happened. Sometimes there is slight loss of bal- ance — the patient, if standing or walking, leans to one side, or staggers, but docs not fall ; sometimes there is pallor of the countenance followed by slight flushing ; sometimes the latter without the former ; sometimes there is slight dilatation of the pupil, and an absence of the expression of "looking at anything ;" sometimes an irregularity and faltering of the pulse ; but often, as I can testify from repeated observations, there is not any one of the physical changes I have mentioned ; the patient's mind becomes a blank for a few seconds, and that is all that can be ob- served. These seizures are often regarded as "faintings," and are described by pa- tients under various terms, such as ' ' blanks, " " forgets, " " faints, " "sensa- tions," "absences," "darknesses," &c. &c. Occasionally these slight attacks are preceded by vertigo; the patient thinks he shall fall, and so lies down to avoid doing so : sometimes he staggers and grasps an object for support ; but, much more commonly, he simply ceases to per- form any act requiring volition — he stops speaking or writing; but the automatic movements of standing or sitting, and the secondarily automatic movements of rid- ing, walking, or holding an object, are maintained. Sometimes the attack is followed, for a few seconds or for a longer period, by an obscured or altered state of intelligence ; the patient speaks In reply to what is asked of him, but in half an hour after- wards is fovmd to have entirely forgotten what was said to him or by him. In more rare cases the mind is dull, or alter- ed from its habitual condition for a period of some hours, the patient being low- spirited, or suspicious, and apparently laboring under some delusion which he afterwards forgets. In this condition he may be listless ; or he may do some odd things which he cannot afterwards ac- count for or even recollect, (6) Epilepsia Ilitior with evident Spasm. — This is more common than the preced- ing, which it resembles exactly so far as the mental condition is concerned. The extent and locality of the spasm differ widely in different cases, and also in the same individual at different times. There may be only slight strabismus, or draw- ing of the mouth, partial turning of the head to one side, or some movement as of swallowing or attempts at getting some- thing from the mouth; or, on the other hand, there may be slight momentary rigidity of the whole body. Sometimes the patient fixes his chest walls, and ap- pears to "hold his breath; sometimes he does some curious thing, such as stoop down to peep under a sofa, lie down and pull off his cravat, jump from his chair and walk quickly half-way across a room ; but in any or all of these apparent at- tempts to do something he is suddenly arrested by the loss of consciousness, which is often absolute. Occasionally peculiar actions are performed after an attack of " le petit mal ;" but it has never occurred to me to find an epileptic who could tell me why he did these things, or who could even remember that he had done them. As to the locality of the muscles af- fected, it would appear that those of "ex- pression" and of respiration are by far the most frequently involved. There is no evidence to show that either "trachelis- mus,"' or "laryngismus," or "phlcbis- mus" occurs witli anything like such fre- quency as to make tliem of any value in tlie interpretation of the epileptic parox- ysm : although it is quite clear that the fjrmer may exist to sucli a degree as to occasion duskiness of the face. The spasm in "le petit mal" is never violent ; and it is only of short duration. It is tonic in its character, and painless to the patient, and the vascular changes w!iicli may be observed are of the same variable degree and kind as those enume- ' Marshall Hall, "Memoirs on the Neck as a Medical Region," 1849. SYMPTOMS. 769 rated in the previous section. Patients somotimes liave warning sensations of tliese attacks, and I liave Imown more tiian one instance in wliicii tliere was a highly marlied and most painful "aura epileptica." ' The most common combination and de- gree of symptoms may be thus described, —a feeling of giddiness, faintness, or dis- comfort ; slight twisting of the neck, with anxious, lachrymose expression of the face, dilatation of the pupils, and pallor ; accompanied, or quickly followed, by en- tire loss of consciousness, which lasts for two or three seconds; the patient "be- coming himself again" after making a few sighing sounds, but feeling faint and be- wildered, and often perspiring freely. (c) Epilepsia Gh-avior, or "Xe Haut Mai." — This, the ordinary form of Epi- lepsy, is in the vast majority of cases characterized by complete loss of con- sciousness, and a peculiar combination and series of spasmodic movements. In very rare instances we have the latter element without the former ; the more common and much larger group shall be described first, and it will be convenient to enumerate separately the premonitory symptoms, those of the attack, and the immediate sequelsB or after-symptoms. Premonitory symptoms are sometimes absent altogether; in certain cases they are of regular occurrence, being in the same individual invariable in character, while in another set of cases they are sometimes absent and sometimes present, and are more or less variable in their fea- tures. Their duration may be almost momentary, it may extend to several minutes, or, but very rarely, to hours, or even days. When of long duration, the prodromata are diminished in specialty and in intensity ; and consist, as far as I have seen, in some mental change, or in some alteration of the general appearance. Thus, there may be an exaggeration of any habitual condition of the mind or spirits ; the patient becoming, to an un- usual degree, depressed, morose, or taci- turn ; or, on the other hand, lively, irri- table, and excited. I have known several instances in which an undue flow of spirits, and an emphatic frivolity and ex- pression of "feeling remarkably well," have almost invariably preceded the epi- leptic paroxysms. Such sensations have occurred in those patients whose attacks were not of very frequent repetition. It is very difficult to describe those changes in general appearance, or in "the looks" of a man, which friends recognize as pre- monitory of an attack. Generally, I be- lieve, they depend upon an alteration in the color of the skin, and some want of ' Infra. VOL. I.— 49 fineness in the outline of the features. The face becomes less red, more yellow, and somewhat dusky in tint, and there is a certain pufiiness which, without altering in kind, diminishes in force its habitual expression. It is said, " He seems quite himself, but he does not look so ; he is sharp enough, but looks stupid ; and we know that an attack is coming on. " There is no oedema, but there is a partial obht- eration of the lines which make up "ex- pression." Those symptoms which immediately pre- cede the seizures are widely different in character, variability, intensitjf, and dura- tion. They may occur in the mind, the sensations, the muscular system, or the general bodily condition. The mental prodromata are of many kinds : in some cases there is a distinct idea, never spontaneously presenting itself at any other period, and one which in its character and bearing is perfectlj' remem- bered afterwards ; while in others there is a vague notion, recognized to be the warn- ing of an attack, but of such indistinct character that only the fact of having en- tertained it is remembered. One gentle- man told me that just as an attack was coming on he always thought, "This is what I had foreseen, I knew it would come on here, I ought to have avoided it by remaining away ;" and this, although there had not been the remotest suspicion beforehand that an attack was imminent, or that the circumstances about to be en- tered upon would be likely to induce it. Much more common is a vague feeling of fear, which is horrible enough, but hap- pily of only short duration. Sensorial changes are by no means un- common, and they are of every kind, de- scription, and indescribability. By far the most common is a "painful feeling," sometimes said to be "most painful," or "horribly painful and distressing," but which, yet, the patient sa\s— when mi- nutely questioned— is not "pain," in the ordinary sense of the word. It would seem to be some condition of sensation I which is intensely distressing, but which is unlike what we mean by smarting, burning, aching, Tissot, Traits de rfepilepsie ; Qiuvres, tome vii. p. 131. 2 See cases recorded by Author, op. oit. p. fl2. a change in the nature of secretions ;' but these are of rare occurrence, and of such variable character that the mere fact of their existence is all that need be stated here. The relative frequency of the different classes of premonitory symptoms, so far as I have been able to ascertain, may be represented thus : — Mental and emotional . 11-1 per cent. Sensational IH 8 " Motorial S-G " Vascular and secretory . 3'7 " Prodromata were declared, positively, to bo absent in 40-7 per cent., ^ whereas information was "doubtful" in regard of 16 per cent. The most common precur- sory sensation was vertigo ; there was little difference to be observed between the relative liability of the two sexes to any one form of " warning." Actual Symptoms of the Attack.— For the purposes of description it is desirable to divide the epileptic paroxysms into three stages. In the ^rst stage of the attack there are the following phenomena, which occur — not successively, as they are necessarily represented in writing, but simulta- neously, or with only slightly varying order : — Loss of consciousness, i. e. of perception and volition. Tonic contraction of the muscles throughout the body, with some excess of power on one side, or in one direction. Impeded or arrested respiration, with or without a crying noise. Pallor, redness, or duskiness of face ; either the one or the other, often the one succeeding the other in the order they are mentioned. Dilatation of the pupils of the eyes. Natural, weak, or imperceptible radial pulses, with throbbing carotids and dis- tending veins. This stage lasts from two or three to thirty or forty seconds. The loss of consciousness is usually sudden and complete ; the patient falls down, or is, as it were, "thrown down" in a moment, with or without warning ; but even when the warning occurs, so that he may change his position, or call attention to his wants, habitually the passage from consciousness to uncon- sciousness is abrupt, and the loss abso- lute. Sensation is, at the same time, in abeyance ; although some reflex acts may be excited. ' Romberg, Manual, Syd. Soc. Transl. vol. i. p. 198. 2 Messrs. Leech and Fox give a smaller proportion. Op. cit. p. 218. SYMPTOMS. 771 The tonic spasm of the muscles is pecu- liar, and it may precede the loss of con- sciousness. The patient usually appears to be straining round towards one side, as if striving to look over and behind one of his shoulders. The muscles of the face and front of the neck are those which most frequently mark the onset of the paroxysm.' The eyeballs, the head, the arms, and the trunk, turn and twist round, so as to give the impression I have mentioned. Tliere is universal strain, but not actual equilibrium. Every limb is rigid, every muscle is at work ; but some one set of muscles in each limb proves slightly stronger than its opposing set ; and the limbs pass slowly, in a stif- fened manner, and sometimes with slight jerking movements, from the positions that they occupied before tlie attack com- menced. The head, neck, and trunk share in a similar movement, and its direction is usually uniform in the indi- vidual epileptic. Eespiration is arrested, the patient ap- pearing just like a man forcibly "holding his breath ;" and in nearly half of the cases which have fallen under my own observa- tion, the stoppage of the breathing has been so complete that no sound whatever has escaped from the mouth. In a certain number of individuals the respiration pro- ceeds without actual interruption, but its movements are diminislied in force ; whereas in a verj' small number there is no change whatever. In an uncertain proportion of cases there is the "epileptic crj^," a peculiar and hideous sound, of which there are two distinct varieties. Some individuals utter a yell at the very commencement of the attack, and just before there is the peculiar holding of the breath I have de- scribed. Others do not "cry," but emit a groaning sound, which is, as it were, squeezed out of them by the quasi-touic contraction of the muscles of the chest. There is, in fact, in regard of respiratory movement, a condition analogous to that observed in the limbs and trunk, viz., that of strain, but of imperfect equilibrium. As in the limbs there is a stiffened move- ment, from the fact that one set of mus- cles overcomes its opponents, so in the chest, sometimes a slow expiration, some- times an inspiration is performed, and with either of these there may be a groan- ing sound. Usually there is but one sound — either a yell or a smothered groan; there is no repetition of either the one or the other. 2 ' In twenty-four of forty-two cases. Leech and Fox, op. cit. p. 222. ' I state this as the result of special atten- tion to this point, as in a singular case, oc- curring many years ago, the question of the possible number of "cries" an epileptic Blight make assumed some importance in a medico-legal inquiry. Pallor of the face is observed immedi- ately before, and at the very onset of the attack in many ; it is not present in all ; and it occurs more certainly and more notably in females than in males. In other instances the face remains absolutely un- changed in regard of color, whereas in a larger number there is sutfusion of a florid dull red, or dusky hue. Messrs. Leech and Fox found pallor to exist in only 38 per cent, of their cases, whereas duskiness was "very marked and present all through the fit" in 53 per cent.' Dilatation of the pupil occurs, and, so far as I have seen, invariably, at the onset of the attack. In one case, however, I witnessed a momentary contraction before dilatation commenced. The pulse, as felt at the wrist, is usually small, and is sometimes quite impercepti- ble ; but in several cases that I have ob- served there has been no change whatever in either the force or rapidity of its beats. When it has been imperceptible, there has been highly marked tonic spasm of the limbs ; and often at the same time the heart may be seen, felt, and heard to be acting, and that even forcibly, and there is obvious tlirobbing of the carotid ar- teries. In the second stage of the attack there are the following symptoms : — Persistent unconsciousness. Clonic convulsion. Laborious breathing, with gurgling, foaming, and the like. Darkness of face, and body generally, with cold and often profuse sweating. Oscillation of the pupils. Throbbing, labored pulse, and palpita- tion of heart. This second stage may last from a few seconds to five or ten minutes, its features gradually passing into those of the third stage. The transition from the first to the second stage is abrupt, and is determined by what may be termed the "letting go" of the breath which had been "held" be- fore. Clonic spasms are, more or less, imi- versal ; often they begin in the extremi- ties, and are more highly marked on one side of the body than'on the other. The jaws are champVd together, the tongue is 'bitten, the limbs are thrown about, the bladder, rectum, and vesicula; seminalcs may be evacuated ; there are rumbling noises in the intestines, hiccup, and vomit- ing. The eyeballs are rolled outwards, and in every direction but that which is natural, and the aspect is as hideous as can be conceived. Eespiration is violently and convulsively performed ; the diaphragm may be felt through the abdominal walls; the chest heaves ; the ate nasi are forcibly dilated ; Op. cit. p. 224. 772 EPILEPSY. and the patient is in the condition of one wlio has made a most violent eflbrt, and is now " out of breath." Mucus is heard rattling in the trachea, and is often blown out of the mouth, bloody from the bitten toQgue or cheek. There is obviously great excess of secretion, and much of the distress of the sufferer appears due to his want of power to get rid of it. Duskiness or lividity of the surface ap- pears to increase, and it reaches its maxi- mum just as the clonic spasms begin to abate in their severitj', and the second stage passes into the third. The sweating is often excess-ive, and in some cases has been observed to have a peculiarly fetid odor. The pupils vary from contraction to dilatation, and back again, not, however, becoming so widely dilated as they were at the onset of the seizure ; and thej- are, to some extent, influenced by exposure to light. The veins are greatly distended, espe- cially those of the throat ; the heart beats tumultuously ; friends of patients say, '■ It seems as if it would beat through the chest;" the carotids throb, and the ar- terial pulsation everywhere is violent, and the vessels are full. In the third sta^e, there are manj- of the phenomena of the second, out of which it is gradually developed, — that which marks its an'ival being the partial return of sensation, consciousness, and voluntary power. The movements now witnessed are not wholly meaningless ; the patient makes an attempt to change his position, or to do something, his efforts often, however, be- ing frustrated by some violent spasm ; he '■ kicks"' at those around him, with a be- wildered, suspicious, or sad expression ; still there is "expression ;" and he maj- make some attempt to speak ; the respira- tion becomes less unrul}', he can clear his throat ; the pupils are contracted, but he can see ; the conjunctivas are injected, and there are often petechiee on the fore- head, the temples, behind the ears, and in the eyelids ; the pulse is variable ; there is a jaded, exhausted state, and the pa- tient seems tired and disposed to sleep. This third stage may last from a few seconds to ten minutes, when the " after- stage" of stupor sets in. Often there is a confused mental condition, with occa- sional involuntary movements, lasting for several hours : often the patient recovers rapidly, and goes on with what he was doing before the attack occurred. There is, indeed, almost every decrree of severity in the seizure; sometimes all the symp- toms I have mentioned being passed through in a far shorter time than it takes to describe them ; sometimes each stage being prolonged, and the patient passing gradually into a condition of stupor, from which he awakes, even after many hours, jaded and " beaten,'" and from which it takes several days for him to recover. Vomiting often follows the attacks in many individuals ; in some it is a constant sequence. Large quantities of pale urine are secreted in the majority of cases ; both the urinarj' water and the amount of urea are increased ; and deposits of uric acid and of urates may be discovered. 1 have, however, failed to find either sugar or albumen In the urine of those epileptics who were not affected by either diabetes or Bright's disease. j The afier-syiiiptfriits of an epileptic pa- roxysm varj- widely in character, severity, and duration. There is usually lassitude and stupor, with headache. It is difBcult to rouse the patient, and, if awaked, he is often peevish and irritable, and some- times suspicious. The sleep is usually tranquil, but occasionally disturbed, as if I by dreams. There is commonly stertor, coming and going, guttural in tone, and unlike the noise made by mucus, rattling in the trachea, during the second stage. The muscular condition is that of relaxa- tion, occasionally interrupted, for a mo- ment, by clonic spasm or fibrillar contrac- { tion. This stupor may last, if the attack has occurred in the evening, throughout the night, passing insensibly into ordinaiy sleep. But when the seizure has taken place in the daytime, its average duration has been one hour. It has not appeared to me to bear any constant relation to the severity of the attack as measured by the violence of con\Tilsion. It is often absent i in lunatics who are subject to Epilepsy ;' I but Messrs. Leech and Fox show that there is some relation to be observed be- tween the interparoxj-smal and the post- paroxysmal mental state. When the post-paroxysmal symptoms are absent or slight, 38 "7 per cent, are in the first men- tal class ; whilst of those in whom these symptoms are shght, only lP-1 per cent, are free from interparoxysmal mental change.^ il. Yoisin states that epileptic fits pro- duce changes in the sphj-gmographic tracings of the pulse, which last for several hours after the attacks, viz. as- cending lines of great height and well- marked dicrotism.'' [d) Epilepsia AtxMiva, or EpAlepsia Crravior vrithout complete Joss of Conscious- ness. — It is for the sake of practical con- venience, rather than because it is strictly speaking pathologically correct, that the 1 Dr. Bucknill, Asylum Journal, for Octo- ber, 1&5.5. 2 Op. cit. p. 22r». ' Ann. d'H.ygiene, xxix. p. 358, quoted in Svd. Soo. Biennial Retrospect, 1867-8, p. 471. SYMPTOMS. 773 class of cases now to be described are mentioned in tliis place. Names, as em- ployed in tlie science of medicine, are useful modes of recognition, and not ex- haustive descriptions of tlie maladies they denote. We must give names to the dis- eases we describe ; we must define what we denote by the names we use ; yet, in so doing, we draw, besides the necessary, some artificial lines ; and it is occasion- ally the least of many evils to overstep them. The attacks to be described are almost excluded by our definition of Epilepsy, yet they so closely resemble that disease in all their own features, that they find a more fitting place in this portion of a Sys- tem of Medicine than they could find elsewhere. They are closely related pa- thologically, and wo find in their position here an example of the general principle of terminology employed in this work, and no departure from its spirit. Abortive attacks of Epilepsy have been described by Dr. Prichard (Treatise on Diseases of the Nervous System, p. 91) ; M. Doussin Dubreuil (De I'Epilepsie en general, p. 16) ; Schr. van der Kolk (Pa- thology of the Medulla Oblongata, Syd. Soc. Transl., p. 211) ; Maisonncuve (Ee- cherches et Observations sur I'Epilepsie, p. 22) ; Dr. Eadcliffe (Epilepsy and other Convulsive Afiections, p. 164) ; Herpin (Du Pronostic et du Traitement de I'Epi- lepsie, p. 429) ; Messrs. Leech and Fox (op. cit. 226) ; and M. Brown-Sequard has detailed the occurrence of similar phe- nomena in animals (Journal de Physiolo- gie, tome i. p. 474). Several cases of seizures of an abortive character have fallen under my own observation ; and what is to be said about them will occupy but little space. There has been sudden tonic spasm of the face, neck, and chest, accompanied by arrest of respiration, and followed by clonic convulsion, having the general form of an ordinary epileptic pa- roxysm ; and yet there has been either no interference with consciousness, or only such slight obscuration as to be at first completely denied by the patient. Such paroxysms may occur, at intervals, for many years ; they may take place in those who are subject to ordinary epileptic at- tacks ; or they may exist in connection with other signs of disease in the nervous centres. The interparoxysmal symptoms of Epi- lepsy may be divided into those pertaining to the nervous system, and those not so related. The "nervous" phenomena exist in regard of mind, sensation, and motility, and they are of varying inten- sity, prevalence, and kind. The most im- portant are those which belong to the mental history, and they will be con- sidered first. (a) Mental Condition of Epileptics.— A prevalent belief is that some form or de- gree of mental deterioration is necessarily associated with Epilepsy. The result of inquiry upon this point is to show that there is no such "necessary" relation. The general belief is, however, to be ac- counted for partly by the strong impression which some notable cases of mental failure have made upon the minds of those who witnessed and recorded them, — such strong impression being followed by an undue inference,— and partly by the fact that the words Epilepsy and Epileptic have been made to include every form of disease of brain, spinal cord, or other organs, and also every variety of that multiform derangement which we call " insanity of mind" which might be as- sociated with fits. It is desirable, again, to assert that this article refers only to such cases as constitute Epilepsy proper ; and that the statistics upon which my re- sults are based, can only with a double injustice be compared with those deriv- aljle from lunatic asylums. A patient may be epileptic and a lunatic : he may be epileptic and asthmatic ; but there are some epileptics whose minds are as healthy as their lungs : and, so far as the natural history of Epilepsy generally is concerned, it is a mistake to derive it from compli- cated cases. The mode in which I have endeavored to answer the question, —what is the ac- tual mental condition of epileptics during the intervals of their attacks ? — has been the following. I have divided epileptics into four classes : in the first there are placed those in whom, neither by the pa- tients themselves, by their friends, nor by myself, could there be detected any devi- ation from mental health; such individuals had "nothing the matter with them," but exhibited for their station in life and educational advantages the full average amount of intellectual vigor and cultiva- tion. The second class consists of those who presented that slight defect of mem- ory which is limited to the occurrence of recent and trifling events, the memory for those long since past being intact ; and in those who formed this group, such im- pairment of memory was the only depart- ure from mental health. In the third class are those cases which present, in addition to the loss of memory described, some diminution of the power of appre- hension. Such patients are dull m ac- quiring new ideas, and often receive in- correct or imperfect and confused notions of what is brought before them. The fourth class includes those who, in addi- tion to the failures exhibited by the pre- ceding groups, are hab'tually confused, and unable to follow out any train of thought ; people who seem to think little, but to be in a vacant, wandering state of 774 EPILEPSY. mind, often idle, stupid, and indifferent, and sometimes almost or completely de- mented. Having determined upon this principle of arrangement, it is comparatively easy to answer many questions of interest with regard to epileptics, and to state the an- swers to such questions in numerical terms. This I have done in another work;' and all that it is thought desirable to do now is to give some of tliese results, — and with them others based upon a wider range of facts, — without burdening the reader with a number of statistical details. In rather more than one-third of all the cases which I have examined there has been perfect (i. e. average) mental integ- ritj- ; in a little less than two-thirds, there has lieen some intellectual deterioration, but this has existed to a high degree in onlj' a very small proportion. Women have been found to suffer more frequently and more severely than men ; and the com- monest form of failure is that of defective memory ; this faculty being diminished, c>pecially in regard to recent and trifling events. It is of much interest to know the con- ditions which determine mental failure in the epileptic, and thus to avoid certain errors which are prevalent upon the sub- ject. The results of inquiry upon this point may be stated in the following pro- positions : — Hereditary taint is without influence. The age at which Epilepsy commences exerts a certain amount of influence, and to this effect — that the disease when ap- pearing late in life is more commonly associated with mental failure tlian it is under the opposite condition ; and that the chances of mental failure are less when the attacks commence before the arrival at puberty than the}' are when Epilepsy is developed after "that epoch. This statement is supported by the fur- tlier statistics of Messrs. Leech and Fox.^ Late rather than early Epilepsy is a pre- disponent to intellei tual failure, and t'.iis whether we divide the cases at the tenth, sixteenth, or twentieth years, and whether we consider the two sexes toirether, or each sex separately. The duration of Epilepsy is, ;;>«•.?'', with- out influence upon the mental condition of the epileptic. The amount of mental deterioration is not in direct proportion — but in inverse ratio — to that of muscular disturbance, as shown by the presence of tremor, or spasm, either clonic or tonic. The stale of the "general health" does not account for that of the mind ; the former may be good, and the latter bad, and vice verm; and, contrar\^ to what ' Auct. op. cit. 2 Op. cit. p. 212. would be expected, such relation is more u^ual than the coexistence of marked failure or integrity in both directions. The number of attacks does not deter- mine either the degree or the existence of intellectual change. Frequency of recurrence of the seizures is, however, associated with mental change ; but in such manner as to show that it is not the sole condition of such result, and that it is not even a necessarj' condition. The severity of the convulsive parox- }sm is without apparent influence, when such severity is judged of bj- the duration of suljsequent coma. The form of the attack appears, however, to exert a con- siderable influence. Neither seizures of '"le haut mal," nor those of "le petit mal," necessarily induce the change of which we are speaking ; but the mental deterioration of epileptics is much more clearly associated with the minor than with the severer seizures. The nature of the exciting cause, viz., its existence in the psychical or the mate- rial elements of life, appear^ to be witliout influence in the determination of mental change. [h] Sensorial CvniTiti'm of Ejyilepiics. — Headache and vertigo are the two forms of disturbance the most frequently com- plained of by epileptics. They exist, how- ever, to a high degree in only a small number of the cases ; and, when they do exist, have no special character which renders them of value in either diagnosis or progno-is. Headache is more frequent in females than males. The vertigo of epileptics is commonly of such kind that the patient rarely imagines that surround- ing objects are in motion, but rather that he is, himself, moving or turning round ; he feels as if he were doing so. and is un- steady in standing, or in his attempts to walk. The pupils are more commonly beyond than below the average size : the special senses exhibit neither constant, preva- lent, nor characteristic change. fc) Condition of the Ilotorial System in E^Alepiics. — Some patients exhibit a trem- ulous state of the muscles , some, either with or without tremor, are affected by clonic spasm ; others present tonic spasm, or cramp ; whereas many are quite free from either of these forms of altered mo- tility. In the majority of cases there is some kind of disturbance ; but in the greater number of this majority the amount of such disturbance is slight. The patient often says that he is "ner- vovis." meaning by this that his hand is unsteadv, or that the body is tremulous, or tliat he feels as if they were so. It is often denied that any jerking of the muscles ever occurs ; but the phy- sician may frequently discover that such RELATIOxVS BETWEEN THE SYMPTOMS OF EPILEPSY. 775 denial is incorrect. Tlie amount of clonic spasm may be, therefore, very slight : it may, on the other hand, be very consider- able, assuming cue or both of two general forms. There may be, more or less con- stant and considerable, clioreiform move- ment ; and this may be observed not only when the patient is awake, but when he is asleep, and often with exaggerated force in the latter condition. There may be violent spasmodic shakings of the limbs or of tlie trunk ; occurring at irreg- ular intervals, but exhibiting an especial frequency of occurrence just as the pa- tient fall^ asleep. Such jactitations have proved excessively annoying in several cases, and have been so troublesome as to entail much ulterior distress from the loss of sleep that they have occasioned. Sometimes the jerk of muscles is so sud- den and so violent that tbe patient is thrown out of bed ; or, if standing, is thrown down. Cramp, or tonic contraction, is com- paratively rare, and has apparently only an accidental relation to the disease. Messrs. Leech and Fox found it more fre- quent in occurrence than I have done (op. cit. p. 216). (cJ) Condition of tlie General Health. — There are no changes in the ' " general health" of epileptics to be observed with such sufficient frequency or specialty that they deserve to be reckoned among the characteristic features of the disease. Epilepsy may exist in every condition of the general health ; but among those who have been primarily poor, or who have become so owing to their disease, a low state of vitality is encountered. A simi- larly depraved condition may be found where the circumstances have been dif- ferent ; but such state is by no means necessarily present. Epileptics may be found in robust as well as in feeble health ; but it is important to know the relative frequency of the one and of the other condition. Patients have been examined by myself in regard to their nutrition, temperature, and strength, and the general results of such inquiry are those stated above. But, further, cases have been divided into four groups, viz. : into, 1st, those exhibiting, in every particular, good health ; the limbs being well nourished, of normal tenaperature, and of natural strength ; — individuals capable of enduring both ex- posure and fatigue, as well as any others of their age, sex, and social condition ; 2d, those in whom some failure in one of the above particulars was noted ; 3d, those in whom a double deterioration was observed ; and 4th, those in whom there was deficiency in all three particulars. The result of such inquiry has been to show that more than one-half of the cases belonged to the first group; less than one- third to the second ; less than one-tenth to the third ; and little more than one- hundredth to the fourth. The niusit fre- quent change has been defective tem- perature ; the least frequent, impaired nutrition. The pulse has exhilnted no constant feature, either in frequency, force, or fulness. There is, according to my experience, an entire absence of any specific change in epileptics, so far as regards their func- tions of digestion, respiration, circulation, and secretion. If, as the result of this mode of inquiry, we regard epileptics as a whole, and put together all the results that have been obtained, we come to this important con- clusion, that in a certain number (12 per cent.) there is nothing, absolutely no- thing, abnormal to be discovered during the intervals of attack ; that in nearly two-thirds of the cases some failure may be observed either in mind, motility, or general health ; and that in less than one-third there is marked alteration. It is then obvious that Epilepsy is a disease characterized only by its paroxj-s- mal symptoms, and having, in the present state of science, no special features by which it may be recognized during the intervals of attack. 4. Relations bbtweek the Symp- toms OF Epilepsy. — (a) Forms of Attach. — The severer seizure. Epilepsia gravior, is nearly twice as common as the milder. Epilepsia mitior ; and the former is much more frequently found by itself than is the latter. Hereditary taint seems to exert an influence in predisposing to the severer form of attack. The milder at- tacks, however, do not appear to take the place of the more severe, but to be found with especial frequency in those cases which exhibit a rapid recurrence of the latter, i. e. of Epilepsia gravior. The form of attack does not appear to be de- termined solely, or even notably, by the age at which the disease commences ; but when Epilepsy is developed early in life, there is an increased proclivity to the attack in its milder form. Duration of the malady does not determine its form of seizure. (b) Frequency of AttacTi's.— In about one- seventh of thecases that I have examined the seizures have exhibited a mode of re- currence which has been termed "serial;'' that is to say, that the patients suffer from two, three, or more attacks in one day, and then pass through a period of freedom lasting from one to several weeks; and this mode of recurrence is more fre- quent in the female than in the male sex. The series, groups, or, as they are often termed, "bouts" of the fits, usually oc- cupy one day only, and they are often limited to a period of twelve hours. 776 EPILEPSY. It is rare, very rare, to find an accurate periodicity in Epilepsy ; but it is exceed- ingly common to observe that the recur- rence of attacks has some kind of relation to time, as marked by its natural division into days, and periods of seven days, or multiples of seven days. Thus a large number of epileptics have their seizures every day, every two weeks, three weeks, and four weeks ; while only a much smaller number suffer at such irregular intervals as cannot be thus expressed. An almost identical number of patients state that they have attacks at each of the periods mentioned ; not meaning by that to say that there was always either perfect peri- odicity, or recurrence ''to the day," but that, as a rule, every fortnight, three weeks, month, or day, there had been an attack. There are four times as many epileptics who suffer from their seizures more fre- quently than once a month than there are of those whose attacks recur at longer in- tervals. The return of attacks at monthly periods is rather mcn-e common in the male sex than in the female; and it is very rai-e to find the seizures limited to the time of the menstrual discharge. It is frequently noticed that they are more common during menstruation ; but, on the other hand, many women whose attacks recur at monthly intervals, exhibit no marked proclivity to their recurrence while the eatamenia are present. A high rate of frequency is more common among women than among men. The number of attacks in a given time ranges between very wide limits— from two to two thousand in a year ; but half the cases are found to have a rate of recur- rence ranging from one attack in fourteen to one in thirty days. Great frequency of attack is not con- stantly associated with signs of motor dis- turbance, such as tremor, clonic spasm, and the like. Again, a high rate of frequency is not determined by an enfeebled state of the bodily health ; but, on the contrary, is observed in those whose general physical condition is up to the standard of health, whereas a low rate of frequency is found in those whose organic powers have under- gone marked deterioration. An early commencement of Epilepsy is commonly, but not necessarily, associated with a high rate of frequency in the at- tacks. As the disease continues it exhibits a tendency to increase in the frequencj' of its paroxysms ; but duration is not the sole condition determining this result. (c) Morbid Motorial Phenomena are not found exclusively in those who exhibit an impaired state of the general health, but the one kind of derangement — marked by tremor, or clonic spasm — is commonly found in combination with the other, viz. diminution of temperature, or nutrition, or strength. The prolongation of Epilepsy is not necessarily associated with impairment of the physical condition ; but a high degree of the latter is oiten Ibund in conjunction with a protracted duration of the disease. [d] Consequences of Epilepsy. — If Epi- lepsy were found to entail, of necessity, any definite changes in the health oi' its subject, in regard of either mind, motility, or general condition, we should expect to find that such changes bore a definite and direct relation to the time during which the disease had existed. On this point, however, the result of a careful examina- tion leads to the conclusion that duration is, per se, without effect, and that the de- monstrable "consequences" are niL' 5. Complications of Epilepsy.— These may exist in any organ of the body, but they have no such definite character, except when they are presented by the nervous system, as to require any special comment in this place. The most im- portant is — EpilepAic Mania. — This complication oc- curs in about one-tenth of the cases, if we reckon all those degrees of such disturb- ance as may warrant the application of such name. Having occurred once in a particular individual, it is likely to appear again, and this is especially the case when several attacks have followed in rapid succession. The delirium is commonly but not uni- versally furious and dangerous; it is some- times ecstatic iu form, sometimes dull and melancholic. It may appear in the form of preternatural gayety before the attacks, or in the intervals of their recurrence ; it may break out as violent excitement just as the patient is emerging from the sec- ond stage of the paroxysm. Sometimes the mania has preceded the convulsions, but this order of events is, comparatively speaking, rare. Epileptics occasionally have some premonition of their maniacal state — an indescribable feeling which leads them to place themselves under re- straint before the occurrence of the out- break. More commonly, however, there is no such warning, and the physician fails to discover any special reason for the attack. Meningitis in an acute, sthenic form, may follow epileptic paroxysms; but when it has done so, it has, in the majority of cases, been determined by some accidental injury inflicted by a blow or fall, which the patient has experienced in one of his attacks. Apoplexy is so rare a sequence of Epi- lepsy that it is mentioned simply for the purpose of stating this fact, because it — ' Auct. op. cit. p. 199 et seq. PATHOLOGY. 777 apoplexy — is one of the clangers often quite unnecessarily dreaded by both epi- leptics and tlieir friends. Idiocy may be coniplicated by Epilepsy ; but wlien the two conditions are found together, or are stated to coexist, the truth appears to be this, that the idiotcy has been congenital, and that the idiot has been "subject to fits." Abundant facts and reasons have been already fur- nished for the purpose of proving that the mode of regarding Epilepsy proper which would show that idiotcy is one of its fre- quent complications is. fallacious, inasmuch as it widens the meaning of the word Epi- lepsy beyond what is pathologically cor- rect, or practically desirable. ConvuUions, such as those attending up- on dentition or parturition, exhibit no special frequency of occurrence in epilep- tics. Paralysis is so rare an event that it may be regarded as having — like meningitis — an accidental, rather than essential, rela- tionship to the disease in question. Cyaiwsis is often accompanied by fits, and these have often assumed an epileptic character ; but cyanosis is a rare malady, and its mere mention as a complication is all that is necessary here. Pathology. — Anatomical investiga- tion has hitherto failed to give any ex- planation of Epilepsy ; every kind of lesion has been discovered in every organ of the body, and, on the other hand, every organ and part of organ has been found in per- fect health. The observations of Wenzel,' those of MM. Bouchet and Cazauvielh,'' and the later researches of Dr. Schroder van der Kolk,' have shown the existence of disease in the pituitary body, in the white substance of the brain, and in the medulla oblongata ; but the changes that each of these authors has described have been found to be inconstant, and some of them quite exceptional. We must, there- fore, admit the disease to be what is termed "functional," using that word in the sense strictly defined in the first part of this volume.'' It is beheved that "nu- trition" is Changed, but that its alterations are too fine for detection by our present modes of examination. Bearing in mind all the facts of Epi- lepsy, and proceeding to their interpreta- tion by the aid of physiology, we arrive at the following conclusions : — ^ } ' Observations sur le Cervelet, &c., traduit par M. Breton. ' Archives G^n^rales de MMecine. ' On the Minute Structure and Functions of the Spinal Cord, Syd. Soo. Transl. * See p. 18 et seq. ' The reader is referred to the Author's Treatise on Epilepsy, chapter Pathology, for a full exposition of the views here stated 1st. That the seat of primary derange- ment is the medulla oblongata, upper portion of the spinal cord, and vaso-uiotor system of nerves. 2d. That the derangement consists in an increased and perverted readiness of action in these organs ; the result of such action l)cing the induction of spasm in the contractile fibres of tlie vessels supplying the brain, and in those of the muscles of the face, pharynx, larynx, respiratory apparatus, and limits generally. By contraction of tlie vessels, the brain is deprived of blood, and consciousness is arrested ; the face is, or may be, deprived of blood, and there is pallor ; by contrac- tion of the muscles which have been men- tioned, there is arrest of respiration, the chest walls are fixed, and the other phe- nomena of the first stage of the attack are brought about. 3d. That the arrest of breathing leads to the special convulsions of asphyxia, and that the amount of these is in direct proportion to the perfection and continu- ance of the asphyxia. 4th. That the subsequent phenomena are those of poisoned blood ; i. e. , of blood poisoned by the retention of carbonic acid, and altered by the absence of a due amount of oxygen. 5th. That the primary nutrition-change which is the starting-point of Epilepsy may exist alone, and Epilepsy be an idio- pathic disease, i. e., a morbus per se. 6th. That this change may be trans- mitted hereditarily. 7th. That it may be induced by condi- tions acting upon the nervous centres directly, such as mechanical injuries, overwork, insolation, emotional disturb- ances, excessive vcnery, &c. 8th. That the nutrition-change of Epi- lepsy may be a part of some general meta- morphosis, such as that present in the several cachexiae, rheumatism, gout, syph- ilis, scrofula, and the like ; and further, that it may often be associated with change in the cortical substance of the hemispheres of the brain.' 9th. That it may be induced by some unknown circumstances determining a relative excess of change in the medulla, during the general excess and perversion of organic change occurring at the periods of puberty, of pregnancy, and of dentition. 10th. That it may be due to diseased action extending from contiguous portions of the nervous centres or their appen- dages.' propositionally, and also for complete refer- ence to the different authorities quoted in support of each proposition. ' See Dr. Wilks's paper in Guy's Hospital Reports, 1866. [2 Referring to the article preceding this, upon Convulsions (especially the part dealmg 778 EPILEPSY. 11th. That the so-called epileptic aura is a condition of sensation or of motion de- pendent upon some change in the central nervous system ; and is, lilce the paroxysm, a peripheral expression of the disease, and not its cause. Diagnosis. — Bearing in mind all the features of this disease as they have been described and limited in the foregoing pages, it will be comparatively easj' to distinguish Epilepsy from every other maladj-. The disease may be simulated, and when such is the case the fraud may be detected by the "over-acting'' of the pretender, and longer duration of the paroxysm ; by the choice of locality for the purpose of display ; by the absence of those changes in color which have been described ; and last, but most certainly', by tlie absence of dilatation of the pupil. After the attack the sphygmograph may be employed in the manner adopted by M. Voisin. Syncopal Attacks olten resemble those of "le petit mal ;" and the latter may be mistaken for the former. There is, per- haps, a much closer analogy between them than is sometimes supposed. For practical purposes of prognosis and of treatment, the distinction will turn upon these points of diflerence; in Epilepsy loss of consciousness is sudden, absolute, and fiften without any sense of "faintness;" n^covery is rapid, and there is no recollec- tion of the attack. Hysteria, when convulsive in form, dif- fers in the presence of some volition, some Sensation, some power of directing move- ments. The attack is " got up, " or passed into, gradually ; and is preceded by sob- bing, crying, laughing, and gesticulations: it continues sometimes for an indefinite period, and passes off through a stage of hysterical excitement.' The history of the case before the attack, and after its occurrence, is that of hysteria ; whereas in JEpilepsy there is or maj' be nothing abnormal to be discovered. In the attack there is not the hideous distortion of the features, neither is there the meaningless eye, nor the dilated pupil, nor the bitten tongue ; respiration may be and generally ■witli Unilateral Conrnlsiona) for an admira- ble, though incidental, discussion of the above subject, it may be added that its au- thor, Hughlings Jackson, is regarded by re- cent writers as one of the pioneers in the study of the localization of brain-lesions and disorders, to whicli so much has been con- tributed since 1870, by Hitzig, Ferrier, Char- cot, Vulpian, Duret, and others. Later in this volume, a further consideration will be given to this subject, in connection with the article upon Cerebral Hemorrhage and Apoplexy. — H.] ' See article on Hysteria; [also, Hystero- Epilepsy. — 11.] is disorderly, but there is no marked aspliyxia. After the attacks the patient is exhausted, but does not pass into stu- por ; hysterical mania or paralysis may follow, but they have their own special features. Convulsions — such as those of teething, of worms, and the like — differ as widely from Epilepsy as attacks of bronchial ca- tarrh do from genuine spasmodic asthma. The presence of dyspnoea, cough, and ex- pectoration does not constitute a case of asthma ; the loss of consciousness and convulsion does not constitute a case of Epilepsy. The real nature of the disease must be determined by those facts of its history which lie behind these symptoms, and determine its position in nosology. Convulsions may occur many times, and may sometimes pass into the disease we are describing; but they do not necessarily do this, and mere periodicity of recurrence is not the only mark of distinction between them. Convulsions are most frequently found during infancj', and especially so while the child is cutting its first set of teeth. It is rare for Epilepsy to date from so early a period. Usually febrile symptoms precede the attack, or there is some defi- nite source of irritation in the mucous membrane or secreting organs — c. g. den- tition, worms, indigestion, scybalse, cal- culi. The first occurrence of the convul- sion and its subsequent repetition maj' be traced to one or more of the irritations enumerated. The attacks cease on tlie removal of their "exciting cause:" and they differ from Epilepsy in the ibllowing features : Their invasion is less sudden, and the paroxysm is of shorter duration ; there, is not absolute loss of consciousness at the onset of attack ; if perception, voli- tion, and sensibility are entirely removed, such removal is during the clonic spasm, and not at the beginning ; there is little or no subsequent stupor, and no paraly- sis. The diagnosis of diathetic convulsions is based upon a recognition of the diathesis. At the onset of some of the exanthemata convulsions may occur, and assume an epileptic form, but they are to be distin- guished by the fact of their appearance in early life, the patient being usually under six years of age ; by the presence of fe- brile disturbance, and of some exantheni, or some acute inflammatory change such as pneumonia or bronchitis. In "Bright's disease" of the kidney convulsions of epileptoid type may be the first symptoms which bring the patient under the notice of the physician. There will, however, be but little difficulty in establishing the diagnosis. There are marked and peculiar pallor, puffiness of eyelids or of ankles, and albuminuria. The attacks are followed, or have been PROGNOSIS. 779 preceded, by drowsiness, listlessness, and a tendency to delirium ; tliere are head- aclie, vertigo, clonin spasm, alternating with marked rigidity of limb, great irrita- bility of the muscles on percussion, and often a highly characteristic state of the mental functions. The latter has these features : The patient lies in apparently profound coma, with some limbs relaxetl, and others rigid or in clonic contraction, breathing heavily with a stertorous sound, which may be found to exist in the mouth, and not in the throat ; but, from this state of apparently profound stupor, he may be readily aroused to do that which he is told to do, or to answer questions ; and immediately afterwards he falls again into the state of stupor. His condition resembles somewhat that of a person poi- soned with opium. It is sufficient to mention such diseases as chronic alcoholism, lead-poisoning, syphi- lis, and rickets, in order to indicate the means by which, when they are attended by convulsions, the diagnosis may be es- tablished. Organic Diseases of the Nervous Centres may be distinguished from Epilepsy by the fact of their presenting symptoms over and above those proper to the latter. "When conspicuous and persistent changes in the functions of the nervous system oc- cm during the interparoxysmal period, we may infer the existence of structural disease. Again, there is more marked impairment of the general health ; and the signs of disordered nerve-function have a more rapid development than have those which may occasionally be observed in Epilepsy. Tumor of the brain exhibits its most characteristic feature in persist- ent, or paroxysmally exaggerated pain, limited to a particular locality, and ac- companied by local paralyses. Chronic softening may be diagnosticated by the gradual failure of mind, sensibility, and muscular power. Chronic meningitis may have a protracted history, but it is one of highly marked interparoxysmal change. There is irritability of temper, and, occa- sionally, delirium with loss of memory and impaired intellectual power : there is spasmalternatingwith local paralysis ; and there are alterations of the special senses, with headache and general malaise. The convulsions which occur in chronic cerebral diseases are not precisely like those of Epilepsy; there is less suddenness in their invasion, there is not the com- plete loss of consciousness, the convulsive movements do not pass through the sev- eral stages that have been described, but are irregular in their manner of develop- ment, protracted in their duration, and often limited to one side, or to one ex- tremity. There are not the asphyxial phenomena of Enilepsy, neither is there tlie subsequent stupor. Again, the ages at Avhich intra-cranial diseases arc developed differ from the prevailing age at which Epilepsy makes its appearance ; neither aneuvisui nor car- cinoma appears, as a rule, so early in life as does the disease under consideration ; cerebral tubercle, when occurring in child- hood, has a history widely different from that of Epilepsy ; and, lastly, each of these is attended by its own special dys- crasia, which may afford all that is needed to complete a diagnosis. Prognosis. — When the disease has been established for some time, and i.s recognized to be an idiopathic affection, the prognosis is unfortunately very unfa- vorable as regards perfect and permanent cure. When it is recent, much hope may be entertained. Cases of eccentric con- vulsions and of chronic meningitis, either syphilitic or simple, may be cured, and such are often spoken of as epileptic ; but I do not include tliem in the present arti- cle : the remarks here made apply exclu- sively to Epilepsy proper. Tlie general prognosis is framed upon several different considerations. Hered- itary taint is of unfavorable omen ; whereas an early commencement of the disease is the reverse. The duration of the malady is of the highest importance ; the longer that it has lasted the greater is the difficulty and improbability of cure. Tliose cases in which the intervals be- tween the attacks are much prolonged are less amenable to treatment than are those which exhibit a more rapid recur- rence. Mental failure is of evil augury, but not to so high a degree as has been supposed. Some of the most obstinate cases are those in which the general health is good ; some of the most tracta- ble are those in which there is a disturb- ance which may be corrected. Next in importance to that of the prog- nosis of the dis(!aso as a whole, is the forecasting of the mental state, supposing that the disease itself cannot be cured. What conditions are there which would render mental failure probable ? The section on "natural history" supplies the answer to this query, but its results may be recapitulated here. Hereditary taint is without influence : the female sex is of unfavorable omen; late commencement of the disease is a predisponent to intel- lectual failure ; mere duration is without influence ; an impaired state of the gen- eral health is of good rather than evil import ; mere number of attacks is of no moment ; rapid recurrence of seizures is indicative of danger; and attacks of "le petit mal" are more injurious than are the severer paroxysms. The danger to life is somewhat remote, and need scarcely be entertained. It is excessively rare for an epileptic to be 780 EPILEPSY. killed bj-, or die in one of his attacks. Van der Kolk' has shown that the dan- ger to life is greater in those cases in which the tongue is not bitten ; but I have no observations to prove either the correctness or the incorrectness of this opinion, as I have never yet known a ease in which the attack proved fatal. Treatment. — There are two distinct elements to be regarded in the therapeu- tics of Epilepsy: the one is the diminution or removal of the condition which is the essential element in the disease ; and the other is the mitigation of the paroxysmal symptoms when their removal cannot be eflected. TVe have to direct the treatment of the disease and that of the attack. It has been already stated that many epileptics, during the intervals of their paroxysms, present no abnormal condi- tion ; yet it is to be inferred that there must exist in them some departure from health, and the conclusion to which we have arrived is, that this departure con- sists in an undue readiness of action in certain portions of the nervous centres. Our object, therefore, is to control this over-readiness of action. For this pur- pose sedatives have been employed, and with success. It would be useless to at- tempt any estimate of the relative value of many of these agents, for there are no data sufficient for the purpose. Opium or morphia, conium, hyoscyamus, stramo- nium, belladonna, cannabis Indica, atro- pine, valerianate of atropine, selinum pa- lustre, cotyledon umbilicus, chloroform, and other medicines have been employed with good effect in some cases, and with- out any appreciable effect in others, and hitherto no principle has been evolved from either their failure or success. When the attacks have been of very frequent recurrence, I have found preparations of the solanacese useful in diminishing the number of seizures, but I have never known them to effect a cure. Opium, or some preparation of morphia, has been of service when the patient was restless at night, and was olsviously suffering from the effects of loss of rest. Chloroform has delayed attacks while the patient was ac- tually under its influence, but has failed to prevent their subsequent recurrence. Dr. Murray has, however, been fortunate in the treatment of some cases by means of chloroform, and his observations are such as to warrant a further employment of this agent.2 Indian hemp has relieved headache and restlessness, but has not cured or notabljr relieved Epilepsy. The salts of zinc, and especially the oxide of zinc, have appeared to be of ser- 1 Op. cit. p. 252. 2 Medical Times and Gazette, April 8, 18G5. vice ii^ many cases ; their action being obviously sedative. I have seen no good results from the sulphate of zinc given in heroic doses, and the good effects that have come under my own observation have been from oxide of zinc in doses of three or five grains given three times daily. The salts of copper and of silver have proved utterly useless in my own experience. Bromide of potassium, or some other salt containing bromine, is the one medi- cine which has, so far as I know, proved of real service in the treatment of Epi- lepsy. Undoubtedly it is "sedative" in its action ; it lessens spasmodic move- ments, especially those of paroxj-rmal character, and sometimes insures sleep when vegetable sedatives, and among them opium, have failed. Bromide of potassium in small doses has appeared to be of little or no service, but in large doses it rarely fails to give some relief. Sir Charles Locock has the merit of intro- ducing this drug to the notice of the pro- fession in this country,' and the testimony of all those who have had much expe- rience in the matter concurs to a remark- able degree as to its utility. Given in doses ranging from ten to thirty grains, three times daily, it has had these effects: In some cases it has completely cured the patient, and the cure has been permanent for years, and is so now. In others it has arrested the attacks so that none have occurred for periods varying from a few months to two or three years ; but, on the omission of the medicine, the seizures have returned. In such cases the attacks have again ceased on the re-administra- tion of the medicine. In a third series of cases it has diminished the frequency and severity of the seizures, but has not ro- nioved them altogether ; the patients while taking the bromide have had one- half or one-third of the number to which they were habituated. Such patients have gone back to the old frequency of recurrence when the drug has been omit- ted, and have again improved when it has been re-administered. In a fourth, but very much smaller number, the influ- ence of the drug has been good for a time, and has then appeared to cease ; and in a fifth, and yet smaller proportion, it has been apparently without any appreciable effect. Still further, there are a very few cases in which the number of seizures has been increased by bromides. Dr. Duck- worth Williams has shown that it exerts much influence over those cases in which the attacks take place during the day, but that it is of little use in those patients whose seizures occur dviring the night. ^ I have found that this is true to a certain ' Lancet, May 20, 1857. ' Op. cit. TREATMENT. 781 extent, but not to the degree described bv Dr. Williams ; for in several instances KBr has been very useful when the fits were limited to the hours of sleep. It is possible that Dr. Williams's cases may have been, from the fact of their compli- cation with insanity, peculiar in this re- spect. Bromides appear less useful in growing girls and youths than in those who have reached adult age. It often happens that the administra- tion of five grains will diminish the fre- quency of attacks, or prevent their oc- currence, for a period of weeks or months ; but that then, the medicine being still taken, the seizures revert to their previous rate of frequency. An increase of the dose is followed by a similar succession of events ; a further increase by a second succession of temporary improvement and subsequent deterioration ; and so on, until a larger dose, of from thirty to forty grains, is administered three times daily, when the attacks cease altogether. It is not the mere administration of the drug, but its presence in certain quantity, that is necessary for a cure ; but the dose which shall prove curative is not deter- mined by either one of the following con- ditions : sex, age, duration of disease, frequency of attack, severity of attack, or form of attack. The number of cases in which it proves of no service, at any dose, is very small ; and some of the cases which resist its ac- tion do not differ in any other obvious re- spect from those in which the bromide is highly efficacious. In an earlier part of this article I have given reasons for thinking that the mode in which KBr proves useful in Epilepsy is not by its diminishing either the sexual propensity, or power. It is positively curative of Epilepsy when given in doses which exert no influence whatever upon tlie generative functions. In some individuals the administration of KBr produces discomforts to which the term bromism has been applied. The most common of these is an acne-like eruption on the face, shoulders, and body generally ; the most important is a state of stupidity and partial aphysia. Drow- siness, dulness of apprehension, muscular weakness, and general lethargy are often met with ; and these symptoms may exist with varying degrees of severity, and be produced very easily in certain individ- uals. On the other hand, KBr may be given for many consecutive years, and in large doses, without producing any one of the discomforts that have been mentioned. It is easy to remove these symptoms by a discontinuance of the drug, and the tem- porary administration of a bitter infusion with a mineral acid ; and it is equally easy, and much more desirable, to pre- vent their occurrence, by omitting the medicine for one or two or even three days in the week. All the good effects of Br are thus secured, and its evils are avoided. Dr. Williams' states some facts which would appear to prove that KBr does di- minish the force of the heart's action ; but in my own experience this has not occurred to any such degree, or with such frequency, as to make me attach any im- portance to its occurrence. Bromide of potassium has arrested Epilepsy without producing any diminution of cardiac ac- tion ; and in all cases where there has been the least suspicion of such effect, the addition of chloric ether, or of tincture of cinchona, or indeed of any diffusible stimulant, has at once removed the threatened inconvenience. The bromide of sodium was suggested to me, some time ago, by my friend Dr. Bansom, of Nottingham, and I have now employed it in a large number of cases with perfectly satisfactory results. The dose is tlie same as that of KBr, but the NaBr has this advantage, that it may be taken alone, as common salt, with food, and when mixed with an equal proportion of NaCl would be quite unnoticed in the salt-cellar. Counter-irritation, and derivants, such as setons, issues, and the like, have ap- peared to me to be of signally little service in genuine Epilepsy, so that I have been led to the belief that those cases in which they have been said to be of great utility have been examples either of some other malady, or of some complication of the disease. As to diet and regimen, these things seem to me important : flr.st that the pa- tient should eat digestible meals, with great regularity ; and second that exer- cise, in the open air, should be taken as much as possible, short of fatigue. Many epileptics have been relieved from noctur- nal attacks by being made to sleep with the head and shoulders well raised, not by pillows, but by a simple contrivance which is placed under the upper half of the bed or mattress on which they lie. Baths used for the purpose of cleanUness are useful in Epilepsy as in many other diseases ; but I have seen more harm than good follow the employment of douche, shower, and sitz baths, when these have been administered in any manner or to any degree which exceeds that of pro- ducing comfort tn the individual. Warmth to the"^ extremities, especially at night, is of great value ; the patient should never go to bed with cold feet, nor run the risk of their becoming cold during the night. Pires, hot water, hot-water baths, and woollen socks, may prevent much mis- chief Sexual intercourse appears to me also to be one of those matters upon I Op. cit. EPILEPSY. ■which the dictates of common sense are sufficient without any special direction from tlie physician. The mental state of the epileptic may be much injured by action upon one very common form of advice, viz. that the pa- tient should "do nothing." It is desira- ble to avoid over-exertion, worry, and undue excitement ; but moderate mental exercise is of great utility ; and some defi- nite employment, carried to a point short of fatigue, should be enjoined as part of the treatment of those cases which are not complicated with cerebral excitement. It is impossible to pay too great an amount of attention to the '"general health" of epileptics, but there is nothing special in regard to tliis matter. Cod-hver oil, quinine, iron, alteratives, and aperi- ents must be given in circumstances which would render their exhibition desirable in other forms of disease. Allusion has already been made to the operation of clitoridectomy, and reasons have been given for suspending judgment on the matter. Doubtless success has fol- lowed such treatment in some cases, but the results are, at present, too uncertain for the formation of a definite opinion, first as to the stability of the cure ; sec- ondly as to the class of case in which the operation is justifiable ; and thirdly as to the therapeutic modus operandi of clitori- dectomy when it has appeared to be use- ful. It is not only possible, but highly probable, that an operation of severity equal to that of clitoridectomy might prove servicable In some cases of Epi- lepsy if it were performed on the back of the neck, the mouth, or the toes. A strong impression upon the mind, or a violent change in the body, such as the opening of an issue, the performance of trache- otomy, or the occurrence of an accidental burn, has often arrested the attacks. It is probable that clitoridectomy and cir- cumcision may, in some cases, act bene- ficially in a similar manner ; but it is ob- vious that, if they do, the form and local- ity of operation might be changed with advantage. So far as my own observa- tion extends, the cases are almost infi- nitely rare in which such an operation would appear to me to be allowable. The application of ice to the spine has, of late, been advocated with great ability by Dr. John Chapman ; and there appear to be many theoretical considerations war- ranting the employment of this mode of treatment. It is not my purpose to de- tail the theory upon which Dr. Chapman has acted, as it is fully explained in his own writings. I regret to say that such application has utterly failed to do any good in a very large number of epileptics for whom I have prescribed it. Ice has been applied in the manner recommended by Dr. Chapman, and has been persevered in for many months, without producing the smallest effect upon the frequency or severity of the paroxysms. In one case, at University College Hospital, it was ap- plied both night and morning, without influencing the disease, and on more than one occasion the fits took place while the ice-bag was on the spine. In one instance it was followed by relief, but in this case the patient was taking at the same time bromide of potassium. For the purpose of testing its utility I have employed it in a number of cases without giving any medicine whatever, and the result has been absolutely negative ; it has done no harm, but it has done no good. It has appeared in several individuals to be of service in the first instance, but soon, in spite of its persevering application, the attacks have recurred with their usual frequency and severity. Patients have not complained of its application, but I have failed to find that it exerted any in- fluence upon their temperature, when this was tested by their own sensations, or by the thermometer applied to either the axillse or the extremities. The treatment of the attach is mainly of value when directed towards its preven- tion ; and there are several means by which some good maj"^ be accomplished. When an "aura" is present, the parox- ysms may sometimes be arrested by cau- terizing the surface from wliich the aura comes, or by applying pressure between the starting-point of the aura and the trunk. Sometimes the attack begins by a special form of contraction in particu- lar muscles, and its progress may be arrested by forcible extension of these muscles. Chloroform, or ammonia, if in- haled, will often prevent the seizures just at the moment of their onset ; and in like manner a draught of wine, of sal- volatile and water, or of some other dif- fusible stimulant, will put off the attack. When patients have warning sensations, of sufficient duration for them to do any- thing, it is desirable that they should carry with them some little draught of this kind, which they may take at the moment of threatening. By such means a large number of fits may be averted. [Xitrite of amyl has been found to ex- ercise great control in this way in some cases. It is a powerful remedy ; to be employed with much circumspection. A few drops only should be inhaled at a time ; the dose to be, after frequent repe- tition, very cautiously increased.— H.] Tracheotomy has been shown to be of no such real service in Epilepsy as to war- rant its recommendation. When the attack is once established, there is little that can be done beyond that of preventing the patient from injur- ing himself. Compression of the carotids may arrest or shorten the attack, but it MUSCULAR anesthesia: symptoms. 783 (loos not cure the disease. It is posi=ible tliat the pressure upon the nerve trunks is an important element in this mode of treatment. A piece of India-rubber may save the tongue from being bitten ; a loose cravat may diminish the petechial discoloration of the face ; and a strong arm may hinder the bruising of the ex- tremities. When the paroxysm is over the patient should be allowed to sleep, and should be placed with the head and shoulders raised. In some epileptics the mental symptoms are the most highly marked features of the interparoxysmal period, and to these attention must be uiaiuly directed. lu otuers tae general healtli is greatly at fault, and in thcni the treatment must be turned towards its improvement. In a third class there is excessive motility of involuntary kind, and in such cases the vegetable sedatives are of marked utility ; but in all, the medicine which has proved most useful, in my own experience, is the bromide of potassium. MUSCULAE AN"^STHESIA. By J. Russell Reynolds, M.D., F.R.S. DEflNlTJON". — A loss of the feeling of mujcular action, attended by irregularity, sluggishness, and diminished force of vol- untary movement ; but unattended by any necessary loss of cutaneous sensibil- ity or by distinct paralysis. NOMBNCLATUEB. — The property which is diminished or lost, in the aliection above defined, has been described under dilx'erent names, of which the following are the more important : — " the muscular sense;" "le sentiment d'activite musculaire ;" "le sens d'activite musculaire;" "la conscience musculaire :" " le sens muscu- laire-;" "le sens de la force :" ''le senti- ment du mou vement ; " " der Muskelsinu. ' ' Symptoms. — The essential features of this condition are the following : — awk- wardness and clumsiness in performing certain voluntary movements, sometimes of the hand and arm, sometimes of the lew, sometimes of the face. The patient tries to do what he wishes, or is told to do, and succeeds in the attempt by look- ing carefully at his limb, and helping it with one of the others which is unaffected ; but if not paying great attention, or mak- ing any great effort, he fails to effect the movement, lets objects fall out of his hands, knocks his legs one against the other, or in some other manner exhiliits clumsiness and want of co-ordinating power. If placed in absolute darkness, or if the eyes are bandaged, he may be unable to execute any movement. The negative features are,'that there may be no loss of cutaneous sensibility ; the special senses may be intact ; and there is no distinct paralysis. jMovements instituted in the affected parts are less vigorous than is natural ; the limbs are somewhat inert, and often hang idly by the side or are carried by some mechanical contrivance ; but they can be, by a strong effort, rendered almost as.vigorous as in health, and the individual, after' two or three awkward failures, may succeed in performing some complex act, provided that he thinks much about it and looks fixedly at what he is attempting to do. If the muscles are pinched forcibly be- tween the fingers, or if they are submitted to the electi'ic current, they exhibit a diminution of sensibility. This has been well shown in a case lately under my care in University College Hospital ; the patient did not know when the magneto- electric current was applied to the mus- cles of the right leg, although they could be seen to act quite vigorously. There was loss of cutaneous sensibility and of muscular power in the same limb, l)ut electric irritabihty, although diminished, was preserved. As the voluntary power and the sensibility of the skin l-eturned, some electric sensibility returned also, but it was notably deficient long after the electric contractility was almost normal ; the patient being scarcely conscious of an amount of actual contraction of the mus- cles induced by electricity, which amount could not be tolerated for a moment in the muscles of the unaffected limb. Without looking to see, the patient does not know the position of his limbs ; and even when he has voluntarily as- sumed any attitude or position, he swerves from it if his attention be directed to some other object than his own Umbs. 784 MUSCULAR ANAESTHESIA. Minor degrees of this disturbance may often be observed in conjunction witli de- finite but partial paralysis, in either a paraplegic or hemiplegic form. Such patients can only move their toes or fin- gers when tliey are looking at them ; and they do not know, if their eyes are closed, whether they are moving their extremi- ties or not, but, in perfect innocence, may ask the physician to inform them. Commonly, Muscular Ansesthesia is seen in combination with other evidences of profound change in the nervous cen- tres ; but sometimes it exists, and that for a considerable time, alone. It may be, and often is, the precursor of paraplegia, and under such circumstances may be con- founded withataxy,spinalcongestion, com- mencing myelitis, or softening of the cord. The following case aflbrds a fair illus- tration of the malady : — A. B., female, at the age of 18 or 19 years, "caught cold" during menstrua- tion, and soon afterwards felt ''loss of power" in the legs and hands ; she stum- bled in walking, and found it very diffi- cult to dress herself The symptoms became slowly better, but occasionally re- turned ; and three years after their com- mencement she married, and at the time of my seeing her, eighteen months after marriage, had a baby three months old. She walked into my room leaning upon the arm of a friend, but she stumbled, and nearly fell down in doing so ; her position in standing, when wifliout sup- port from another person or a table, was that of inclination forwards, and she rocked about from side to side, and an- tero-posteriorly : when she attempted to walk she occasionally reeled, and did this especially when engaged in conversation. If told to make an effort to walk in a straight line, she looked carefully at her feet and managed to do so without much deviation. When standing with her heels together she maintained steadiness of position as long as her hand was on the table, or she was paying attention to her drill ; but, in a moment, if her mind was distracted with conversation, she stag- gered, and caught at some object for sup- port. She told me that her hands were much better than they had been pre- viously ; but that still "they were " very odd." It was, as I observed, difficult, and indeed impossible, for her to do sun- dry httle things, such as putting a pin into her dress or taking it out, fastening or unfastening a button, without seeing cither her fingers or the reflection of them in the glass. She found it impossi- ble, or very difficult, to play on the piano- forte, and, as she expressed it, she " could not fasten anything she could not see." Objects fell out of her hands when she did not look at them; when standing with support on both sides, but with the eyes closed, she could not raise either foot from the ground,— the sole of the foot seemed glued to the carpet. The cuta- neous sensibihty was perfect ; the electric contractility and sensibility were natural ; there was no failure of general health, no tenderness of spine, no alteration in the special senses, no pain; and there were no symptoms of hysteria. All that was lost in this case was the sense of muscular condition and action. Causes.— Kothing definite is known with regard to these, beyond the frequent association of Anaesthesia Muscularis with hysteria. I once saw a marked case of Muscular and Cutaneous Ancesthesia which had been induced by exposure to cold. The symptoms in this instance were developed suddenly ; but in other cases their com- mencement has been insidious, and their progress slow ; and it has been impossible to assign any rational cause for their pro- duction. In many they have followed a series of convulsions or other symptoms of hysterical character. Diagnosis. — From paraplegia gene- rally, whatever may be its cause. Muscu- lar Anaesthesia may be distinguished by the facts that power is not lost, and that forcible movements may be determined, although not directed with exactness. In ordinary paraplegia the awkwardness of movement is due to and proportioned to the want of power ; in Muscular Anaes- thesia there is no such relation. More- over, the patient exhibits none of the signs of interference with those functions of the spinal centre which are speedily involved in all cases of paraplegia depending upon changes in the nutrition of the cord. The limbs do not waste, the skin undergoes no special alteration, the urine is not altered, and sensation in other directions is un- changed. From hemiplegia, indicative of those cerebral diseases which are usually ac- companied by paralysis of one side of the body. Muscular Anaesthesia is separated by considerations similar to some of those which have just been mentioned ; but mainly by the absence of conformity of the case to the known types of cerebral lesion, by freedom from intellectual change, and by the limited distribution of the symptoms. Locomotor ataxy resembles Muscular Ana3sthesia in its most striking symptom, viz. want of co-ordinating power ; and in many cases of the former there are symp- toms of the latter. It was present, for example, in 28 of 50 cases analyzed by Topinard ;' but it was absent in 22 cases, • De I'Ataxie locomotrice, p. 203; Paris, 1864. PATHOLOGY — PROGNOSIS. 785 and was but slightly marked in 8. The clinical history of locomotor ataxy is dif- ferent.' There is not necessarily the special want which is the essential con- dition of Muscular Antesthesia ; and in the latter there is an absence of pain in the limbs, of implication of the genital organs, and of affections of the eyesight. Hysterical patients often exhibit the phenomena of Muscular Anesthesia ; in- deed it is one of the expressions of their malady ; and the only point of interest to ascertain is the degree to which this con- dition, the hysteric, may account for all the symptoms. The general course of the case usually aifords the information that is required ; it would be unsafe to refer Anfesthesia Muscularis to hysteria, unless otlier symptoms of the latter disease ^vere present ; it would be unwise to suspect the existence of grave central lesion unless hysteria could be excluded. PATHOtoaY. — The present state of physiology with regard to the existence and nature of the muscular sense is so unsatisfactory that it would be cj^uite idle to occupy much space in the discussion of its pathology. With regard to the existence of such sense there appears to be evidence similar to that which we possess in respect of other senses, viz. our consciousness of its existence. It is a matter of fact that we do know when, in what direction, and to what degree we contract our muscles. We guide our movements without looking at our limbs, we know where our extremi- ties are placed, we determine movements when we like, and apportion the amovint of effort to the task set before us ; we guess at the weight of a body by the effort we make to raise it, and do not break an empty egg-shell if we hold it between our fingers in the dark. The patient with Muscular Anaesthesia has lost the power or faculty which renders these adjust- ments of movement possible. The fact of the existence of a muscular sense may be regarded as established, and also that of its distinctness from all other modes of sensation. It is tolerably certain that the peripheral expansion of the muscular- sense nerves exists in the muscular tissue itself, and not in either the skin or the structures around the joints ; but beyond this point there is grave doubt even as to whether the fibres pass in the anterior or posterior roots of the spinal nerves. M. Trousseau^ admits the existence of mus- cular sensibility, but denies that of the sense of muscular activity ; and the most ' See article on Locomotor Ataxy. ' Article "Ataxic locomotrice progressive," NouTeau Dictionnaire de Medecine et de Chi- rurgie pratiques, tome 3me, p. 777. VOL. I.— 50 important fact upon which he bases his opinion is contained in the following words : " Lorsciue, fermant les yeux, nous executons sans efforts un mouvement as- sez etendu, il nous est impossible, avec la plus severe attention, de sentir nos mus- cles se contracter ; niais nous sentons le mouvement imprime aux leviers que la contraction des muscles met en jeu. Le fait est si vrai, ciue si nous intcrrogeons une personne fort intelligente, mais'cora- pletement etraugere aux notions anato- miques et physiologiques, et si nous lui demaudons quel est le siege du mouvement d'extension et de flexion des doigts, elle le place exclusivement dans la main et jamais dans I'avant-bras." This obser- vation is quite correct, but M. Trousseau's conclusion from it is, I think, erroneous. We do not see objects nor hear sounds in either our eyes or ears ; but involuntarily project these sensations, not into a distant part of our own body, but into space out- side ourselves. The senses of taste, smell, and of tact, we refer to something or somewhere just bej'ond the extreme peri- pheral expansion of the nerves which minister to those senses. We do not feel — or mentally recognize as such — the con- dition of our own nerves, but instinctively and of necessity feel and believe in some- thing outside ourselves, or objective, that presses on the skin ; something not our- selves that we taste in our mouths ; some- thing not ourselves that we smell in our noses. It is well known that a patient who has lost his leg imagines that he feels pain in his amputated toes, and in this we have another illustration of the principle that the mind does not refer sensation to the spot which receives the impression wdiich may occasion it. Because, there- fore, in the act of muscular movement our consciousness refers the sense of such movement to the extremity moved, and not to the moving organ, it is not proved that there is no sense of muscular ac- tivity ; on the contrary, it is shown by this fact that the muscular sense obeys a law similar to that which we recognize in regard of other senses. Tor the existence of the sense we have the evidence of con- sciousness ; and for the absence of the sense, there is the testimony of disease. It matters, comparatively speaking, little for our present purpose to determine the exact nature or metaphysical relations of the propertv in question ; it is enough that in health there is a faculty which has been called " muscular sense," and that in dis- ease this function is destroyed ; that such disease may exist alone, and that the name by which it is denoted is "Muscu- lar Anffisthesia. " Peogxosis.— The future of such cases cannot be predicted with certainty. It may be guessed at by regard to conditions 786 WASTING PALSY. other than those of the affection itself. If it be but one of many symptoms of that manifold disease called hysteria, the prog- nosis is that of the latter malady ; if it be associated with grave changes in other portions or functions of the nervous sys- tem, the nature of such ulterior symptoms must determine the prognosis. There is nothing special in the character of the symptoms of Muscular Anaesthesia, per se, which can form a satisfactory guide. Teeatment. — Faradization of the af- fected muscles has proved of service, as has friction of the skin, and its electric irritation ; but there are no medicines that have been shown to exert any special influ- ence upon this variety of nervous disorder. WASTING PALSY. By William Roberts, M.D., F.R.C.P. Definition. — A chronic disease, con- sisting in a progressive atrophy of the voluntary muscles, independent of any antecedent motor or sensory paralysis. The disease attacks the muscles in groups: in some cases it is partial, and limited to the extremities ; in other cases it is gene- ral, and implicates the muscles of the head, neck, and trunk. Stnokyms. — Paralysis Atrophica ; Pro- gressive Muscular Atrophy ; Cruveilhier's Atrophy ; Atrophic Musculaire Progres- sive (Pr.); Progressive Muskelatrophie, Progressive Muskel-lahmung (Ger.). History. — Cases of extreme wasting of the muscles of the upper and lower limbs, without loss of voluntary power, were published in this country, in the earlier decades of the present century, by Cooke, Bell, and Darwall ; but the establishment of the affection as a distinct type of dis- ease is due to the labors of Cruveilhier, Aran, and Duchenne, in Prance, in the years 1851-53. The present writer col- lected all the information existing on the subject up to 1858, in an Essay published in that year.' To this Essay the reader is referred for the earlier notices of the dis- ease. Since 1858 the pathology of AVast- ing Palsy has been elucidated by the in- vestigations of Gull, Lockhart Clarke, Luys, and others. Etiology.— The subjects of "Wasting Palsy are mostly found among young adults and middle-aged individuals ; but children are not unfrequently attacked. The mean age of eighty-eight cases col- lected by me was thirty years — the young- ' An Essay on "Wasting Palsy, by William Roberts, M.D. London, 1858. est was only two years of age, and the eldest sixty -nine. The male sex is considerably more liable to the disease than the female (about six males to every one female). This disproportion probably depends, mainly, on the greater and more sustained muscular exertion which men's occupa- tions demand ; also on the greater expo- sure to cold and external violence of indi- viduals of the male sex. Women of the working-class — washerwomen , domestic servants, sempstresses, &c. — are seem- ingly not much less liable to Wasting Palsy than men employed in kindred oc- cupations ; but females belonging to the easy classes enjoy a remarkable immu- nity from this disease. It is, however, somewhat difficult to explain why cases arising from hereditary influence should occur more frequently among males than females. Partial or local muscular atrophy pre- vails mostly among handicraftsmen— me- chanics, masons, smiths, miners, needle- women, scriveners, laborers, and domestic servants. The subjects of general Wasting Palsy are found equally in every grade of life. The influence of consangidnity in the production of this disease has been marked in a number of instances. The present writer collected the history of ten families in which a tendency to Wasting Palsy prevailed. In four of these families the disease was confined to two brothers in each. Dr. Meryon's first described cases were four boys who had six healthy sis- ters. In another family mentioned by him, all the boys— namely, two— were af- fected, while the two sisters were healthy. A sea captain, whose history is related by Aran, had lost two maternal uncles and a sister by the same disease. In an- other instance, recorded by the same ob- ETIOLOGY. 787 server, the patient's two aunts had died from general muscular atrophy ; and, in a family known to Oppenheimer, two un- cles and a cousin were already deceased, while another cousin and two brothers still suffered from the same disease. Al- together these ten fixmilies included twen- ty-nine individuals affected with Wasting Palsy, and of these only four were females. Cases arising from hereditary influence present another well-marked feature — in nearly all of them the disease became generalized, and consequently tended to a fatal termination. As a rule, the subjects of Wasting Palsy have been persons of good physical devel- opment : in several cases the patients are reported to have been men of remarkable muscular power and activity ; in a few instances — nearly all of which were asso- ciated with a hereditary proclivity to the disease — a certain weakness existed from early youth. The exciting causes of Wasting Palsy (excluding hereditary predisposition) may be ranged under three heads : namely, excessive muscular action, cold, and dis- ease or violence affecting the spine. In a considerable number of cases, however (36 per cent.), no reasonable cause could be assigned for the breaking out of the dis- ease. Aran directs attention to the fact that the particular muscles which are neces- sarily in long-continued contraction in per- sons following certain mechanical trades (masons, milliners, shoemakers, smiths, &c.), are those which are first invaded and most deeply involved. In persons of this class the muscles of the shoulders, arms, and hands are first affected, and very frequently the atrophy is permanently limited to these parts. There are numer- ous exceptions, however, to this rule. Gases arising from cold (wearing of damp apparel, immersion of the limljs in cold water, rapid cooling of the perspirin,^ surface, exposure to inclement weather) are marked by a train of neuralgic or so- called rheumatic pains in the affected parts, either at the onset of the atrophy, and ceasing when this has fairly set in, or continuing throughout its progress, and imparting a special character to the symp- toms. The invasion of the disease in this class of cases is often somewhat sudden, and accompanied by cramps and twitches of the muscles. In cases traceable to cold, the wasting is more apt to extend to the muscles of the trunk than in cases due to overwork. Of twenty-five cases attributed to over- work, eighteen were partial and only seven general ; whereas, of the sixteen cases charged to the agency of cold, six were local and ten general. These two causes are often in operation together : the miners in my neighborhood, who work in damp or wet excavations, are frequent victims of Wasting Palsy. The connection of Wasting Palsy with injury or disease directly or indirectly implicating the spinal cord, has of late years attracted increasing attention ; and the interpretation of these cases has an important bearing on the pathology of the disease, as will be more particularly noticed hereafter. The history of some antecedent violence occurs too frequently in the re- ports of cases of Wasting Palsy to allow of its being set aside as a merely fortuitous circumstance, though the precise connec- tion between the injury and the subse- quent atrophy is often obscure. In a youth under my care at the Manchester Infirmary, who ultimately died from im- plication of the respiratory muscles, the first symptoms of atrophy in the ball of the right thumb occurred six months after the fall of a bale of cotton cloth on the nape of the neck. The immediate effects of the injury were confined to slight stiff- ness of the neck, and occasional pains extending down the arms. Yalentiner records a case in which the first failure of health followed a fall on the back from a height of eight or ten feet : yet the atro- phy did not appear until six years after. Bergmann's patient' fell on his back from a horse, and lay for a while unconscious. Prom this time he suffered pain and stiff- ness in moving the head ; afterwards, and very slowly, a weakness in the shoulders came on, which ended in complete atro- phy of the muscles around the shoulder joints. In a remarkable case recently re- ported by Dr. Thudichum and Mr. Lock- hart Clarke, a gentleman, eet. 54, suffered what he considered a slight injury. In jumping across a flower-bed for a wager, he came down heavily on his heels, and then fell backwards upon his head. He was stunned for a time, but gradually re- covered, and, after some days' confine- ment to his bed, appeared to be quite well again. It was, however, soon perceived that a great change took place in his hab- its. Having been extremely fond of manly sports and exercises— rowing, cricketing, riding on horseback, dancing, and the like— he discontinued to take part in any of these, although he continued to go every autumn to the Scotch moors for the purpose of shooting grouse. Five years after the above-mentioned accident, while engaged in this last-named sport, he per- ceived that his right leg had lost a part of its usual strength. Prom this time grad- ual atrophy and loss of power in the mus- cles crept over the patient, until at length death took place from failure of the re- spiratory muscles. Wide-spread degene- ration of the spinal cord was found after .' St. Petersbiirger Med. Zeitsuh., p. 116. 1864. Y88 WASTING PALSY. death. (Beale's Archives of Medicine, 1863.) In other cases, disease, manifestly pri- mary, of tlie spinal cord is followed by com- plete atrojjhy of certain groups of muscles. In a case published a few years ago in the London Medical lieview by the present writer, a young man suffered from acute general paral3-sis of all the muscles of the extremities, and of most of those of the trunk. The intellect was not affected. Gradually, in the course of months, the patient recovered the power of the mus- cles ; but after complete restoration of the remainder of the body, the intrinsic mus- cles of hoth the hands and feet passed into a state of total atrophy, and still con- tinue in the same condition. In the so- called essential paralysis of infoncy and childhood — which is evident!}' of spinal origin — certain limited groups of muscles not unfrequently pass into a state of per- manent atrophy, while the remaining portions of the paralyzed members recover their mobility. Certain other exciting causes of "Wast- ing Palsy are sometimes doubtfully men- tioned — nameh', constitutional syphilis, venereal excesses, onanism, and antece- dent zymotic fevers. Symptoms. — The invasion of "Wasting Palsy is ahvays gradual, and the disease has usually been in progress some weeks or months before the jjatient discovers its existence. The first symptom perceived is a certain weakness in the affected mem- ber : the tailor finds he cannot hold his needle ; the shoemaker cannot thrust his awl ; the mason fails to wield his hammer ; the gentleman experiences an awkward- ness in handling his jjen, in pulling out his pocket handkerchief, or in putting on his hat. Some such incident calls atten- tion to the affected limb, which is then usually discovered to be more or less wasted and shrunken. The disease begins, in the great major- ity of cases, in the upper extremities, either in the ball of the thumb and hand, or in the shoulder — much more commonly in the former than in the latter. Some- times, however, it begins in the muscles of the neck, of the face, the tongue, in the thigh, the leg, or the foot. The extension or spread of the disease follows an erratic course. In the immense majoritj' of cases the disease is permanently limited to one or a few groups of muscles in the upper or lower extremities ; in other cases, and these are liy far more formidable, the atrophy invades successively the voluntary muscles of the entire body, trunk and ex- tremities. The only muscles which, as yet, have not been known to be attacked, are those of mastication, and those whicti move the eyeball. "When the atrophy is confined to certain regions of the extremi- ties, the life of the sufferer is not imper- illed ; but when the trunk is invaded, and the muscles of respiration participate in the disease, death by suffocation is the ultimate result. The wasting and disappearance of the muscles produce notable changes in the configuration of the body. The natural rounded contour of the limbs is replaced by an unsightly flattening ; the bones stand out in unaccustomed distinctness, giving to the member the appearance of a skeleton clothed in skin ; but the skin itself, and the subcutaneous cellular tis- sue, undergo no change, and cannot be distinguished from the integuments of healthy parts. Certain distortions of the head, trunk, and extremities are also occasioned by the unequal wasting of op- posed groups of muscles — those less atro- phied overcoming the resistance of those more diseased. These changes of configu- ration are a marked feature of "Wasting Palsj^ The hand is frequently the seat of a very singular deformity — namely, the "claw-shaped" hand, or " main en griffe" of French writers. The palm is robbed of its muscular cushions ; flat planes or hol- lows occupy the sites of the thenar and hypothenar eminences ; the hollow of the hand is traversed by the visibly promi- nent diverging flexor tendons, which are stretched between the wrist and the bulg- ing bases of the fingers ; the proximal phalanges are bent backwards, away from the hollow of the hand, while the middle and distal ones, inclined in an opposite direction, are in a state of continued semi- flexion. The back of the hand is hollowed out in long furrows, corresponding to the interosseous spaces, and the first joints of the fingers are pulled backwards, giving the hand a broken-backed appearance. Passing up the limb, the forearm is found flattened, or even hollowed, on its anterior and posterior aspects. "When the shoulders are affected, the whole arm dangles powerlessly at the side; the round- ness of the shoulder has given place to a flattening, and the head of the humerus, the acromion, and the coracoid processes are plainly discerned through the thin covering of skin. If the serratus magnus be destroyed, the angle of the scapula is tilted upwards and inwai-ds, and stands prominently out from the trunk. Corre- sponding deformities are witnessed when the lower limbs are invaded : the foot is distorted by the unequal involvement of its extrinsic and intrinsic muscles, and contractions of the toes on the sole, deflec- tions of the foot inwards, or of the heel upwards, are produced — interfering very seriously with the steadiness of progres- sion. But perhaps the most remarkable of all the anatomical changes are seen in the face, when the muscles of expression are COURSE AND DURATION. 7S9 destroyed. The face is veileJ, as it were, by an impenetrable mask ; no emotion changes its unvarying aspect — tlie expres- sion is always solemn, stolid, and un- moved. Tlie muscles of the eyeball are, however, spared, and bjr their movements alone, in the later periods, the mind holds an imperfect communion with the exter- nal world. The oral and buccal muscles are usually invaded early, and the saliva dribbles over the lips. When the muscles of the neck are involved, the head falls forwards— the chin resting on the sternum — or, laterally, the head falling over on the shoulder. When the abdominal muscles are impli- cated, the lumbar curve is enormously ex- aggerated by the unopposed action of the erector spinte, and the belly projects in front, while the chest is thrown back as a counterpoise. The invasion of the lingual muscles leads to a talter in the speech, and to imperfect comminution of food in the mouth. The involvement of the laryngeal muscles produces a change in the voice, which loses its register, and is finally reduced to a monotone. When the diaphragm and intercostals are reached, violent suffocative fits of cough- ing are occasioned ; the play of the chest is at length so reduced that a slight addi- tional diflSculty to respiration proves fatal. Dissolution is usually brought about by a bronchitic seizure ; the air-tubes are speedily clogged with mucus, which no efforts of the patient can dislodge, and rapid asphyxia closes the scene. When the disease is partial in its ex- tension, it is observed that certain parts of the body, and certain groups of mus- cles, are much more obnoxious to its in- •roacls than others. The muscles of the trunk are Less liable than those of the ex- tremities, and those of the lower extremi- ties are far less frequently affected than those of the upper. Of sixty-two cases of partial Wasting Palsy collected by me, the upper extremities were alone afiected fifty-one times, the lower extremities alone five times, and the upper and lower together seven times. The right arm was much more frequently attacked than the left, and the hands oftener than the shoulders. As a general rule, it was found that when one limb was attacked, its fellow of the opposite side shared its fate ; that when the disease was unila- teral, the right side was more likely to be its seat than the left. One of the most striking characteristics of Wasting Palsy is the capriciousness of its line of attack. Scarcely two instances are exactly alike in the combination of muscles implicated — hence an almost in- finite variety of feature ; j'et there are certain more common combinations. Among the most common cases are those in which the disease is confined to the hands, or to the hands and forearms. Not uncommon, likewise, arc the cases in which the shoulder and upper arm of one or both sides are atrophied, while the fore- arms and hands remain healthy. Uoincidently with the loss of substance in the muscular masses, there is necessa- rily a corresponding loss of power. Cer- tain less constant symptoms also some- times make their appearance— namely, fibrillary tremors, cramps, twitches, and diminution of electric contractility in the muscles. The loss of power corresponds, in the typical cases, very exactly to the grade of muscular atrophy, and graduaUy proceeds as the muscles diminish in bulk. In ex- treme cases absolute immobility of the limb, or part, is at length produced; more commonly the various movements are still capable of being performed, but with greatly diminished force. Not unfre- quently, however, this correspondence is not exact ; and the loss of power exceeds, ]iiore or less considerably, what is due to mere atrophy of the muscular fibres. During the active stage of the disease the aftected muscles sometimes exhibit curious vibratile tremors — fugitive wavy oscillations of the muscular fibres — which are visible under the skin, but do not pro- duce any movement of the limb, nor are they sensible to the patient. When ab- sent, they may occasionally be evoked by stripping the' part or filliping the skin. These vibrations are sometimes the earliest symptom of a new advance of the disease into parts not yet aftected. They disappear altogether when the atrophy has reached an extreme degree, or when its progress has been arrested. In uncomplicated cases the muscles of the wasting members respond to the elec- tric stimulus readily, and with a force corresponding to their bulk. As a rule, there is no alteration in the tactile sensi- bility of the affected limbs ; but in rare cases there is a slight numbness of the skin, and not unfrequently the parts are highly sensitive to impressions of cold. In" about half the cases there is more or less pain of a neuralgic character in the course of the nerves leading to the dis- eased muscles, or in the neighborhood of the muscles themselves. In some cases pain of an agonizing character is a marked feature of the complaint. The general health is usually quite un- affected, the intelligence is clear, and the functions of organic life are performed with their usual regularity, so long as the muscles of deglutition and respiration are spared. CouESE AND DiTKATiOK.— The course of Wasting Palsy is essentially chronic, and its duration uncertain. After de- stroying a certain group of muscles it may 790 WASTING PALSY. be permanently arrested, or it may pro- ceed step by step until nearly all the volun- tary muscles are disabled. The atrophied muscles may be again restored by thera- peutical means to their original bulk : this is unfortunately not a very common ter- mination — more commonly the wasted parts are crippled for the remainder of life. When the disease is progressive, its advance is seldom continuous, but is rather marked by repeated pauses and re- commencements. The pauses may ex- tend over a few weeks or months, or even several years. In a case now under my care in the Manchester Infirmary, the dis- ease has started afresh in great intensity, after complete arrest for five years. In twenty-eight cases in which I was able to ascertain the continuance of the active process, the mean duration was thirty- eight months. Of these, four ended in recovery, thirteen in permanent arrest, and eleven in death. The cases which ended in recovery had a mean duration of fourteen months, those ending in arrest a mean duration of twenty-seven months, and those ending in death averaged a duration of more than five years. Cases which could be traced to the effects of over-exercise of the muscles, were nearly always found to terminate in permanent arrest after the destruction of one or more groups of muscles ; whereas cases which appeared to have arisen from exposure to cold, or from hereditary pre- disposition, showed a more decided ten- dency to a progressive course and a fatal termination. DiAGisrosis. — The partial form is liable to be confounded with paralysis from in- jury to a motor nerve, lead palsy, and malarious palsy. In all these there is a marked atrophy of the muscles ; and the affection may be confined to a narrow re- gion, around which are healthy muscles, offering a strong contrast to the decayed ones. Atrophy, resulting from injury to a nerve, is distinguished by the exact limi- tation of the wasting to the parts supplied by that nerve ; also, if the nerve be a mixed one, there is, or was, an accompa- nying loss of sensation. In lead palsy there is a comparatively sudden invasion: in a day or two — a week, or a fortnight, at most — the para- lysis is at its height ; whereas in Wasting Palsy the loss of power is excessively gradual. The precursory or concomitant phenomena distinctive of lead poisoning, seldom or never altogether fail — namely, colic, blue line on the gums, tremblings, pallor, and other symptoms of saturnine cachexia. Duchenne states, that the electric contractility of the muscles is markedly diminished or altogether lost in lead palsy ; whereas, in Wasting Palsy, the muscles respond to the electric stimu- lus in a degree proportionate to their bulk. It will also be remembered that in saturnine poisoning the atrophy is dis- tinctly essential to the paralysis. From ordinary general paralysis of cen- tral origin, Wasting Palsy is distinguished by the dissecting character of its march. It attacks the muscles in separate groups — in detail, as it were — and does not dif- fuse its ravages uniformly over extensive regions or the entire body. It is very rare also that in general paralysis the wasting of the muscular masses bears any proportion to the loss of power. Extreme muscular atrophy sometimes follows infantile paralysis, and the distri- bution of the disease may resemble that of Wasting Palsy and produce ultimate re- sults indistinguishable therefrom. The cases are, however, totally different in tlieir history. Infantile paralysis has al- ways a sudden invasion, and the wasting is subsequent to the loss of power. Morbid Anatomy. — The essential changes found in the bodies of persons who have died from Wasting Palsy are confined to the muscles, the spinal cord, and the nerves. The muscles of the affected regions are found wasted in various degrees. Some are only slightly atrophied, others more profoundly, while others again are re- duced to pale, thin, membranous strata, or are altogether destroyed, and can only be identified by comparing the origins and insertions of certain fibro-cellular bands, which are the vestigial representa- tives of the previously existing muscular masses. The color of the wasted muscles is changed to a pale red or rose, some-" times with a buff or ochreous tinge, and not unfreqnently streaks of adipose tissue run, in lines, between the fibres. Where there is much fattj' change, the wasting, which is so conspicuous a characteristic of the disease, is less marked ; sometimes even the muscles are almost undiminished in bulk, but are transformed into masses of fat. This peculiarity has been observed only in the lower extremities. The difference in the degree of atrophy undei'gone by adjoining muscles, and sometimes even by different parts of the same muscle, is very remarkable. Scarcely any two muscles are affected in an equal degree. Side by side with a pale, almost filamentous remnant, may be found a muscle of full red color and undiminished bulk. One or two fasciculi of an affected muscle may survive in vigor after the destruction of the remainder. The decayed muscles have been exam- ined microscopically by Meryon, Galliet, Oppenheimer, Virchow, and others. Me- ryon describes the primitive fibres as com- pletely destroyed, the sarcous elements MORBID ANATOMY. 791 being diffused, and, in many places, con- verted into oil-globules and granular mat- ter ; while the sarcolemma was broken down and destroyed. Gailiet, who ex- amined the muscles in one of Cruveil- hier's cases, states that iu those parts of the muscle which had retained a rosy hue, the primitive fibres had preserved their strife tolerably distinct, and between the striae were seen fine gray or brilliant molecules, resembling fat. In the com- pletely decolorized parts — those which to the naked eye appeared of a straw tint — there could still be recognized long cylin- ders, representing the primitive fibres. The sarcolemma was preserved, but the contained substance had lost its striated character, and was replaced by a uniform granular mass, presenting numerous mi- nute gray molecules mixed with fatty granules. In parts where the disease was still further advanced, the granular matter and its enveloping sarcolemma had entire- ly disappeared, and there remained only the flbro-cellular framework of the muscle, destitute of any true sarcous tissue. The condition of the spinal cord and of the spinal nerves has been examined in some thirty-five cases, of which thirty- four have been tabulated by Bergmann.' The results of the investigations have not been by any means uniform. In sixteen cases the cord and the nerves were pro- nounced healthy, and in six of these the parts were examined microscopically. In six cases the cord itself was found healthy, but there was marked atrophy of the ante- rior roots of a certain number of spinal nerves. In one case both the spinal cord and nerves were healthy, but there ex- isted disease of the medulla oblongata. In six cases the cord was found diseased when examined microscopically, though it appeared sound, or nearly so, to the naked eye. Lastly, in seven cases the cord appeared to the unaided senses pal- pably softened and disorganized. Atrophy of the anterior roots was first noticed by Cruveilhier, and was supposed by him to supply the key to the pathology of this disease. He thus describes the condition of these structures in the body of the showman Lecompte, who died from general Wasting Palsy of five years' du- ration : " The anterior roots of the spinal nerves are remarkably small compared with the posterior, and this inferiority of size is particularly great in the cervical region. The proportion between the two roots had become greatly changed. Ac- cording to my observations, in the normal state, the posterior roots compare with tlie anterior, in the cervical region, as ttiree to one ; in the dorsal region, as one and a half to one ; and in the lumbar re- ' St. Petershurger Medicinische Zeitschrift, Bd. vii., 1864. gion, as two to one. But here the pro- portion was as ten to one in the cervical, five to one in the dorsal and lumbar re- gions. Further, by plunging the cord into dilute nitric acid, I was able to ob- serve that a very large number of the an- terior cervical rootlets had been com- pletely reduced to their neurilemma, and appeared as gray filaments, which, search- ed with a strong lens, presented no trace of nervous tissue ; while, on the other hand, the anterior roots in the dorsal and lumbar regions had only sufiered atrophy by emaciation. I was unable to trace the gray nervous filaments, or those simply atrophied, beyond the point where the anterior root joins the posterior ; but I was able to establish the existence of atro- phy of the nerves as they were about to penetrate the muscles.'" A similar atro- phy of the anterior roots was found in ten other cases, either with or without discov- erable disease of the corresponding re- gions of the cord. In the great majority of the cases, however, the anterior roots were not perceptibly atrophied, and this leads directly to the inference that such atrophy is not an essential feature of the morbid anatomy of Wasting Palsy. The morbid anatomy of the spinal cord is confessedly a subject of great difficulty. Until recently only the coarser changes of consistence — softening or induration — were appreciated by pathologists ; and even after the microscope had been brought in aid of the examination, it soon became apparent that very important changes in the structure of the cord might be overlooked, unless the observer possessed special skill and practice in this branch of inquiry. The positive results of Gull, Lockhart Clarke, and Luys, who may be rcijarded as experts in the exami- nation of the spinal cord, throw consider- able doubt on the trustworthiness of the negative results obtained by Meryon, Savory, Oppenheimer, Friedburg, and others, who failed to detect in the spinal cords of patients who had died from Wasting Palsy any appreciable changes of structure. Luys describes as follows the microsco- pical changes in the apporently sound cord of a man, aged fifty-seven years, who died of pneumonia, and who had been the sub- ject of advanced atrophy of the muscles of the left hand and forearm. There was also slight atrophy of the muscles of the right hand. The loss of power had cor- responded accurately with the degree of wasting. Five of the anterior roots com- inn- off from the cervical enlargement of the cord were atrophied. The microscopic examination of the cord showed increase of the capillary vessels in the gray sub- stance at the level of the atrophied roots. ' Archives Gfaerales, 1853. 792 WASTING PALSY. The walls of the vessels were thickened and surrounded with a granular deposit, which extended into the gray substance. In the anterior gray cornua, at the point of exit of the anterior roots, there was an absence of nerve-cells, which were re- placed by granular deposit. Some of the nerve-cells of the anterior horns were in process of degeneration — brownish, and tilled with dark granulations. These changes were found especially on the left side, "and very slightly on the right side. The rest of the cord was healthy.' Dr. Gull gives an account of a man, aged forty-nine years, who became the subject of Wasting Palsy after striking his head against a beam, whilst driving under an archway. Some months after this acci- dent he began to suffer pain from the occi- put down over the shoulders, and in about a year the muscles of the upper extremi- ties began to waste. Three years after the accident he was admitted into Guy's Hospital. He then presented a remark- able example of muscular atrophy, with- out actual paralysis. The upper extrem- ities were principally affected. The ex- tensors of the right hand, the muscles of the thumb, and the interossei were ex- tremely wasted. The wrist dropped. The muscles of the shoulder and arm, includ- ing the pectoralis major and minor, were much wasted ; but in a marked degree less so than those of the forearm and hand. Very slight diminution of sensa- tion, lie could still lift the arm over the head. The left arm was similarly aflFected, but less than the right, so far as muscular atrophy was concerned — but there was numbness through the whole arm down to the fingers, accompanied with severe neuralgic pains. The trapezii, serrati postici superiores, rhomboidei, and all the long muscles of the neck and back were remarkably atrophied. The legs were wasted and weak, but the patient was able to walk. There was constipation and dribbling of the urine. He died with febrile symptoms and dyspnoea. Autopsy. — Sections of the cord exam- ined with the naked eye gave no distinct evidence of disease. There was a slight yellowishness of the posterior columns, and increased vascularity and thickening of the pia mater covering them. In these columns, especially in the right one, abundance of granule-cells were discov- ered with the microscope. The exudation was greatest in the middle and lower third of the cervical enlargement. The gray matter was hyperffimic. There was no exudation into its tissue, nor into the anterior columns. The ventricle of the cord was enlarged and distended with delicate granular nuclei.'' ' Gaz. M^d. de Paris, 1860. No. 32. ' Guy's Hospital Reports, 3d Series, vol. iv. p. 194. The limitation of structural changes in the cord to narrow tracts and spaces, with a healthy state of the intervening parts, and the absence of any alterations visible to the naked eye, are also strikingly illus- trated in the case of Dr. P., whose spinal cord was subjected to an exhaustive ex- amination by Mr. Lockhart Clarke. Dr. P. , set. 65, engaged in literary pur- suits, began to complain some five years be- fore his death of neuralgic pains in the ball of the thumbs of both hands, which before long extended to the forearms and arms. After some mouths there was marked weakness and wasting of the muscles of the thumbs and index fingers, which also became bent inwards towards the palms. The loss of power and volume in the muscles progressed steadily, accompanied with the most excruciating pains, until his death. The right hand and arm were more profoundly affected than the left. In the later periods of the disease the pains extended to the lower limbs. The right pupil was constantly larger than the left, but the movements of the two were normal. The cerebellum, pons Varolii, medulla oblongata, and spinal cord, were hardened in dilute chromic acid, and sent to Mr. Lockhart Clarke. He found nothing un- usual in the external aspect of the cord, neither were the anterior roots of its nerves, in any of the regions, smaller than usual to any appreciable extent. The in- terior of the cord, from the filum terriii- nale through the whole of the lumbar and dorsal region, to the lower end of the cervical enlargement, presented no actual change of structure, either in the white or gray substance ; but there was a con- siderable deposit of corpora amylacea round the central canal. In the cervical region, however, the case was different ; for here there were decided evidences of morbid changes of structure in the pos- terior gray substance. These structural changes extended in a variable degree from the lower end of the cervical en- largement upwards to the third cervical nerves : they were more conspicuous at its upper than its lower part. Thin trans- verse sections of this part of the cord pre- sented to the naked eye no appearance that would excite suspicion of any lesion whatever ; for the morbid portions, al- though numerous, were small and iso- lated. Under a low magnifying power the posterior gray substance was seen to be interspersed with a number of un- naturally transparent streaks, patches, or spots, of different shapes and sizes. Some of these spots were seen to interrupt the course of certain nerve-fibres which ex- tended from both the anterior and pos- terior cornua to the opposite side. In all the sections examined, it was around or at the side of the bloodvessels that the PATHOLOGY. 793 morbid appearances were most frequently found. The morbid spots were more numerous and extensive on the right side tlian on tlie left. The morbid spaces varied in shape, size, and relative posi- tion in the different sections. In some they appeared as mere fissures or cracks, which, under a low power, might have been considered as the result of accident, if they had not been so uniformly found in only one portion of the gray substance, and more on the one side than on the other. But when a suiBciently high power was employed, it became at once evident that they were not merely vacant spaces, but composed of a substance which dif- fered entirely in its nature from that of the surrounding tissue. This substance had a delicate, transparent, and very fine- ly-granular aspect. The granules were more closely aggregated towards the cen- tre of the mass, but were generally so fine that they could not be distinctly seen under a magnifying power much less than 400 diameters. Sometimes at the edges of these morbid spaces there seemed to'^be a kind of transition or degeneration of the surrounding nerve-tissue into the granu- lar substance of which they were com- posed. In some instances, the broken ends of nerve-fibres proceeding from the posterior roots were seen to project into the opposite sides of these spaces, across which there was strong reason to believe that they had once been continuous. The morbid appearances generally dis- appeared about the level of the third pair of cervical nerves ; in the middle third of the cervical enlargement they appeared to be more extensive than elsewhere, and they disappeared on approaching the dor- sal region. The sympathetic in the neck was also examined, and found normal. ' The peripheral distribution of the nerves to the wasted muscles was in some cases found unaltered ; in other cases the nerves Were found ati-ophied ; and in one in- stance, examined by Frommann,^ the nerves leading to the atrophied muscles contained fat-molecules and granular pig- ment. The sympathetic in the neck was found diseased in a case examined by Schnee- voogt.'' The ganglionic cord was found extensively affected with fatty degenera- tion. Two similar cases have more re- cently been communicated by Jacoud to the Societe Medicale des Ilopitaux.* On the other hand, the sj^mpathetic, in two other cases, examined by Landry and Bayldon,^ was found perfectly healthy. ' Beale's Archives of Medicine. 1861. ' Deutsche Klinik. 1857. ' Schmidt's Jalirh. 1857. ' Nouveau Diet, de Med. et de Chir. Paris, 1866. P. 48. ' See Author's Essay, p. 163, and Beale's Archives, 1861, p. 11. Pathology.— Although defective nu- trition of the muscles, ending in degene- ration and atrophy, is an invariable fea- ture of Wasting Palsy, it is evident that something more is necessary to the con- ception of the disease as a nosological entity. Muscles may bo atrophied uiidcr a variety of pathological conditions, which are essentially distinct. Muscles may waste from want of use, as is witnessed in limbs which are temporarily kept im- movable by surgical appliances, or more permanently by anchylosis of the joints. A similar result follows severance of the connection between a muscle and its ner- vous centres, especially its spinal centres ; and, lastly, atrophy of muscle may follow metallic poisoning. In Wasting Palsy there is also muscular atrophy, and, so far as is known, the local changes are not essentially difl'erent from those occurring in the afore-mentioned cases ; and yet how widely different is the clinical signifi- cance of the fact ! In order, therefore, to obtain any clear idea of the pathology of Wasting Palsy, it is absolutely necessary to consider circumstances which are ante- cedent to the mere atrophy. It must be borne in mind that the sev- eral vital endowments of a muscle may be struck with paralysis in their entirety, or singly, or in certain combinations. A muscle paralyzed by a cerebral lesion loses its voluntary power, but it retains its reflex functions and its power of self- nutrition, and does not become atrophied. Other cases are known in which the pecu- liar "muscular sense" is lost, with pre- servation of all the contra,ctile and nutri- tive endowments. In Wasting Palsy, the muscle preserves its voluntary and reflex contractility, its muscular sense, and its sensitiveness to the electric stimulus ; but it loses its power of healthy nutrition, and becomes degenerated and atrophied. Pathologically, Wasting Palsy may be defined as an atrophic degeneration of certain groups of muscles, independent of any antecedent loss of mobility, or of any metallic poisoning. But the question immediately arises, whether the morbid process is primarily in the muscle itself, or in some part of the nervous system which controls its functions. The former opinion has been adopted by Aran, Duchenne, Priedberg, Dr. Merjron, and others ; it was also advocated by the present writer in his Essay on the subject, published in 1858. It must, how- ever, be admitted that the additional facts observed since that epoch have tended materially to weaken this opinion, and to give support to the view that the primary lesion in Wasting Palsy exists in the spinal cord, or, at least, in some part of the nervous system. The principal arguments against a ner- vous origin of the complaint consisted in 794 ■WASTING PALSY. the failure to discover, in several of the earlier post-mortem examinations, any palpable alteration in the spinal cord ; and, secondly, in the want of correspon- dence between the range of muscles af- fected and the distribution of the nervous trunks. With regard to the former point, the multiplication of post-mortem exam- inations has very greatly increased the proportion of cases in which a lesion was discovered in the nervous system, and very much strengthened the suspicion that the earlier observations, in which the spinal cord was pronounced to be healthy, were not altogether trustworthy. The researches of L uys and Lockhart Clarke have demonstrated that profound changes in the substance of the cord may exist in detached and very limited areas, which might very easily be overlooked, seeing that it is exceedingly difficult to examine every individual section of the cord with the requisite care. Mr. Lockhart Clarke, speaking on this point, very significantly observes: "There may be very obscure structural changes in the gray substance of the cord, or perhaps only in the ganglia on the posterior roots of the nerves, that may affect the nutrition of the parts to which they are subservient, without in- terfering with the functions either of sen- sation or motion ; and in cases where the lesions occur in small isolated spots, the limitation of disease to particular muscles, or even to particular fasciculi of any one muscle, could be explained, I think, by the particular nerve-fibrils within the gray substance." (Beale's Archives, 1861, p. 21.) The opinion, also, seems to be steadily gaining ground, that the nutrition of the muscles is placed under the control of a [Fig. 41. 'MainenGriffe." (Roberts.)] special set of organic nerves, having up- ward connections with the sympathetic ganglia and the cerebro-spinal axis, which are by no means identical with the cen- tral connections of the motor nerve-fibres of the same muscles. Assuming the existence of such nutri- tive centres, all the clinical phenomena of Wasting Palsy, and the various findings of the post-mortem examinations, admit of easy explanation on the supposition that these centres, or some of their gangli- onic connections, are the primary seat of the disease. And the numerous associ- ations and complications of the disease can scarcely be accounted for on any other hjfpothesis. In considerably more than one-half of the cases now collected, and examined after death, actual disease was found in some part of the nervous system. This is a proportion which does not permit the assumption of a coincidence of two inde- pendent morbid processes. Some relation between the atrophy of the muscle and the disease of the nervous system must, I think, be admitted. Either it must be assumed that the disease of the muscle is capable of evoking disease of the cor- responding nervous centre, or the con- verse. And although the former supposi- tion is by no means a difficult one a priori, it stands on a very slender basis of fact. So far as I know, the only authenticated instance of the centripetal transmission of a morbid process along a nervous trunk is atrophy of the optic trunks after de- struction of the eye. With regard to the muscles, evidence of any such transmission has yet to be given ; the observations hitherto made, indeed, tend the other way. Schiff,' who made resections both of mixed and of purely motor and sensory nerves, found no alteration in the central portions of the cut nerves even after the lapse of a year and three-quarters. Turck^ also examined the central origins of the nerves and their vicinities, in withered and amputated limbs, without finding appreciable alteration therein. Nor are suppurative and cancerous affections of the muscles known to be capable of trans- mission along the nervous trunks to the nervous centres. The etiological conditions of some cases of Wasting Palsy, and the collateral phe- nomena in others, point also very strongly to a nervous origin. Several of the cases were sequential to falls or blows on the neck, or were associated with morbid growths in the spinal canal. In several ' Muskel-und Neryen-physiologie. Jahr. 1859. P. 122. 2 Zeitsch. der K. K. Gesellsohaft der Aerzte in Wien. 1853. PATHOLOGY. 795 well-marked cases of Wasting Palsy, also, motor paralysis, of undoubted central origin, affecting either the atrophied muscles or some other parts, preceded the atrophy. A strong impression was made on my mind by a case of this kind which fell under my notice four years ago. A young man was affected with acute paralysis of the voluntary muscles of the upper and lower extremities, unaccompa- nied by any wasting beyond what was due to general emaciation. After an almost total loss of motion for a period of three months, recovery set in, which, in the course of a few months, ended in com- plete restoration of the muscular power in all parts except the hands and feet. The muscles of these latter parts passed on to a state of characteristic atrophy, from which only partial recovery took place. Dumenil, Duchetme, and Trousseau have also published cases in which there ex- isted motor paralysis of the tongue with- out atrophy, combined with atrophy [Fig. 42. Brrnich of the median nerve for th^ Prouator teres Talmaris loagua Flexor carpi ulnaris Flexor sublimis dlgitornm (middle aod ring fiugers; Ulnar nerve Flexor sublimis digitorum (index and liEtle fingers) Deep brancli of ulnar nerve Palmaris brevis Abductor minimi digiti Flexor brevis minimi digiti Oppouens minimi digiti Lumbrioales (2, 3, and 4) < Flexor carpi radialis. Flexor profundus digitorura. Flexor Bublimis digitorum. Flexor longus pollicis. Median nerve. Abductor pollicis. Opponens pollicis. Flexor brevis pollicis. Adductor pollicis. Lumbricalis (lat). Ziemssen's Motor Points.] without paralysis (Wasting Palsy) of the upper extremities.' It is easy to con- ceive that a morbid process in the motor centres may extend by continuity of tis- sue to contiguous nutritive centres (sup- posing such to exist), or, conversely, that disease of the nutritive centres may im- plicate motor or sensory centres in their vicinity, and so produce complicated clin- ical phenomena, analogous to those above mentioned, and which on any other sup- ' Bergmann, loo. cit. p. 88. position are very difficult of rational explanation. The case-history of Wasting Palsy is rich in combinations of this sort. In the pure typical, uncomplicated cases— where atrophy of the muscles is unmixed with any degree of motor paralysis, or convul- sive movements, or with numbness, or neuralgic pains— it may be assumed that the morbid process is strictly limited to the nutritive centres in the cord, or to their connections in the sympathetic ganglia. In the complicated cases it may 793 WASTTXG PALSY, be assiimed that the morbid process radi- ates into those contiguous parts of the cord which control motor and sensory functions. Tlie question can only be finally elucidated by repeated accurate examinations of the spinal cord in com- plicated cases. [Of those who have more recently in- vestigated this subject, Jotfroy, Hayem, and Charcot, assert the coincidence of Progressive Muscular Atrophy with de- generation of the anterior gray cornua of the spinal cord. Friedreich, Lichteim, and Cohnheim, however, have reported cases in which no lesion either of the cord or nerves was found. — H.] Prognosis. — Wasting Palsj- must be counted among the most intractable dis- eases ; and when it invades the muscles of the trunk, it almost always goes on sometimes very slowly, sometimes more rapidly — to a fatal termination. In the partial forms — when permanent hmita- tion of the disease to one or two members is established — life may be regarded as no longer menaced, but the usefulness of the limb, if the atrophy be complete, is hope- lessly impaired. If remedial measures Pu^anator li^n^ns E -tensor carjri rddialis lougior Extensor carpi ridiaUs brevier Extensor communis di^'ltomm. Extensor indicis _.. Exteusor indicis and extensor ossis ) metacari'i poiticis S '" Extensor ossis metacarpi iioU.cis Extensor primi internodll pollicis. Flexor longud pollicis Dorsal interossei ^ 2 3 I ^'-^ — -- Ex'ensorcarpi uhiaris, t-<^? Extensor minimi digitL ^^^ Extensor indicis. Extensor eecundi internodii pollicis. Abdnctor minimi digitl. Djrsal interosseus (4), Ziemssen's Motor Points.] can be applied early, and persevered in, ! while the atrophy is still in progress, there is some pro>pect either that the ad- vance of the disease may be permanently ' checked, or even that partial or perfect restoration of the injured muscles may be effected. The gravity of the prognosis, in so far ' as the preservation of life is concerned, depends on the disease confining itself to the extremities, or extending its ravages to the muscles of the trunk. When the i respiratory muscles are invaded, the fatal i termination is not far distant. i The probability of the disease becoming generalized is greatest when the origin of it can be traced back to hereditary pre- disposition. The same danger, though in a greatly inferior degree, is to be appre- hended 'when the disease has arisen from cold, and when the lower limbs are the first attacked ; also when the upper and lower limbs are bnth implicated. On the other hand, the prognosis is much more favorable when the disease is occasioned by overwork, and when it is confined to the hands and forearms. The longer the atrophy has existed, the PROGNOSIS. 97 less is the prospect of recovery : if the disea^^e has become stationary for a year or two, there is no chance of any con- siderable improvement in the condition of the muscles, but the danger to life has be- come comparatively small. [Fig. 44. Anterior crural nerve ■-- -/ Obturator uerve -- Bartoriiis Adductor lonf^ns Branch of crural uerve to quadriceps ) extensor cruris \ CrureuB Branch of crural nerve, to vastus in- ^^^ i ternus ^^^i-i Tensor fasciaj femoris (branch of su- perior gluteal uerve). _.Teu8or fasciae femoria {branch of crural uerve). Rectus femoris. Vastus externus. Vastus externus. Ziemssen's Muter Points. Fig. 45. Inferior gluteal nerve for gluteus maxiraug Gi-eat sciatic nerve — - E^ " I Long head of biceps -^— ^- Short head of biceps — . ^-^ J Posterior tibial nerve ^t i'eroneal nerve Gastrocnemius (exteru;U head) Boleua Addurtor mas-nns. Seniitendino&us. iSemimembranosus. Gastrocnemius (internal head). Ziemsseu'a Motor Points.] 798 WASTING PALSY. Therapeutics. — In projecting the treatment of a case of Wasting Palsy, tlie first necessity is to ascertain, as ac- curately as possible, the etiological cir- cumstances under which the disease has originated. The removal of these — sup- posing them to be still in operation — fol- lows as a matter of course. Mercury and iodide of potassium have been employed with success in cases where the disease depended on a syphilitic taint. If the disease has arisen from overtasking any set of muscles, these must be allowed to remain at rest. The direct treatment embraces the em- ployment of hygienic means — baths, me- thodical exercise, change of air, &c. — and the employment of galvanism and fric- tions to the affected muscles. Remak strongly advocates the use of the constant galvanic current applied to the spinal cord — especially the cervical portion. Thermal and sulphur baths have been highly recommended by a number of writers. Wetzlar has especially called attention to the beneficial effects of the waters of Aix-la-Chapelle. Cold baths are objectionable. The most efieetive remedy in "Wasting Palsy is, undoubtedly, galvanism. Nu- merous observations attest its value when applied locally to the affected muscles. After a very considerable experience of its employment, I am convinced that it very rarely fails of some good effect when perseveringly applied. This effect is too often temporary : too often also it is found difficult to keep up the treatment with the requisite regularity for a sufficient length of time. In some cases marked improvement in the power and bulk of the muscular masses was witnessed ; in others, the disease, previously progres- sive, was brought to a standstill. In the case of a man, still under observation, suffering from atrophy of the muscles of the thighs and upper arms, and of the erectores spinse, which had been steadily progressive for twelve months, the daily application of the secondary current ar- rested the disease completely. The arrest has now continued for more than six years. _ Duchenne gives the following direc- tions for the employment of galvanism : "Every muscle ought to be faradized in a special manner, according as it has suffered more or less in its electric con- tractility and nutrition. Thus the more a muscle is atrophied and its contractility diminished, the longer it should be sub- jected to the stimulation, the more intense should be the current, and the more rapid its intermissions. And tliis strong cur- rent and quick intermissions are the more necessary, according as the sensibiUty of the muscle is more benumbed. But when the sensibility is seen to return, it is pru- dent to diminish the intermissions and abate the intensity of the cuiTent, and even to abridge the number of sittings, lest there be provoked unmanageable neural- gia, and, which sometimes has arisen, in- flammatory accidents. During the faradie treatment, I have excited the musculnr sensibility, as much as possible, by rapid intermissions, inasmuch as I have found this the most effective means of reacting on the nutrition of the atrophied muscles. Sittings of too long duration fatigue and even exhaust the muscles, just as forced exercise induces atrophy, instead, like moderate exercise, of favoring nutrition. I believe that no sitting should be pro- tracted beyond fifteen minutes, at the [Fig. 46. Gastrocnemius (iuterual head) Abductor poUicis Ziemssea's Motor Points.] most. I rarely give more than one min- ute to each muscle. To prevent weari- ness, and a bruised feeling, that sometimes follows the application of electricity, I pass rapidly over the muscles, taking care to return to each of them several times during the same sitting, so as to leave a short interval of repose between each excitation." ' The secondary symptoms — cramps and neuralgic pains — are most effectually sub- dued Uy warm baths, temporary rest in ' De rKlectrisation looalis6e, p. 702. THEKAPEUTICS, 799 bed, and anodynes. The hypodermic in- I iection of morphia lias, in my hands, heen followed by the happiest ellects in reliev- ing the excruciating neuralgia which is not unfrequently associated with this dis- ease. One of my patients, thus afflicted, ■ is in the habit of having half a grain of morphia injected early in the morning, when the pains are severe. Such an in- jection enables him to pursue his employ- ment through the day in comfort — a result which he fails to attain by any dose of the same remedy internally administered. [Fig. 47. PeroneuB longus Tibialis anticus. ■■ Peroneal nerve. - Gastrocuemiustexternalliead) - Soleus. _^^s^- Extensor communis digitorum ^^" longus. ^^ Peroneusbrevis. .- Soleus. ... riexor longus pollicis. Extensor longus polUcia Branch of peroneal nerve for extensor brevis digitorum.. Dorsal interossei Extensor brevis digitorum^ Abductor minimi digitl. Ziemssen's Motor Points.] [Pstudo-hypertropMc Muscular Paralysis, after having been described by Costa and Gioga in Italy (1838), and Meryon in Eng- land (1852), was, in 1868, more definitely studied and classified by Duchenne. Many pathologists, in America as well as in Europe, have, since that time, reported cases. It occurs in children, up to the age of 13 or 14, mostly in boys. No causes have as yet been made out ; but its occurrence in several children of the same family, or nearly related to each other, has been established, especially by Poore.' In thirty-seven instances, there were two or more of the same family thus affected. Hereditary transmission of the tendency to it appears to have been observed only [' N. Y. MedicalJournal, June, 1875.] on the mother's side ; that is to say, when the parents of children having it were not subiectto it, examples have been found m the' mother's family; her brothers, .tc. The first well-marked symptom is mus- cular weakness of the lower limbs and back. This gradually increases. 1 he child stands with the legs far apart the shoulders thrown baclcvvard, and the belly forward. The toes point downwards, sometimes approximating taZ^pes equmns In the course of a few months some of the muscles of the lower hmbs will be found to be enlarged ; and this gradually ex- tends to thSse of the trunk aiid uppei extremities. Sometimes those of the lace also are involved. i „ „<• n-,o The enlargement of the muscles of the calves of the legs, in many instances gives an appearance^ike that of extraordinary 800 WASTING PALSY. strength ; and yet the hmbs are almost powerless for locomotion. In from one to three years, paralysis extends to nearly aU the muscles of the body. An impair- ment of the mental faculties has been Fis. 48. Early stage of Pseudo-hypertropliic Paralysis. (Bristowe.) noticed in a number of cases. In this condition, unable to rise from the position in which he is placed, the child may live for several years more ; seldom to adult age. Sensation is not involved in this dis- ease ; neither are the functions of diges- tion, respiration, or circulation. At first, the electro-contractility of the muscles is unchanged ; at a late stage, it is gradually lost. Griesinger and Billroth, in 186.5, first ascertained the presence of deposits of fat in the enlarged muscles of this affection. Duchenne and others have observed also the great increase of connective tissue, along with atrophy of the muscular lihres. It is altogether a degenerative, not a hypertrophic alteration that the muscles undergo. Fifi. 40. Pseudo hypertrophic Muscle. (Charcot.) Several facts in the history of this dis- order point, in its pathology, to a nervous origin. 1. It is symmetrical, and pro- gressive upon both sides of the body alike. 2. The intelligence is not unfrequently impaired. 3. It presents an analogy (not- withstanding that shrinking occurs in the one, and increase of bulk in the other) to progressive muscular atrophy ; in which, as above seen, lesions of the spinal cord, and sometimes of the sympathetic ganglia, have been demonstrated. Yet no satis- factory demonstration has been obtained of the association of Pseudo-hypertrophic Muscular Paralysis with morbid changes of the nervous system. Tlie only treatment so far suggested as affording much prospect of advantage, is the use of electricity. Duchenne advised local faradization ; under which he re- ports two recoveries. McLane Hamilton' recommends massage; of which Bristowe* also expresses approval. — H.] [' Nervous Diseases, &o., Philada., 1878; p. 27.-5.] [2 Manual of the Practice of Medicine, American Edition, p. 1052.] METALLIC TT^EMOR: CAUSES. 801 METALLIC TREMOR. TREMBLEMEITT METALLIQUB. By William Ruthbrfoed Sanders, M.D., F.R.C.P. Synonyms. — Tremor Metallurgorum ; Paralysis Agitans Metallica ; Rheumatis- mus Metallicus (Schbnlein) ; Metallic Shaking Palsy ; The Trembles. 1st. Mercurial Palsy or Tremor ; Mer- curial Shaking Palsy ; Mercurial Trade Disease ; Tremor ab Hydrargyro ; Paral- ysis Agitans Mercurialis ; Tremblement Mercuriel ; Tremblement des Doreurs ; Merourial-Zittern. 2d. Lead Tremor or Shaking Palsy ; Tremor Saturninus ; Paralysis Agitans Saturnina ; Saturnines Zitteru. Definition.— Metallic Tremor is a species of paralysis agitans, caused by the slow poisonous action of certain metals, particularly mercury and lead. It con- sists of spasmodic tremors with dimin- ished muscular power, occurring in vari- ous parts of the body. 1. The Mercurial Tremor or Shaking Palsy, being the form best known and most important, will be first described. Causes. — Exciting. — The chief source of this disease is the inhalation of mer- cury in a state of vapor, this metal being volatile at nearly ordinary temperatures (68° to 70° Pahr. ). By some authors this lias been regarded as the only mode of origin ; but it is certain that the intro- duction of mercury by the skin, either in consequence of manipulating the metal, or of prolonged friction with mercurial ointment, has sometimes brought on the peculiar tremors ; and the same effect has also resulted, in a few instances, by ab- sorption, from the intestinal canal, of mer- curial preparations administered medici- nally. The principal sufferers from the disease are accordingly : — 1st. The work- men employed in the quicksilver mines, especially when fire is used in the reduc- tion of the ores. 2d. Water-gilders (who plate with gold dissolved in mercuryl, looking-glass silverers, barometer makers, workmen in chemical manufactories, where mercurial preparations are made, button and toy gilders, furriers, and others whose business exposes them to contact with mercury. ' 3d. Persons using ' Ramazzini, De Morb. Artif. caps. i. — iii. 1717; Patissier, 1822; Thacrah, 1S32; Dar- VOL, L— 51 mercury medicinally. In former times, the latraliptse, an inferior class of sur- geons, who practised as mercurial anoint- ers or rubbers, without protecting their hands, were frequently subject to tremors which sometimes proved incurable. A similar instance is recorded recently. Dixon, the anatomy porter of the Irish College of Surgeons, "who at one time rubbed in immense quantities of mercury for the cure of venereal among the JIo- hawlcs, or swells of the day," was subject for thirty years to mercurial stammering (psellismus mercurialis).' Syphilitic pa- tients, after long courses of mercurial treatment, especially by friction, often suffered severely from the trembles. ^ On the other hand, the internal use of mer- curial medicines alone very rarely gives rise to the tremors ; nevertheless un- doubted examples of this kind have been observed even in recent times, both in venereal and in other cases.'* In the pre- sent day, there is little risk of tremors originating from excess in either the es- ternal or internal medicinal use of the mineral, but the possibility must not be overlooked. 4th. Persons are sometimes accidentally exposed. In 1810, the 2'i-?- umph, man-of-war, took on board a cargo of mercury, saved from a wreck. In con- sequence of the bladders bursting, in which it was held, the mercury spread through the ship, and in the space of three weeks " two hundred men were affected with ptyalism, ulceration of the mouth, partial paralysis in many in- stances, and bowel complaints."'' In 1803, a fire broke out in the quicksilver mine at Idria, near Trieste, and about wall in Forbes' Cyc. Pract. Med. 1. 151, 1833; Tardieu, Diet. d'Hygifene, 1852 ; Whitley in Sixth Report of Med. Officer of Privy Council, 18G3, p. 358. 1 Mapother, Mercurial Trade Disease, Med. Press and Circular, i. 531, May 23, 1SU6. 2 Hutten, De Morb. Gall. ; Fernelius de Luis, Yen. Cur. u. vii. p. 234, 1656; Ramaz- zini, 1. u. > Colson, Arch, G^n. de Med. xv. 338, 182;; Lancet, ii. 1838-9, p. 767. * Burnett, Phil. Trans. 1823, Pt. ii. 402. The Phipps, schooner, which assisted, waa similarly affected: Ed. Med. and Surg. Jour, vi. p. 5i3, 1813. 802 METALLIC TREMOR. nine hundred persons in the neighborhood were attacked with nervous tremblings.' Medico-legal questions have also risen as to the alleged deleterious effects of emanations from workshops where mercury was used.^ In a few instances a single strong ex- posure has been known to cause the tre- mors ;3 but usually a prolonged and ha- Ijitual contact, for months or years, is required, under conditions which favor the development of the disease. Predisponintj Causes. — The circum- stances which dispose to the disease or aggravate it, are : — 1st. Bad ventilation ; 2d. Cold and damp weather (hence the tremors are worse in winter, in conse- quence of the low temperature and close confinement) ; 3d. Defective cleanliness ; 4th. Intemperance ; 5th. Violent emo- tions (a fit of passion has sometimes orig- inated an attack of tremors suddenly) ; 6th. Idiosyncrasies must be taken into account. Certain constitutions are more susceptible than others to the mercurial poison. The same exposure which in some individuals affects the mouth, pro- ducing salivation and ulcerations of the gums, without tremors, will, in others, cause tremors without salivation. 7th. The mode of application has considerable influence. As a rule, inhalation of mer- curial vapor is followed by tremors ; in- unction or internal medicinal use, by sali- vation. DEsCRiPTioisr. — Previously noticed by several writers, and especially by De Haen,'' the tremulous mercurial disease has been most fully described by Merat,' as observed among the water-gilders of Paris. Less complete accounts have been given by various authors of the disease among workmen in other countries, and as it affects the quicksilver miners at Al- maden and Idria.* ' Murray's Handbook to S. Germany, 9tli edit. 1863, p. 400. 2 Chevallier, Annal. d'Hygifene, xxv. 388, 1848 ; Orfila, Toxicologie, 4th edit. 1843, i. p. 593. ' Christison on Poisons, Mere. Tremor, 4th edit. p. 418, 1845. ' De Haen, Ratio Medendi, Pt. iii. c. 28, 1761. 5 M^rat, M^m. sur le Tremblement des Doreurs, &c. ; Appendix to the Traits de la Colique Mgtallique, Paris, 1812; also in Diet, des Sc. Med. xxx. 232, 1818, and Iv. 521, 1821 ; Bateman, Ed. Med. and Surg. .Tour, vili. 376, 1812; Mitchell, Lond. Med. and Phys. Jour. 1831, p. 394 ; Bright, Med. Rep. ii. 495, 1831: Stokes, Ryan's Lond. Med. and Phys. Jour. V. 519, 1834; Lancet, ii. 1853, pp. 231 and 317; Med. Times, ii. p. 578, 1853 ; Marshall Hall, Watson, Romberg, Val- leix, Falok in Virch. Handb. der Spec. Path, u. Ther. I. iii. 136, &c. ' Jussieu, M6m. de I'Acad. Roy. des Sci- ences de I'AnniJe 1719, p. 357, &c. Symptoms. — 1st Stage. Simile Tre- mors. — The commencement is sometimes sudden, but most frequently the disease comes on gradually. The upper extremi- ties are nearly always first aftected. The patient finds his hands and arms getting weak, unsteady, and less under control ; they vacillate and tremble whenever they are used. He can do coarse work, but nothing requiring precision. The at- tempt to seize or hold anything increases the trembling. At the same time numb- ness or formication is sometimes felt in the hands or feet, and occasionally pains in the joints, particularly the thum1)s, elbows, knees, or feet. These simple tremors are very common among quick- silver miners and water-gilders. They are not so severe as to prevent work alto- gether, and by judicious means they may be kept from increasing. 2(1 Stage. Convulsive Tremors. — If the patient continues or increases the expo- sure, or becomes more susceptible to it, the trembling augments in intensity till it becomes convulsive or spasmodic in character. Muscular subsultus occasions vibration and jerking of the hands and arms. The tremor is easily excited either by exertion or emotion, and once begun cannot be stopped for some time. The voluntar}' acts also become spasmodic as well as tremulous, and are accomplished by interrupted violent starts, like the movements in chorea. In bending the arm, for example, the flexion cannot be done by a single continuous contraction, but takes place bj' two or three jerks. The tremulous hand cannot be directed with precision, but is projected beyond or beside or away from the object ; it soon becomes unfitted for work, and can scarcely convey food or liquids to the mouth. As Dr. Pope tells of a miner at Friuli, "he could not with both his hands carry a glass half full of wine to his mouth without spilling it, though he loved it too well to throw it away.'" The convulsive nature of the movements depends greatly on the predominance of the flexors over the extensors ; so that when a patient has seized an object, he often cannot let go his grasp. At this period, the patient is usually obliged to discontinue work, and after an interval of rest, steadiness may still be completely restored. But if he persist, or resume his employment too soon, the tremors become greatly aggra- vated, and extend by degrees over the whole body. The legs begin to shake, especially at the knees, and in walking they tremble and dance as if hung upon wires. The lips, tongue, and jaws are In tremulous vibration, and speech is hur- ried, staccato, and stammering, becoming at last unintelligible (psellismus mercu- rialis). The head oscillates, shaking, or ' Phil. Trans i. p. 21, 1665. SYMPTOMS. 803 nodding ; and sometimes the features are distorted by spasmodic grimaces ; tlie eyeballs alone are unaffected in their movements. Mastication is impeded. Finally, the tremulous subsultus appears in the muscles of the trunk, and the res- piratory movements are convulsive and attended with dyspniea. Tonic spasms also occur in the affected parts, and are frequently attended by pains, to which the Spanish miners of Almaden give the name of "calambres," i. e., cramps. These pains are sharp and lancinating, and sometimes of intolerable intensity ; they are not always in proportion to the muscular contraction.' When the tremors attain their greatest intensity, they amount to a kind of con- vulsion, and the patient presents a most pitiable aspect. In constant tremulous commotion, tottering, trembling, shaking, and stuttering, he is powerless to execute any combined movement ; he cannot walk, or speak, or chew ; he dares not touch any object for fear of breaking it or letting it fall ; on raising his agitated •hand, with food to his mouth, he misses his aim and inflicts involuntary blows on his face. He must be fed and clothed like a child. ^ Some unfortunates deprived of assistance, have been known to creep on all-fours, and seize food with the lips, Uke the lower animals. Unless in the very worst cases, however, whenever the body is supported, sitting or reclining, the tremors gradually subside, and soon cease altogether, and they do not return until excited in consequence of some voluntary movement or mental emotion. During sleep, they remain in entire abeyance. The patient is thus allowed time for re- pose and recovery. But in the most ad- vanced cases, the subsultus takes place even when the body is reposing, so that the involuntary shaking of the head on the pillow has prevented sleep.' In the tremulous parts, the muscular strength is diminished (paresis), but there is no inter- ruption to the conduction of the stimulus of volition (paralysis). The sensibility is not impaired. I Tardieu, Diet, d' Hygiene, ii. 481, 1854, who quotes Roussel, Lettres Med. siir I'Es- pagne, Union Mgl. for 184P-9; Ed. Monthly Med. Jour. Retrospect for 1848, p. 254. * De Haen's description is graphic. Case 2. " Deanrator, 25 anrorum, horrendo artuum omnium, maximfe superiorum . . . vex- atus . . . ita ut nihil laboris ultra per- ficere, ut nee comedere, bibereve solus, nee loquens amplius intelligi potuerit. Nutri- endus, vestiendus et infantis instar, alvum nrinamque positurus, adjuvandus erat; dolo- rum cajterum iramunis." It is satisfactory to add, ' 'Virtute electrea trium septimanarum spatio adhibita, perfectissimfe convaluit, ita nt ipsi, sive in motu, sive in loquela, ne vel minimum quidcm desit." (Loo. cit.) ' De Haen, loc. cit. case 7. Concomitant Symptomx.—The condition of the other functions, accomi)anyini,' the disorders of the nervous system just de- scribed, indicates the presence of the mer- curial cachexia. At the beginning this is slight and unimportant. The skin ex- hibits a sallow, brown, or earthy tint ; it is dry and sometimes rather warm ; the expression is sometimes animated, at other times languid ; there is little or no emaciation, which indeed does not ap])ear till the disease is of long standing. The digestive functions are unimpaired ; there is no colic, the abdomen is soft and of ordi- nary volume, and the urinary and alvine excretions are natural. But as the tre- mors become more 8e\ere, the appetite diminishes, and it ultimately ceases alto- gether ; the tongue becomes white and pasty, but witliout bad taste, and gas ac- cumulates in the intestines. The respira- tory organs are natural, till dyspncjea and asthma arise, from the respiratory nerves being involved in the tremors. The pulse is usually at first strong and slow, as in metallic colic, but it may afterwards be- come small and weak ; sometimes it is accelerated. But sooner or later signs of general mercurialism usually make their appear- ance, especially sahvation, loose teeth, inflamed and ulcerated gums, aphthte, fetid breath and sweat, swelling of the parotids, and a pustular eruption over the body. These symptoms occur early, and are particularly obstinate in workmen who take their food in the workshops or mines, and who are not careful to use ab- lutions, and change their clothes and shoes. Attacks of excited circulation (erethism) are frequent in the early stages; and in the later, anemia, emaciation, and great debility. If we except the cachec- tic symptoms just described, complications are rare in the" course of mercurial tremors. The colic, which is sometimes observed, depends upon lead which is mixed with the mercury, or has been used along with it. 3cZ Stage. Mercurial Tremors, icith Affection of the Brrtin.— The tremors are not of themselves dangerous to life, but in the advanced stage they are often accom- panied by serious cerebral disorders, as headache, loss of memory, loss of con- sciousness, sleeplessness, delinum, epi- lepsy. These symptoms would soon end fatally were it "not that generally their gravity compels the sufferer to desist from his employment ; and by this fortunate interruption, recovery usually takes place even from this dangerous condition. In- deed, the disease when subjected to treat- ment is rarely fatal.' Some invetexate cases prove incurable, or are succeeded by I See fatal case from " general failing of the vital powers." Lancet, 1839-40 n. p. bsb, and Guy's Hosp. Rep., 1864, p. 175. 804 METALLIC TREMOR. motor paralysis, but it is only in those instances where the noxious exposure is obstinately persisted in, notwithstanding repeated attaclts of increasing severity, that death finally takes place, accompa- nied by symptoms of profound mercurial cachexia, and especially extreme maras- mus and exhaustion. But although mercurial tremor by itself is not directly fatal, and is a curable dis- ease when submitted to proper treatment, j^et, under the circumstances in which workmen were placed till within a recent date, the effects of the mercurial poison, taken as a whole, were most disastrous, and the mortality in certain employments was excessive. In Paris, in 1821, it is stated that the looking-glass manufac- turers could not remain at the trade above eight or twelve years. When necessity compelled them to persevere too long, their faces became pale, with an expres- sion of intoxication, their intelligence and memory gradually failed, they fell into a kind of idiotcy, and after lingering in this state for some years, they died of con- sumption, or were struck with apoplexy. ' In 1847, Dr. Sanderet reports that the trade of water-gilding at Besan9on, where it was extensively carried on, was most injurious to health, ^ the mortality among the workmen being enormous, and due chiefly to phthisis. Fortunately these trades, conducted under better hygienic conditions, or by means of new processes, are either entirely innocuous or are much less injurious at the present day. The condition of the quicksilver mines was, in ancient times, most dangerous." At a comparatively recent date, when Jussieu visited Almaden, in 1719, he found that the free miners, who adopted proper precautions, preserved their health and lived like other men, but the convicts and slaves who took no care suffered severely, and fell victims to disease. In 18-18-9, there were no slaves nor convicts in those mines; but it was observed that the native miners, who knew the risks and avoided them, were little affected, while the poor laborers from a distance, careless and dis- sipated, experienced the most disastrous effects. The average number of workmen was 3911 ; of these forty-eight were ' 'calam- bristes" (in the second stage of mercurial tremors), half of which number died within the year, and the other lialf remained unfit 1 Burdin, Art. Tain, Diet, des So. M^d. 1821, liv. 276. 2 "Une des industries des plus fatales fl la sante." (Anual. d'Hygifene, 1847, xxxviii. 457.) ' At Idria, in 1665, Dr. Pope says, "All of the miners in time (some later, some sooner) become paralytick and dye heclick." (Phil. Trans.) Also Dr. Edward Brown, in Phil. Trans. Deo. 13, 1669. for work in the mines. Besides this, there were two deatlis from accidents, three mutilations, and thirty-nine injuries more or less serious. And although many work- men do not fall victims to the mercurial poison, none of them entirely escape its action. ' At Idria, although the hygienic conditions of the place are in other re- spects highly favorable, it is stated that the whole population is subjected to the influence of mercury, not the workmen at the mines only. The annual mortality is 1'20 out of 4500 inhabitants. The work- men exposed directly to the action of the metal suffer severely. In 1856, 122 out of 516 were seriously affected.'' Information is wanting in regard to the quicksilver miners in California and Australia. Course and Prognosis. — Mercurial Tremor is essentially a chronic and pro- tracted disease. It runs a uniform course. Once begun, if the exposure is persevered in, the symptoms gradually get worse ; the tremors become more intense, are ac- companied by spasms clonic and tonic, and spread over the whole body. But if the patient be removed from the exciting cause, exposed to fresh air, and placed under suitable treatment, amelioration soon begins, and, after a few weeks or months, perfect steadiness may be re- stored. The prognosis, therefore, is gene- rally favorable, provided tlie patient can avoid the contact with mercury. The prospect of cure, and the time required for it, will depend on the severity of the symptoms, and especially on their dura- tion previous to treatment, on the age of the patient, the presence of serious cere- bral symptoms, and the degree of mercu- rial cachexia which may accompany the tremors. The affection is most frequent probably in middle life (thirty to forty); it is more severe in old people. If taken at an early stage, twenty days may effect a cure, but in a confirmed case usually from two to seven months, sometimes a year or more, are required. "When the tremors are spasmodic and generalized, the cure is tedious and imperfect, some tremor of the hands nearly always re- maining permanently. The upper ex- tremities, which are the parts earliest and most severely affected, resist cure the longest. It is seldom that the tremors are persistent and irremediable, and, as alread}' stated, fatal i-esults only ensue in consequence of general cachexia or phthi- ' Tardieu, loc. cit. and Roussel. In tlie inclosure called Brutrones, where the fur- naces are situated, the animals which are allowed to graze there are liable to Mercurial Tremors. (Edin. Month. Med. Jour., Retro- spect for 1848, p. 255.) * Med. Times and Gazette, xxxix. p. 616, 1859. and Gaz. Hebd. PATHOLOGY AND MORBID ANATOMY. 805 sis or apoplexy, the effects of an unhealthy- constitution, or of unpardonable neglect, or of obstinate persistence in exposure to the poison. After a first seizure relapses are fre- quent, and usually of increasing severity. If the patient, in spite of due care, is still subject to attacks, he ought to change his employment. Some constitutions, pecu- liarly sensitive to the poison, are unfit for any trade requiring the use of mercury. Diagnosis. — The symptoms and the cause distinguish Mercurial Tremor readily from other diseases. It could only be confounded, 1st, with chorea, or St. Vitus's dance, ■which it resembles in the jerking nature of the movements, but it differs by the presence of tremors ; 2d, with idiopathic paralysis agitans, with which it is identical as regards the cha- racter of the irregular movements (viz. tremors and jerking), but it is distin- guished from it by the exciting cause (mercury), and by the concomitant symp- toms of mercurial poisoning. In addition, the speech (tongue and jaws) is much sooner, more invariably, and more cha- racteristically affected in the mercurial disease than in idiopathic shaking palsy. The loss of memory and consciousness, and other cerebral symptoms also, are pe- culiar to the mercurial disease. On the other hand, the irresistible tendency to walk or run forwards, which marks the paralysis agitans festinans, is not met with in the Mercurial Tremors ; the only disturbance of equilibrium in the latter is that which results from debility, tremors, and spasmodic jactitation.' 3d. It is not likely, with ordinary care, to be mistaken for delirium tremens, or alcoholism. Pathology and Morbid Anatomy. —The disease being rarely fatal, the in- formation in regard to the morbid anat- omy is scanty. In a recent case,* Dr. Alfred Taylor found the brain and spinal cord, the muscles, lungs, heart, liver, and kidneys, in appearance quite health}'. On chemical examination of the brain, liver, and kidney, minute globules of metallic mercury were obtained, in largest propor- tion from the kidney. The spinal cord and medulla oblongata are doubtless the seat of the principal morbid action, just as in idiopathic paralysis agitans. The molecules of mercury entering probably into combination with the nervous sub- ' De Haen's foiirth case presented consid- erable disturbance of the balance in locomo- tion. "Adeo difficulter ingreditur, ut ssepius humi concidat, dumque corpus pronando sus- tinere se nititnr, vi quasi supinatur." (Loc. cit. p. 230.) ' Guy's Hosp. Eep. 1864, x. 176 ; Lancet, 1839^0, ii. p. 589. stance, seem both to irritate and partially to paralyze the nervous centres of motion, while they leave the apparatus of sensa- tion intact.' The opinion which some authors entertain, that the morbid lesion has its seat in the muscles and not in the nerve-centres, is insufficient to account for the spasmodic and variable nature of the phenomena, and is inconsistent with the cerebral symptoms which ultimately become developed. The treatment is twofold, preventive and curative. Prevention is accomplished, 1st, by lim- iting the exposure to a short period at considerable intervals, or by adopting various contrivances which remove the mercury from contact with the operator. In the time of Pliny* the workmen pro- tected their faces with masks of loose bladder skin, sufficiently transparent to admit of being seen through. Masks of glass were afterwards substituted. Sponges over the mouth, and various kinds of re- spirators, have also been proposed. But the chief improvement has taken place in recent times by the better construction and ventilation of the workshops, and by the introduction of fines and chimneys, which carry off the mineral vapors by a powerful draught out of the apartment, while the workman is further protected by a glass sash interposed between his face and the stove where the mercurial vapors are disengaged. To D'Arcet's' draught chimney fot this purpose the French Academy of Sciences, in 1816, awarded the prize founded by M. Ravrio, who had made his foi;tune as a manufac- turer of gilt bronzes, and was anxious to obtain some means for protecting work- men from the risks of the employment. Merat bears testimony to the efficacy of D'Arcet's chimney in warding off the tremors, to some extent. Similar flues and stoves have been used in this coun- try ;'' but none of these inventions have proved successful in entirely preventing the disease. 2d. On the part of the workmen, regular habits, personal clean- liness, change of clothes, frequent ablu- tions, and the practice of never eating in the mine or workshop, or with unwashed hands, are essential. Intemperance inva- riably predisposes to or aggravates the disease. Melsens observed that workmen ' Jussien's idea of the pathology is curious. The tremors, he says, are "les tristes effets du sejour du sang dans les vaisseaux du cer- vean, d^venus variqueux par le poids de quelques particules mercurielles, qui y ont s^journ^." (Loc. cit. p. 360.) 2 Hist. Nat. xxxiii. 40. 3 Meraolre sur I'Art de dorer le Bronze ; Paris, 1816. Diet, des So. M«d. 1818, xxvii. p. 299. * Darwall in Forbes' Gyc. Pract. Med. 1833, i. 157. 806 METALLIC TKEMOR. ivho used much salt with their food are less liable to sutler from Mercurial Tremors, aud he also recommended the iodide of potassium as a powerful preservative. Of lute years in this country Mercurial Tre- mor has greatly diminished in frequency, and under proper hygienic rules would probably cease altogether, at least in its more aggravated forms. Water-gilding, the most dangerous kind of mercurial trade, has heen now almost altogether superseded by electro-plating, which is completely innocuous. Looking-glass sil- vering, when conducted in large well- ventilated apartments, with means for preventing the diffusion of the metallic dust, is also quite safe, if the workmen are employed only at intervals, and are careful and temperate. But when these conditions are not attended to, and espe- cially if the men are kept too continuously at work, slight tremors soon make their appearance, and severe cases occasionally happen.' According to Dr. Whitley's report," the number of persons affected in England and Wales appears to be small, and the cases, for the most part, slight. The same statement may be applied to Scotland and Ireland. The condition of the quicksilver mines is probably still one of considerable danger to health and life. But full and accurate information is want- ing in regard to the amount of sickness and mortality among the miners, and the means used for their protection. The Curative treatment consists, first, in complete removal of the patient from his noxious employment ; next, in change of dress, ablution, exposure to a free atmos- phere of moderate temperature, and the administration of a nutritious tonic diet. The objects of treatment then are, 1st, to eliminate the mercury from the system by the secreting organs. Sudorifics' have been much used for this purpose : acetate of ammonia, Dover's powder, guaiac, sar- saparilla, sassafras, &c. Sulphur has been regarded by some as specific ; warm and vapor baths, or sulphurous baths, &c., are always employed. Neufchatel had a re- putation for the successful treatment of water-gilders' palsy, chiefly by means of ' See recent cases, Scott Orr in Glasp;. Med. Jour. i. 37, May, 1866, and Mapother, loo. cit. Also Taylor, loc. cit. 2 Sixth Report of Med. Officer of Privy Conncil for 1863, p. 22 ; and 1864, p. 3.58. ' Jussieu remarks (1719) that at the mines of Almaden the medical treatment differed from the usual practice then in vogue of purging and bleeding, and consisted simply in exposing the patients to the free air, and administering absorbents, as hartshorn, ivory, or crab's-eyes ; and what is singular (he adds) the treatment succeeds almost always in temperate subjects and those who abstain from wine, whilst those who indulge perish without resource. (Loc. cit.) vapor baths.' Diuretics have become fa- vorite remedies, and especially the iodide of potassium, since Melsens" brought evi- dence to show that this .salt has the power of redissolving the mercury contained in the tissues and eliminating it by the urine, in which its presence may be detected chemically.' The caution" must be ob- served not to give the iodide so largely as to disengage an excess of mercury at once within the body. Various other diuretics, common salt, bitartrate of potash, &c., may be employed. Purgatives are also useful. 2d. Another indication is to soothe and strengthen the nervous sys- tem, by means of antispasmodics, narcotics, tonics, and stimulants. Steel and quinine, singly or in combination, are especially serviceable. Opium is useful. Nitrate of silver has also been recommended. Stim- ulants, particular^ alcohol, wine, &c., ex- ert a powerful immediate effect in arrest- ing the tremors : hence workmen are apt to resort to them to steady their hands ; but when the immediate effect is over, they a^rgravate the tremors. The most beneficial stimulants are electricity and galvanism, which have afforded very satis- factory results."* Dr. Haen's cases were cured, some of them rapidly, with elec- tricity as the only remedy applied. 2. Lead Tremors; Tremor Saturninus; Paralysis Agitans Saturnina. Merat denied that any other metal than mercury could give rise to tremors, and, with few exceptions,^ other writers appear to be of the same opinion. In regard to artisans using lead, this view is probably correct ; but the case is different with miners exposed to the vapors of the metal. Brockmann,* in particular, from his ex- perience in the Harz Mountains, has de- scribed a species of lead tremors, which ' Sandaret, Ann. d'HygiSne, 1847. 2 Annal. de Chimie et de Physique, 1845, xxvi. 215, and transl. in, Brit, and I'or. Med.- Chir. Rev. for Jan. 1853, p. 217. ' Schneider of Vienna controverts the as- sertions of Melsens, Ed. Med. and Sur. Jour. 1861-2, p. 394. * De Haen, loc. cit. Gull, Guy's Hosp. Rep. 1853, viii. p. 136. 6 Perclval, Ed. Med. and Surg. .Jour. 1813, ix. 62, ascribed tremors rathertolead than to mercury ! 8 Die Metallurgischen Krankheiten der Ober- harzes, 1851, p. 282; Schoijlein, AUg. und Spec. Path, und Ther. 2 Thele, p. 191 (St. Gallon, 1841); Falck, in Viroh. Handb. d. Spec. Path, und Ther. ii. 1 Abth. 517-8, 1855. Wilson, in Edin. Essays Physical and Liter. 2d edit. ] 771, p. 517, in describing the disease called Mile-Reek among the miners at the Lead hills, mentions that the "extremities tremble and are convulsed." Sauvages, No- sol. Meth. 1768, p. 558, Tremor Metallur- gorum. SYMPTOMS — TREATMENT. 807 affects the miners there, and which is almost identical with the mercurial shak- ing; palsj^, consisting, like it, of oscillating spasmodic contractions of the muscles, aud consequent tremulous motion in vari- ous parts of the body. His account in- cludes two forms, the local (partialis) and the general (universalis), both the result of an affection of the nervous centres by lead. Symptoms. — 1st. Tremor Saturninus pmiialis. — As a rule, the upper extremi- ties are alone ati'ected. The arms and hands are in continual vibration, more or less, greatest when any powerful effort is made, or during emotion. AVith this there is often associated a peculiar nervous tre- mor of the Kps (muse, orbic. oris) and angle of the mouth (levator an^uli oris), like that observed wlien a shy sensitive person opens his lips. The local tremor usually follows violent and persistent at- tacks of lead colic, especially in highly nervous subjects, or in those exhausted by previous disease. It disappears mostly in a few days, but is apt to return when the exciting causes are renewed. Under v?ry unfavorable circumstances, however, it may increase and extend into the gen- eral form of affection. 2fL Tremor Saturninus universalis. — In this the tremors are not confined to the arms, but appear in the legs and muscles of the head and trunk. The patient pre- sents a peculiar and pitiful aspect. When at rest, his back is bent like an old man's, his head is bowed, and the chin falls upon the breast ; in walking, the legs are ro- tated tremulously as in paralysis agitans. In advanced cases the jaws, and indeed all the muscles of the head and bo ""y, are the seat of the uncontrollable tremors which characterize the disease. Causes. — The general tremor never re- sults except from deeply-rooted lead-poi- soning. It is preceded by repeated out- breaks of the severer forms of the lead disease, and progresses hand in hand with the lead cachexia. All the causes of the cachexia predispose to it, and the ten- dency is increas d by an excitable ner- vous constitution, together with lax fibre and weak muscular system. Age has no appreciable influence. The saturation of the system witli lead is the only exciting cause of the disease. The CoTJKSE of the general disease is chronic and very protracted. Months or *Yen years elapse before permanent im- provement takes place. Often a radical cure IS impossible. Frequently, also, the tremor becouK-s associated with some form of anaesthesia, or ends in complete paralysis. Tlie Prognosis is consequently almost always unfavorable. Only when the dis- ease is partial, and follows a violent colic, or an acute attack of convulsions, can a speedy favorable issue be anticipated. Under all other circumstances, lead tre- mor is a most serious affection, and is apt to be the precursor of more sudden and dangerous disorders, such as paralysis or cerebral disease. Pathology anu Morbid Anatomy. — No specific lesion has yet been pointed out in the brain or spinal cord. The affected muscles have been found altered, but this is of subordinate importance. The pathology is doubtless analogous to that of mercurial tremor, and idiopathic paralysis agitans. The Diagnosis is sufficiently deter- mined by the symptoms of tlie lead ca- chexia which accompany the tremors, and by the absence of any source of mercurial poisoning. The Treatment must be directed to neutralize the lead poison, and to strength- en the nervous centres, which are the chief seat of the disease. The energetic employment of sulphur batlis, cold water douches to the spine, and the internal use of nervine tonics, nux vomica, or strychnia, valerian, quinine, &c., are the appropriate means. Sudorifics, sarsaparilla, &c., have also been used, and Melsens recommends the iodide of potassium on the same grounds as in the case of mercury. Brock- mann states that he never concludes the treatment without the persevering use of baths of aromatic herbs, and the cold plunge bath, as well as the internal ad- ministration of chalybeates. In obstinate cases electricity and galvanism must be resorted to, but frequently without much success. The most essential part of the treatment consists in the removal of the patient from his unhealthy employrnent, and placing him in free pure air, with a nutritious animal diet, and a moderate allowance of good wine and beer. In poisoning with arsenic, zinc, or bis- muth, tremors frequently occur, but they only form part of a general group of symp- toms, and do not require particular de- scription in this article. B.-PARTIAL DISEASES OF THE NERVOUS SYSTEM. 1. Diseases of the Head. a. Meningeal Diseases : — Simple Meningitis, tubebculae meningitis. Chrootc Hydbocephalus. Meningeal Hemobehage. Adventitious Pboducts. Congenital Malformations. 6. Cerebral Diseases: — Congestion of the Beain. Cebebritis. Softening. Adventitious Pboducts. Cebbbeal Hemoeehagb. Abscess. SIMPLE MEN'mGITIS. By J. Spence Ramskill, M.D. Definition. — By Meningitis is gene- rally meant inflammation of the pia ma- ter and arachnoid. Inflammation of the dura mater is described separately. At- tempts have been made to separate in- flammation of the arachnoid from that of the pia-mater, and some, as Lallemand, Parent-Duchatelet, and Martinet, have even gone so far as to apply the term Arachnitis to inflammation of the arach- noid, on the ground that the serous mem- brane was the one chiefly affected. But an analysis of the cases given by the very advocates of that opinion shows most con- clusively that the pia mater is in all cases affected, and always bears more marked evidences of inflammation than the arach- noid. There is no symptom which, during life, could help to distinguish between in- flammation affecting the pia mater and inflammation involving the arachnoid alone ; and as the treatment in either case would be the same, there would be no practical advantage gained by such a distinction. Cerebral fever is a name given by Trousseau to various acute affec- tions of the head in children, amongst which he includes Meningitis. Menin- gitis may be primary or secondary ; un- complicated or complicated ; aciite or chronic. Acute Meningitis. Symptoms.— In some rare cases, certain prodromata pre- cede the invasion of the disease, in the shape of slight but increasing pains of the head, irritability of temper, sleeplessness, and general malaise. But, as a rule, the invasion of the disease is decided, and from the outset its gravity is not to be mistaken. Its course may be divided into three stages : — 1st, a period of excitement; 2d, a period of transition ; .Sd, the stage of collapse. These three stages are not always present, nor are they always dis- tinctly marked. When the disease is very violent, the first stage may rapidly pass into the third, or comatose period. In old and feeble people the first stage may either be absent altogether, or be so little marked as to escape observation. Again, the third stage may be absent, from life being abruptly cut short by vio- lent general convulsions in the second period ; and lastly, the first and third stage may coalesce during the transition from one to the other, and may present mixed phenomena of delirium alternating with coma. Sta^je First. Period of excitement. — A well-marked rigor, with pallor of the sur- face and cutis anserina, opens the scene, and is very quickly followed by intense ACUTE MENINGITIS. 809 febrile reaction. In very young children a paroxysm of general convulsions may be the first symptom ; in adults, however, convulsions are the exception. The fever is very high; the skin is hot and dry; the pulse frequent, sharp, and hard ; the ftice flushed, particularly about the malar bunes : sometimes it is alternately flushed and pale. The eyes are glistening, the conjunctivse injected ; the pupils in this stage are usually contracted ; there is photophobia ; and, in order to keep the light out, the patient keeps his eyes firmly closed, and resists all attempts at opening them on the part of the practitioner. There is sometimes strabismus on one or both sides, particularly in children. Acous- tic dyssesthesia distresses the patient : the least sound, the lightest footstep about the room gives him pain. Cephalalgia of the most acute character sets in from the first. It is referred to the forehead, vertex, temples, or occiput, or to the head gene- rally : pressure on the scalp increases, and movement intensifies it ; hence, in order to prevent his head frnni moving, the patient holds it between his hands. Sensorial impressions of light and sound also exaggerate it. The pain is continu- ous, but presents also frequent exacerba- tions, duriuCT which the patient, especi- ally if a child, utters a peculiar, loud, piercing cry. The headache may precede the other symptoms for a day or two, or for a few hours only, or it may appear simultaneously with them. It is the most striking symptom of the disease; it is pre- sent in nearly every case, but not in all ; and Andral has related in the "Clinique Medicale," cases in which it was absent from first to last ; and, in one of these, sero-purulent effusion was found in the lateral ventricles after death. The inten- sity of the pain does not bear any relation to the stage of the inflammation and the nature of its products. Thus, it has been found as severe in cases where a post- mortem examination disclosed mere injec- tion and increased vascularity of the men- inges, as in cases of serous or purulent infiltration of the membranes, or when false membranes had time to develop. The extent over which it is felt is not pro- portionate to that of the inflammation, for it may be felt all over the head, and yet the Meningitis be partial only; on the other hand, it may be exactly limited to one particular spot, and yet the inflam- iination be general. When partial, it does not always correspond to the exact seat of the inflammation, although when an individual complains of a fixed pain in a spot never varying, the probability is, that the meninges are inflamed at that point. The cephalalgia of Meningitis dif- fers from that of continued fevers in its intensity, and in the fact that the patient does not wait, as in the latter, till asked whether he has any pain in his head, be- fore speaking of it himself, and cravin Refer to paragraph on Heat of Body 2 See paragraph (8). 822 TUBERCULAR MENINGITIS. another pause, and so on. A careful ex- amination will sometimes be necessaiy to detect ii-regular breathing. Sighing ex- piration is particularlj' common when children become half-inseusible from Tu- bercular Meningitis. (4) Heat of Body. — The first three or four days of the established disease are attended by what seems to be (judging by the hand) a distinct increase in the heat of the skin. This is followed by a period of low pyrexia, during which the tempe- rature only occasionally exceeds 101°. I do not say that the temperature is not sometimes persistently higher, but I do not happen to possess notes of any cases in which it was so ; whilst, on the other hand, for days together the temperature may vary between 90-" and 98°. As death approaches (say for about the four days preceding death) cases have seemed to me to group themselves into three classes : in one, the state of moderate fever continues up to the very day of death ; in another, the fever greatly increases before death ; in a third, the body-heat falls below the standard of health. An example of each class will make this more clear : — Day before death. Third. Second. First. Day r death. Type 1. Boy : 4 years 99-5 102-0 99-0 101-0 100-5 101-5 99-0 101-5' Type 2. Boy : 2J years 97-0 99-3 99-2 101-0 100-0 103-0 104-4 107-25! Type 3. Girl : 2J years 97-S 9()-6 96-2 93-0 S2-S S2-1 80-5 79-42 The minimum and maximum tempera- tures of each day are given. The peculiar variety of ardent fever re- ferred to the second type (the lipyria of Galen) is, perhaps, more common in Tu- bercular Meningitis than in any other dis- ease.' "Heat of the viscera, as if from fire, but the external parts cold ; the ex- tremities — that is to sa}', the hands and feet — very cold" (Aretfeus). A thermo- meter in the arm-pit will prevent our being misled by the coolness of the ex- posed parts. In the third type the al- gidity involves the viscera themselves ; the temperature in the example adduced was taken by i-neaus of a thermometer kept permanently in the rectum ; and, as the hyperpyrectic cases might deceive the hand applied to the limbs only, so might the state of algidity deceive the eye. The example chosen one hour before her death, when her temperature was 79-8°, her breath cold to the hand, and her pulse imperceptible at the wrist, still kept a little color in her cheeks, and (except that her eyes were half-open) it would have been impossible for one merety looking at her to have said that she was not a tolera- bly healthy child eahnly asleep. The pulse, as a rule, agrees with the tempera- ture, rising in frequency as the tempera- ture rises, and falling as it falls : no pro- portion is kept in the amount of the rise and fall. Excessive frequency of pulse may concur with a moderate elevation of temperature ; or, reversely, the tempera- ture may be higli and the pulse infrequent (e. g. temperature 103°, pulse 72 — a ratio really observed, and sucli as would serve to clench the diagnosis of acute disease of ' See article ou Scarlet Fever, vol. 1. p. 83. the brain) . Heat of the head greater than of the rest of the body is a symptom far from alwaj's observed in the earlier stages of the disease, and still less frequently" in the later. (5) Xervous Sj'stem. — i. Headache con- curs with the invasion, or, if present pre- viously, is much increased then. The pain is mostly referred to the top of the frontal bone. The headache is tolerably constant, subject to paroxysmal exacer- bations, and lasts until stupor sets in. The temporary increase of headache is sometimes made known by the moaning of the child ; sometimes he cries out, " Oh 1 my head," or shrieks,' or holds his hands hard on his head ; he greatly dis- likes any disturbance, for that increases the headache. But it must not be sup- posed that headache of this severity is present even occasionally in all cases, ii. Ei-ie-symptoms are very important. One pupil is often distinctly larger than the other : this state is present at some time or other in every instance of the disease, does not occur at any special period, and is not always constant ; thus the ine- qualitj' in size, present in the earlier part ' One hour and a half before death.. 2 At very moment of death. 3 I copy the folio-wing particulars relating to the " hydrocephalic cry" from Trousseau (Clin. Med. 2me edit. vol. ii. 239) : — "It is a single, violent cry, resembling the cry of a person suddenly exposed to great danger: the expression of the face is not that of suffering: any period of tlie disease may be attended by this cry, -wliicli may occur every hour, half hour, or even every five minutes." Eilliet (iii. 503) does not consider this to he either a common or a special symptom — an opinion witli whicli my own experience would lead me to coincide. MENINGITIS OF THE BASE. 823 of this stage, not rarely disappears later on in the disease, in order, it may be, tliat the relation of size may be reversed for a day or two before death : or, some- times, the variations are much more rapid. Dilatation and sluggish action of the pupils is the rule towards the end of the disease, but the absolute size of the pupils is of small value in diagnosis. Squint is present sooner or later in every case. Hemiopia may occur so early in the disease as to be discoverable (Trous- seau, ii. 236, 237). Oscillation of the eyeballs, or of one eyeball (the other being fixed), is common in the later period.' iii. Paralysis of the Face, one eye opened less widely than the other, one nostril being rounder than the other, one corner of the mouth less acted upon by the muscles than the other, one side of the upper lip straightened — these are frequent concomitants of the later period, iv. Paralysis of the Limbs. — Quite towards the end of the disease we often observe one or more of the limbs to be unmoved, relaxed or feebly rigid, flexed or extended. V, Convulsions and Rigidity. — These have been already mentioned as occasional in- vasion symptoms. As terminal symp- toms they are equally frequent, occurring on the day of death, the child perhaps dying immediately after a convulsion. Yet they are not to be trusted as a sign of impending death, or even of death likely to occur in a day or two. When convulsions have been invasive they do not necessarily recur. The following may be taken as an example of the state of a child in convulsions towards the end of the disease : he lies unconscious, whole skin injected, eyeballs drawn upwards and to one side, pupils large, one side of face more wrinkled than the other, teeth clenched, limbs rigidly extended — except the hands, the fingers of which are iiexed —slight twitching movements of face and hmbs, more marked on one side than the other, respiration labored. As the child comes round the unconsciousness dimin- ishes, pupils become smaller, he is left bathed in sweat. Sometimes the clonic movements are more marked. Sometimes the limbs are relaxed throughout, and the twitcliings limited to the face and eye- balls. Permanent feeble spastic rigidity of one or more groups of muscles is com- mon during the latter period ; sometimes the rigidity is much stronger. Opistho- tonos may be present during the last few days of life ; it may be paroxysmal and last only a few minutes, or it may be con- tinuous and last until death. In such cases I have not found any signs of in- flammation about the cord or its mem- branes. Tremulousness of the limbs is ' For the ophtliahnoscopio appearances, refer to paragraph (6). very common. A shudder may be often observed to pass through the body from head to foot. Many other niceties of motorial symptoms might have been de- scribed : enough has been said to show the infinite variety present in Tubercular Meningitis, vi. S«wation.— Tenderness of the skin can be demonstrated to be present in some cases ; it is often very obviously present in the scalp when a barber is employed to shave the head. Pains in the limbs are sometimes com- plained of early in the disease. Dislike of light is common at the same period. Blindness is difficult of recognition, be- cause occurring late. All these symptoms are sometimes unilateral, vii. Conscious- ness. — The children soon become somno- lent : they lie with their eyes shut or half-shut, reply to questions in a dry short way or by a nod : when raised up in bed they complain much, knit brows, throw head Imck, and slip down in the bed. They dislike disturbance extremely : will clench their teeth against food. As the somnolence increases, the children cease to speak, but they will put out their tongues when shaken and pertinaciously asked to do so ; they then relapse willingly into their former soporose state. By de- grees, or sometimes suddenljr, the sopor becomes deeper ; but not until near the very end, and not always even then, does the coma become so deep that the child wiU not withdraw his limbs (provided they are not paralyzed or rigid) when pinched, and also give other signs of being discommoded. Inability to swallow accompanies the coma. Retention of urine is sometimes rather an early symp- tom. The consciousness may be perfect the day before death. The semi-coma may he continuous from the invasion to the end of the disease. Delirium is com- mon, but is not a symptom of much value in diagnosis, prognosis, or treatment. (6) Physical Signs of tuberculosis of the lungs are not often to be detected in eases ■^^•hich, by reason of their course, are ar- ranged under the head of Primary Tuber- cular Meningitis. Yet occasionally, and that even when the foregoing poorliness has not been greater than usual, I have detected the signs of a cavity under one or other clavicle. Sonorous rales may be met with, sometimes a little mucous rale; and in exceptional cases, which are, nev- ertheless, cases of Tubercular JMeningitis as opposed to acute tuberculosis, all the physical signs are present of that very fine capillary catarrh which, in children,^ is nearly always indicative of the coexist- ence of tubercle or pneumonia. This sign I have observed in Tubercular Meningitis, and in no other disease: namely, the chest heaves equally well on both sides, and yet over a very large part, or even the whole of one side, no respiratory sound is heard 824 TUBERCULAR MENINGITIS. by the stethoscope. In a few hours this sign will have passed away. It is proba- bly due to a slight pulmonary catarrh concurring with the respiratory uncon- sciousness of the brain disease. When the fontanelle is large, it is mostly dis- tended ; when small, the distension can- not be perceived. Of late years the ophthalmoscope has taken an important place among the means for discovering Tubercular Menin- gitis. Actual tubercles may be occasion- ally seen in the ocular choroid during life; but this is not a common occurrence, and if the ophthalmoscope were useful in this way only, its use would be very small. Choroidal tubercle was discovered, in one case, six weeks before the invasion of Tu- bercular Meningitis : Fraukel, Virchow's Jahresbericht, 1869, p. 621. Steffcn found choroidal tubercle in four out of five cases of Tubercular Meningitis, and in three cases of the four during life: cod. loc. 622. It is by detecting changes in tlie vascu- larity of the retina that the ophthalmo- scope renders real service. Whenever meningitis is basilar, we find congestion of the retinal vessels, and sometimes optic neuritis. It will be obvious that there is nothing peculiar to meningitis in these signs ; and also, that to find a state of retina which is probably dependent upon intracranial causes must be a very impor- tant item in the diagnosis, when we are doubtful whether a convulsion or an at- tack of vomiting be due to meningitis or not.' Meningitis whicli affects the con- vexity of the brain, and spares the base, is unattended by any unnatural condition of the optic disks : of this fact I have seen two instances. (7) Urine. — In the case of a boy, aged four years. In whom it was necessary to employ the catheter, I had an opportunity of examining the urine. The following was the result : — Day of disease. Water. tTrea. Oil. sod. Plios. acid. 19-20 20-21 21-22 (day before death) Mean of 3 days in healthy ) hoy of same age j 122 c. 0. 122 c. V. 171 c. c. 431 0. .;. 5-07 grammes 5'51 grammes 7-34 grammes 15'27 grammes 0-195 gramme absent absent 3-062 grammes 0-432 gramme 9-3G7 grammes 0-583 gramme 0-967 gramme Weight of body — case of meningitis " " healthy child 1911b. 28 lb. (8) General Appearance : Summary. — Although the individual symptoms which have been now described are grouped in almost every possible manner in the dif- ferent actual examples of Tubercular Meningitis which we meet with, yet it may be well to recapitulate the chief mat- ters in what has gone before, and so to arrange them as to form a sort of idea or type of primary Tubercular Meningitis in the child. A boy of five years old, in whose pa- rental antecedents there are signs of a tendency to tuberculosis, begins to feel poorly, to lose flesh, and to complain oc- casionally of his head ; he is restless at night, and languid by day; his bowels are rather confined ; he is subject to irregular feverish attacks. These symptoms last two months, and then, one day, the child vomits for the first time ; during the next three or four days the vomiting is re- peated several times; afterwards it ceases; at the same time the fever runs higher, the headache increases, the nights are noisy, the constipation is obstinate. About the time that the vomiting ceases, other symptoms pointing to cerebral dis- ease appear ; say, for example, on the sixth day after the first vomiting, he looks thin and pale ; skin hot and dry ; tem- perature 100-8° (evening); pulse 81, irreg- ular ; respiration 20, regular ; tongue dry, red tip, light fur elsewhere ; bowels not open ; belly natural ; converging strabis- mus of one eye ; pupils of middle size, mobile, one larger than the other ; he says he has headache, and points to his forehead as its seat ; physical signs of chest are negative ; tache cerebrale uncer- tain ; the boy is quite rational, moves about in bed, sits up, answers questions, and the expression of his face is not pecu- liar : the diagnosis rests (and rests surely) on the previous history, the pulse, and the condition of the eyes. On the seventh day he is much the same ; belly rather retracted ; pulse 108, very irregular ; res- piration regular; temperature 100 •4'^ (morning) and 101° (evening). Eighth day : no marked change, rather lower ; pulse 112, still irregular ; temperatures, morning and evening, 100-2° and 100-6° : all the other symptoms remain unchanged. Ninth day : clearly much worse ; con- sciousness failing ; does not cry out ; probably can still see ; tache cerebrale easily produced ; cheeks, habitually pale, easily flush ; cannot sit up ; no special • See especially Dr. AUbutt's papers "On Optic Neuritis as a symptom of disease of the brain and spinal cord." Med. Times and Gaz. 1808, vol. i. pp. 495 et seq. MENINGITIS OF THE BASE. 825 expression in face ; swallows well ; pulse, laO, regular, weaker ; eyes as before ; anus very tremulous ; temperatures, 101-20 and 103°. Tenth day: still worse, semi-stupor, fannot be made to speak : eyes only half-open ; passes excreta under him ; lies fidgeting and picking with tremulous hands ; pulse, 168, regular ; temperatures, 101 -8° and 1024'^. Elev- enth day : stupor greater ; he occasionally moans ; whole surface much injected, face and head greatly flushed, dusky; and as the child lies on his back, motionless, with his half-opened and prominent eyes, their corners filled with thick secretion, and the corneas dusty and filmed, he has a look quite characteristic of hydrocepha- lus ; pupils dilated ; one eye fixed, and probably blind ; swallows pretty well ; belly greatly sunken ; pulse, 180, regular, very weak ; respiration, 15, irregular ; temperatures, 101° and 103°. Twelfth day: stupor deeper still ; moves limbs of one side feebly ; those of the other side are somewhat rigid ; swallows badly ; pulse so frequent and feeble that it can- not be counted ; feet cold ; temperatures, 101'5° and 103'6o. The next morning he dies. Duration. — The duration of primary Tubercular Meningitis with prodromat'a is from seven to three-and-twenty days. It has been already mentioned, on the authority of Eilliet, that when the pro- dromata are wanting the duration is from twenty to tliirty days. Eemission in the gravity of certain symp- toms is not uncommon in the acute cere- bral diseases of children. The direct ner- vous symptoms are the most variable ; the squint, the unequal or dilated pupils, the rigidities, and the somnolence. The variations in the last symptom are the most striking and deceptive, semi-stupor passing away so as to leave the intellect perfectly clear. But when once the phy- sician has satisfied himself of the exist- ence of meningitis, he should not let his diagnosis be easily shaken. As Eilliet observes, "the improvement does not show itself in all the symptoms ;" the pulse remains irregular, it may be, the squint or inequality of pupils persists, and though the remission should last a day or two, the child will die as surely and as early as if all the symptoms had been continuous. Termination. — Tubercular Meningitis, running the course which I have now de- scribed, has but one termination, and that is death. But it has been suspected, and with good reason, that recovery some- times takes place in the earliest stage of the disease.' The probability of this ' See Dr. Allbutt's papers " On the diag- nostic value of the ophthalmoscope in ' Tuber- cular Meningitis.' " Lancet, 18(39, vol. i. pp. 5S(i and 599. opinion has been greatly increased by the result of ophthalmoscopic examinations. If a child become febrile, and cimvulsed, generally or partially ; if it vomits, or complains of headache, and at the same time the optic disks be found congested, it is very likely that it has basilar menin- gitis. AH these symptoms may pass quite away : but occasionally the patient is left more or less imbecile, or epileptic, or par- tially paralyzed, or with progressive atro- phy of the optic disks. In these cases, however, a recurrence of the disease is to be greatly dreaded. [The following is the report' of a case occurring in my practice, of a suthciently exceptional character to be given in full : — " A strong predisposition on the part of the patient, was proved to exist toward cerebral disease, by the facts that the child's grandmother has been for eight years hemiplegic after apoplexy ; that one of her sons has been insane, and another died of disease of the brain ; that the child's mother died a few months since at the Pennsylvania Hospital, having been there under treatment for chronic mania; and that the elder brother of the patient, aged ten years, having attended the fune- ral of his mother, was attacked by a con- vulsion on the same daj', and, in spite of prompt treatment, died in thirty-six hours. "11. S. , a boy, — aged five years — had enjoyed tolerable health during the past summer, with the exception of occasional diarrhcea. Never, however, had he ap- peared to be a robust child. About the first of October he became languid and peevish, with loss of appetite, and soon afterwards vomiting, with deranged cha- racter of the fecal discharges, and a ten- dency to costiveness, alternating with slight diarrhcea. . "On the 9th of the month, he was brought to me, complaint being made by his nurse of his vomiting repeatedly through the day, and seeming fretful and miserable. His face -was very pale, and lips bloodless. Some mild stomachic treatment was advised, the nature of the case not being then suspected. "The next'day, pain in the head came on, with great restlessness ; the forehead being hot, and pulse full and about 100. The" vomiting continued; two dozen American leeches were applied to the nu- cha, his bloodless aspect of the previous day, and other indications of an enfeebled condition, forbidding venesection. The leeches drew blood freely. Citrate of magnesia was directed, as the bowels were constipated. In the evening, the heat of the head was lessened, but opis- thotonos had come on ; the head was re- tracted so .that he lay at times in a per- [I Transactions of Phila. College of Physi- 3ians, New Series, vol. ii. iVo. 7, p. 343.] 826 TUBERCULAR MENINeiTIS. feet arch, with the top of the head upon the pillow ; even during the short periods of his sleep, this unnatural contraction of the muscles continued. "On the morniui; of the 11th, as the citrate of magnesia had failed to operate, a laxative enema was administered. Through this day, the opisthotonos per- sisted,"and the child lay without signs of intelligence, screaming and sleeping alter- nately ; the cry being mostly sharp and not prolonged, the ' hydrencephalic cry' of authors. His pulse had now become slow — and the heat of head was very moderate. On this evening a blister, four inches square, was made to vesicate the back of his neck. "The 12th found him with some tem- porary amelioration. The tetanic arch of the neck had partially relaxed. He was still indifferent and restless, however, especially at night, at which time some fever was said by his attendants to come on. Bowels costive — moved only by injection. Urine retained tvfenty-four hours, and very dark colored ; warm fo- mentations and sp. ffith. nit. dulc. were used for the relief of the retention. The great nervous excitement caused by the effort to overcome his resistance against medicine, deterred me from advising any- thing further at this time. " On the 13th, I find it stated on my notes that he appeared to be a little better. No decided alteration, however, 0(!curred, and the night was much dis- turbed by his restlessness. Vomiting had at this time ceased. His nourishment was thin tapioca, made with milk. The bowels still required movement by injec- tion. During the 14th, 1.5th, and 16th, no important difference in his symptoms occurred ; the costiveness, retention of urine, indifference through the day, and restlessness at night, being the leading symptoms. Pulse, at the time of my visits, about 80 ; head not hot. "On the 17th, eight days after I had first seen him, and about twice that inter- val since his first signs of indisposition, a violent general convulsion occurred, lasting fifteen or twenty minutes. • Pediluvia, and cold to the head, were resorted to, and a hyoscyamus and asafetida mixture was given by the mouth. After the con- vulsion, the pulse was slow, the pupils dilated, and consciousness more obscured than before. " On the 18th, his nurse reports that he had during the night numerous convul- sions, at intervals of less than half an hour. He screams frequently, and rolls from side to side. Eyes entirely vacant in expression. The convulsions continued through this day in the same manner, affecting chiefly the left arm and leg, and the muscles of the face. The pulse at this time, and for the four following days, was slow and irregular ; the irregularity being verj' strongly marked. The bowels and bladder were opened during the spasms repeatedly, and, when in the in- terval, involuntarily and unconsciously, in the bed. A warm bath was at this time employed, his resistance while con- scious, having interfered with it. "During the 19th, the same condition was maintained. His father told me that he had a spasm every fifteen minutes — but feebler. The right limb occasionally moves during the convulsion, but is mo- tionless otherwise. Pulse has not lost its strength or irregularity. He refuses to swallow — or chokes when compelled to receive fluid into the mouth. No evidence, whatever, of sight or hearing exists ; the breathing is ahnost stertorous, and grit- ting of the teeth nearly incessant. Through this night also the convulsions continued. I noted, in my memoranda, that he would certainly die, and gave nearly the same opinion in reply to Inqui- ries of some of the family. " On the 20th, at my request a renewed attempt was made to induce him to swal- low, although the attendants declared that he could not open his lips. He was raised up, and drank a few teaspoonfuls. Some slight appearance of improvement in his aspect, with the subsidence of the convulsions, induced me to urge, although without any hope, the renewal of the blister. This was attended to ; he was nourished with tapioca ; the bowels were once more emptied by injection ; and sponging briskly all over with warm spirits and water was advised and prac- tised. The father continued the use of the hyoscyamus mixture, avowing that it calmed his restlessness. "21st No more of the convulsions. Pulse still irregular. He certainly looked decidedly better, turning his eyes towards us with a conscious and attentive expres- sion. The right arm and leg, however, were paralyzed, and his apparent efforts to speak proved abortive. The blister raised well. "22cZ. All the symptoms have im- proved, except the paralysis. Eepeated stimulating frictions were used to the affected limbs. " 23d. The right leg already begins to show some return of control. Speech is yet very slowly and imperfectly accom- plished, but his senses appear to be acute, and consciousness perfect. He receives nourishment with aviditjf, and sleeps well. He continued to improve from that date, and, by the 30th of October, had entirely regained the use of both the limbs which were paralyzed, being, in all respects, so far as I could discover, well. " I had, during its progress, supposed this to be a case of Tubercular Meningitis, from the slowness of its approach and ad- MENINllITIS OF THE CONVEXITY, 827 vnncc, with but moderate circulatory ex- citement, and most obstinate cerebral symptoms. Apart, also, from the difli- culty of diagnosis between this form of the disease and simple meningitis, I had founded an unfavorable prognosis upon the same facts, with the knowledge of the child's inherited predisposition. The symptoms which especially pointed to this expectation were, the great frequency of the convulsions (according to the child's father, at least every twenty minutes dur- ing the night of the 17th, the day and night of the 18th, and the day-time of the 19th— two days and two nights) ; the oc- currence of these convulsions., also, at a hte period of the disease — between the eighth and the sixteenth day ; the irregu- lar pulse, observed steadily during four or five days ; the total absence, through most of the same period, of sensation or any evidence of consciousness ; the invol- untary discharges ; and, lastly, the hemi- plegia. "Eilliet and Barthez assert that when, with symptoms of meningitis, general convulsions occur frequently or with vio- lence, they almost always coincide with tubercles of the substance of the brain. 'Perfect paralysis,' says Dr. Gerhard (Amer. Jmirn. of Med. Sci., May, 18.34, p. 107), 'did not occur, unless immediately before death.' And Dr. Meigs termi- nates his list of the signs which most positively indicate the near approach of death in meningitis with the phrase, ' par- ticularly general convulsions. ' "The same writer (Dr. J. F. Meigs) alludes, without details, in his work on the Diseases of Children, to a case which I suppose to have been somewhat similar; and, while treating of Sir Benjamin Bro- die's plan of mercurial inunction, he refers to a parallel instance, occurring under that treatment, recorded by the editor of Braithwaite's Betrospect (vol. iv. 1846). "But I do not, in any of the works I have had opportunity to consult, find such deiiuite statements, particularly with re- gard to the possible time of duration of convulsive symptoms, in cases which re- cover, as enable me to judge, authorita- tively, of the degree of rarity of such an occurrence as has just been narrated. Charpentier asserts that, in the first pe- riod of tubercular meningitis, a cure is possible. In the second stage, when no doubt can exist as to its nature, Guersant believes that he has seen one recovery in a hundred cases. Of those which arrive at the third period, he has seen none re- cover, even temporarily. " It is, then, my duty to record that the above-mentioned child, H. S., continued in good health, with excellent appetite, digestion, and spirits, and increasing in flesh, until November 26th, about a month after the date of his previous re- covery. He was at that time, while returnmg m an omnibus from Frankford attacked with a convulsion, which did not leave him entirely until the middle of the next day, the 27th, when he died. " Must not this, however, be considered a new and separate attack from the one above described ? "On referring to Guersant's elaborate article on 'Meningite Tuberculeuse,' in the Duiiomuiire de Mklecine (1839), I find a record by him of two cases somewhat similar in their mode of termination. " The one, he says, having been treated in the Hopital des Enfans, ' en etait sorti dans un etat de demi-convalescence, lors- qu'au bout de cinq seraaines il fut repris de nouveau de tous les symptomes de la maladie aigue, a laquelle il succomba : les caracteres anatomiques de la meningite tuberculeuse furent parfaitement con- states par la necropsie. ' The other case resembled this, except that the period of apparent convalescence lasted two months, with a good appetite, and 'ayant repris I'embonpoint ; ' after which he was re- attacked, and died. " May we not imagine, however, that, if such a convalescence could last two months, it might, in a case affected with nearly similar lesions, be prolonged in- definitely ? "—H.] B. MElflNGITIS OF THE CONVEXITY. No doubt Tubercular Meningitis usu- ally affects the base of the brain ; but it is equally certain that this is not always the case. And inasmuch as the most characteristic 3j-mptoms of ordinary Tu- bercular Meningitis are in fact the symp- toms of basilar meningitis, it follows that when the meningitis is not basilar, it is not attended by those symptoms. That is to say, the vomiting of the invasion period, the constipation, the infrequent and irregular pulse, the unequal pupils, the ophthalmoscopic signs of disease, the strabismus and other local paralysis, are absent from meningitis which does not involve the base of the brain. A state in which general convulsions are either pres- ent or imminent, the intervals between the convulsions being occupied by trem- blings and twitches of the hmbs and face, turning of the thumbs in upon the palms, clenching of the fists, stifl'ness of the back, neck, and limbs— in short, a convulsive state, which is constant (except perhaps quite at the close of the disease)— this is the prominent symptom of Tubercular Meningitis of the convexity. Add mode- rate pyrexia, and a pulse which is frequent and very variable in its frequency.' The I I wish it to be understood that I do not speak of cases of cerebro-spinal meningitis. 828 TUBERCULAR MEXINDITIS. clue to diagnosis is to be found in tlie acuteness of the disease, tlie convulsive state, and the constant pyrexia : the evi- dences of basilar meningitis and of cere- bral abscess being wanting. Meningitis of tlie convexity runs a more rapid course than meningitis of the base : two weelis, one week, or even less, commonly see the fatal termination. Secoitdary Tubercular Meningitis IN THE Child. As before explained, meningitis is called Secondary when its symptoms have been preceded by manifestations not to be doubted of tuberculosis elsewhere. It has also been mentioned that, with this con- dition, the onset of the meningitis is, as a rule, obscure ; a fact whieli will not sur- prise the reader when he considers the nicety of the premonitory symptoms, and the slight prominence of the commoner invasion symptoms appearing in the midst of a state of tuberculosis already existing. A state of acute tuberculosis, we ought rather to say ; for when the tubercular disease is oi that chronicity which we sometimes see, lasting for years (inso- much that tuberculization having prob- abl}' ceased, the patient suffers from its permanent effects merely), the recurrence of actual tuberculization is only some- what less marked than its supervention upon a healthy state. The small number of cases then (with regard to children, very small) which belong to the latter class may be dismissed from further con- sideration, differing as they do from pri- mary Tubercular Meningitis only in this, that they run more rapidly to death. On the other hand, in a case of acute tuber- culosis the cerebral lesion may have reached the point of complete softening of the septum lucidum and fornix, and not have produced any symptoms of hydrocephalus which could be discovered even by the observer watching for them. Between these extremes with regard to curtailment of symptoms there are all possible grades. Tubercular Meningitis, when secondary to cerebral tubercle, is attended by symp- toms which are for the most part distinct enough. This, indeed, would almost fol- low from the law before laid down ; for cerebral tubercle (that is to say, a tuber- cular tumor), which has caused symptoms whereby it has been recognized, must be BO chronic that the onset of the meningitis is well marked. If, on the other hand, the symptoms of tumor have been so slight as to have been insufficient for its diagno- sis, then the case is, for clinical purposes, primary Tubercular Meningitis. Masses of yellow tubercle are often found embed- ded in the brains of children dead of hy- drocephalus acutus, whereof neither the prodromata nor the symptoms had leil us to suspect the presence of anything more than the constant accompaniments of the latter disease. It is uncommon for meningitis to super- vene upon chronic phthisis in children ; when this does happen, the new disease has been, so far as I have seen, easy of discovery ; the more easy, the more chro- nic the precedent disease. Contrariwise, meningitis which occurs in the course of acute tuberculosis of the pulmonary form is mostly latent ; when not so, very rapid in inducing death. When tubercular peritonitis which has been diagnosed is complicated by menin- gitis, the latter is of the curtailed kind, apt to be overlooked, being, as it were, rather the harbinger than the cause of death — affording another proof of the truth of that aphorism which may be here repeated under another form, that the more tuberculosis has involved the health at large, the more obscure are the signs of a sequential meningitis ; its premoni- tory and invasive symptoms have been anticipated. I have not known meningi- tis to supervene upon tabes mesenterica of such gravity as to have been a disease by itself The recognition of the occurrence of meningitis in the course of acute tubercu- losis, which has been previously known to exist, depends greatly upon the degree to which the brain becomes implicated. Cere- bral symptoms may be well marked (though shortened in duration, reduced to a week or less) even when they have been preceded by such grave symptoms, independent of the brain, as have not per- mitted us to doubt the existence of acute tuberculosis. Acute tuberculosis, not primarily cerebral, assumes for the most part one of two forms, namel}', the typhoid form, or the pulmonary form. I cannot do better than quote Eilliet's description of the typhoid form when it precedes men- ingitis : — "In rare cases the invasion symptoms are more acute and febrile than usual, the .skin is somewhat hotter, the pulse somewhat more frequent. The child complains of his head and belly at the same time ; he does not vomit, but his bowels are obstinately constipated ; he does not shriek, nor sigh, nor grind his teeth. The symptoms last from six to twelve days ; fever continued ; tongue covered with a thick fur ; belly somewhat swelled and tender. The child is drowsy, but easily roused ; answers sensibly ; no photophobia ; pupils natural ; pulse regu- lar, equal, 120 or more ; no spots or suda- mina anywhere ; facies not that of hydro- cephalus. This state is followed by the second (established) stage of meningitis." Let me add, that I have remarked, in such cases, the tongue to be pointed, with DIAGNOSIS. 829 a central white fur and red tip and edges, and the bowels to be si)ontaneouKly relax- ed. The pulmonary ibrni .is more common. The child sickens with what seems to be a bad cold; rapid loss of flesh and strength; fever rather high. The catarrh continues, fever increases, dyspnoea and lividity en- sue ; the rales heard in the lungs become more and more abundant, fine, sharp, and metallic ; the percussion note is high- pitched and hard, without losing in reson- ance. After two or three months from the beginning, symptoms of meningitis ap- pear, more or less distinct, therein follow- ing the rule already several times laid down. TUBEECULAE MexINGITIS IN THE Adult. It will be no small gain, if, by treating separately of Tubercular Meningitis as it occurs in the adult, a single reader be put upon his guurd against supposing that acute hydrocephalus is a disease peculiar to childhood. As a matter of fact Tuber- cular Meningitis in the adult is not often diagnosed ; yet were every one to study acute tuberculosis in the child, and then to transfer the knowledge acquired to the investigation of the diseases of the full- grown, there would probably be no special difficulty in the recognition of Tubercular Meningitis at any age. Meningitis, when intercurrent in the course of chronic phthisis, is characterized by more or fewer of the following symp- toms ; — Headache, complained of for the first time; or, if previously present, greatly increased in severity; mostly, but not al- ways, very painful ; frontal. Yomiting is an early symptom, occurring in almost every case : vomiting in uncomplicated pulmonary phthisis is uncommon, except when brought on by the violence of the cough. Convulsions, occasionally, mark the onset of the meningeal disease. De- lirium, of a quiet talkative kind, ensues. Sometimes the patients become speechless ; they make ineffectual efforts to answer a question, or they look steadily at the speaker for a few moments, and then, without any expression of face, turn the head away. Numbness, paralysis, rigid- ity, of a limb, or of some other part, may be a very early indication of the affection of the brain. At the same time, the symptoms, so far as the chest is concerned, ' ' abruptly improve or actually disappear. ' ' Then follow : comparative infrequency of the pulse, and irregularity both of pulse and respiration ; squint ; inequality of the pupils ; the patient lies in a meditative, semi-unconscious state, then becomes more and more unconscious, while moto- rial symptoms, of any kind, ensue. The phthisis is not often advanced. Prhnary Tubercular Meningitis is at least as common, in tlie adult, as second- ary; and, hkc as in the child, the symptoms may be nearly wholly cerebral from the first, or may assume a typlioid character. In tlie latter case, the disease is rather acute tuberculosis than Tubercular Men- ingitis ; the non-cerebral symptoms pre- dominate, at least at first. In the other case, the symptoms do not difter from those previously described, as occurrhig in the child, either in their character or their order of appearance ; headache, at the beginning, is mostly very severe, but is not always so. Vomiting, strabismus, diplopia, more or less loss of power over some part of the body, convulsions, numb- ness, dilated pupils, infrequency of the pulse, early delirium, the presence of any of these symptoms in an adult suffering from an acute illness, should suffice to put us on our guard : the physical examina- tion of the chest does not often help the diagnosis. The duration of the disease is from eight to fifteen days. Diagnosis.— The diseases which are confounded with Tubercular Meningitis may be divided for practical purposes into two classes : the first comprehending those diseases which simulate the earlier, and the second those which simulate the later, periods of meningitis. And it so happens that the resembling diseases of the first class are not attended, and of the second class are attended, by organic le- sions of the nervous centres, or their ap- pendages : this, speaking generally. The difficulty is greatest in the diagnosis of the earlier, the premonitory and invasive, pe- riods of Tubercular Meningitis from the diseases of the first class ; and the reason of the diflflculty is obvious, namely, that the premonitory symptoms of Tubercular Meningitis are common to many diseases; so that the physician, full of a just dread of tuberculosis, and not wishing to be con- fronted by meningitis unawares, is con- tinually suspecting tuberculosis wlien it is not present. To have treated incipient hydrocephalus slightingly is a mistake which, once made, is not readily forgot- ten ; the patient's friends, at any rate, will remember the failure in prognostics. Loss of flesh going on steadily is a symp- tom to which it is" wise to give the worst possible meaning. Eepeated vomiting, in the child or the adult, occurring as a hew symptom during a state of good health, or after a period ol' poorliness, is worthy of all our attention. Very carefully do we examine a child who has had a convul- sion, lest it should be the first warning of the existence of incurable disease. The First Class of diseases includes :— 1. Simple Exhaustion ; 2. Derangement of the Alimentary Canal; 3. Typhoid Fever ; 4. Scarlet Fever and Smallpox ; 830 TUBERCULAR MENINGITIS. 5. Hysteria ; 6. Simple Convulsions ; 7. Pleurisy and Pneumonia. 1. Simple exhaustion of the vital powers (Morton's nervous atrophy) sometimes occurs so acutely and reaches such a pitch as to be mistaken for tuberculosis, or, in- deed, actually existing Tubercular Men- ingitis. The exhaustion may be 'primary: a child, without any obvious cause, or perhaps in consequence of a slight catar- rhal state or change of diet, loses its ap- petite, and therewith its flesh ; becomes pale, languid, and restless ; there are no distinct dyspeptic symptoms ; the nurse fancies that the child is feverish ; the pu- pils are large, and do not act very readily; a convulsion, or a series of fits, may occur —no other of the symptoms of meningitis being present. Wary in our prognosis, we submit the child to the test of treat- ment. We order pounded meat, milk, wine, or brandy, the aromatic confection, or a mixture of muriatic acid, cinchona, and chloric Eether ; the next day we shall be able to prognosticate much less du- biously ; possibly, in the end, we may really have warded otf Tubercular Menin- gitis. The exhaustion which is secondary to acute diseases, and especially to the longest acute disease, typhoid fever, is sometimes so great as to be mistaken for established hydrocephalus. It is chiefly in the houses of the poor that we see chil- dren, wofuUy mismanaged during their illness, wasted past belief. The alimen- tary canal ceases to perform a single nat- ural function ; the disgust for food" is com- plete, the children are not even thirsty ; forced to swallow broth, or food which is called light by a foolish metaphor, vomit- ing ensues ; the child is somnolent, yet extremely restless, lies rooting with his head in the pillow, tossing from side to side, waving his arms in the air, or con- stantly passing his hand over one side of his head ; incessantly whining, occasion- ally screaming, and, if old enough, com- plaining, when asked, of severe pain in the head ; the tongue rolls from side to side, the lips are dry and peeling ; the eyesight becomes dim, the somnolence deepens into unconsciousness, and the child dies. Post mortejn we And the ma- rasmus has invaded the brain ; it is small and very bloodless ; the pia mater is watery. The sketch is from nature, and the possibility of mistake is more than a mere possibility. The diagnosis will de- pend upon the previous history of the case, upon the character of the symptoms, and the order in which they have been developed. 2. Derangement of the alimentary ca- nal. — i. Acute Dyspepsia, causes symptoms which are almost identical with those of the earlier periods of Tubercular Menin- gitis. To take an example : a child of four years old, of a phthisical family, sud- denly vomits several times, becomes fever- ish, complains of pain in his head, has no appetite ; coughs a little ; is very irrita- ble, thick-looking, and heavy ; greatly dislikes being touched ; the bowels are confined. Occasional vomiting continues; in the course of a few days (measured by the thermometer, the pyrexia in such a case may last a week) the fever dimin- ishes, the pulse becomes irregular and much less frequent. But, happily, at the same time, the child begins to look bright- er, and to sleep better. It is important to bear in mind that during convales- cence, even from so trivial a complaint as dyspepsia, the pulse of many children be- comes actually infrequent and very irreg- ular. To increase the ditflculty, I have known one pupil to become larger than the other at the same time, and to remain so several days. A diagnosis ofi'-hand is often impossible ; there is no help for it but expectation — expectation of the active kind. The patient is visited more often, examined more minutely, and treated more carefully than if there were no doubt ; at least he does not suffer, proba- bly he derives benefit, from the uncer- tainty of the physician, ii. Gastro-intes- tinal catarrh. — A little child, who had lost appetite and flesh for several weeks past, has one day a fit, which lasts, say, a quar- ter of an hour ; on the same day her bow- els become loose ; they remain so for a week, then she vomits several times. All this time there is more or less pyrexia ; what heaviness there is, caused by the diarrhoea, tends to complicate the diag- nosis. From one example the reader will learn all : diarrhoea, although no doubt an uncommon, is not an impossible, accom- paniment of Tubercular Meningitis. When dentition coincides, the pain caused there- by is not always distinguishable from the headache of meningitis : nor must we at- tribute too much to dentition ; I have known the canines to pierce the gum and Tubercular Meningitis to break out at the same time. 3. Typhoid fever resembles not so much Tubercular Meningitis as acute tuberculosis. But typhoid acute tuber- culosis is sometimes immediately fatal by way of meningitis. With regard to chil- dren, the physician, when in Soubt, is far more ready to suspect acute tuberculosis than typhoid fever. The difficulty is caused by the aberrant forms of typhoid fever which we meet with ; cases with confined bowels, with an empty belly, with spots which are small, dusky, and hard to the feel, or even vesicular at the apex ; cases which have the facies of acute tubercle ; cases complicated with consolidation of one or other apex of the lung, and attended by universal mucous rhonchi. In the adult, however, tj'phoid fever is far more likely to be suspected DIAGNOSIS. 831 than acute tuberculosis. The practi- tioner, if fully aware that acute tubercu- losis does occur in the adult, will not fail of making the diagnosis as soon as it be- comes possible. Diarrhoea may accom- pany acute tuberculosis. Acute tubercu- losis, with or without meningitis, some- times greatly resembles typhus fever. 4. Smallpox and scarlet fever, both of which invade by vomiting, may be at- tended at the same time by verj^ severe cerebral symptoms. ' 5. Tubercular Meningitis sometimes at first simulates the symptoms of ulcer of the stomach, or may assume a quasi- hysterical form. 6. Simple convulsions cannot per se be discriminated from those which are pre- cursory of Tubercular Meningitis. 7. The vomiting of incipient pleurisy and pneumonia, if accompanied by con- vulsions, as may be the case, is apt to divert attention from the chest to the head. But acute tuberculosis tends to cause inflammation of all the serous mem- branes ; and, as a matter of actual experi- ence, I have heard the friction sound of pleurisy in cases of Tubercular Meningitis ; so that, on the contrary, attention must not be diverted from the head to the chest. The rale of lobular pneumonia is less general than that which we hear in some cases of miliary tubercle of the lung. In the lobular pneumonia of children, chlorides are often present in the urine while the body temperature is still high. The Second Glass of diseases which simulate Tubercular Meningitis includes : 1. Simple Meningitis ; 2. Abscess of the Brain ; 3. Thrombosis of the Sinuses of the Dura Mater ; 4. Caries of the Atlo- Axoid Joint ; 5. Arachnoid and Sub- arachnoid Hemorrhages ; 6. Intracranial Tumors ; 7. Hypertrophy of the Brain ; 8. Essential Brain Fever. 1. By simple meningitis is meant men- ingitis which occurs totally unconnected with tuberculosis. Simple meningitis of the convexity is not a common disease. The symptoms are the same as are de- scribed under the head of Tubercular Meningitis affecting the convexity of the brain f but the course of simple menin- j gitis is more rapid. Convulsions and ' pyrexia in children ; headache, active de- lirium, and pyrexia in adults, are the symptoms present early in the disease, unconsciousness ensues in a day or two ; the duration of the illness does not often exceed a week. Sporadic cerebro-spinal meningitis (the membranes of the base and ventricles of the brain, and the sub-arachnoid space of the spinal cord, being especially affected), totally unconnected with tubercle, has ' See vol. i. pp. 132 and 85. ' Page SI 7. [ been, in my experience, comparatively ; common. Uerebro-spiual meningitis is frequently quite a chronic disease ; when acute, it resembles Tubercular Meningitis of the base very strongly. ' 2. Cerebral abscess occurs under seve- ral different circumstances, and differs accordingly in clinical details. The diag- nosis of Tubercular Meningitis continually opens up the whole field of diseases of the brain ; the ability to distinguish them greatly depends upon a full and minute , knowledge of their history. The reader will refer to the special articles, and make the necessary comparisons for himself. i. Cerebral abscess of pytemic origin may be dismissed at once as never complicating diagnosis, ii. Cerebral abscess due to suppuration of the pia mater, going on so far that numerous large collections of pus are protruded into the brain substance, which disappears by rapid atrophy, so far as I have seen, does not modify the ordi- nary course of simple meningitis, iii. Cerebral abscess (due to disease of bones of the skull or not) differs in its symptoms according as pyaemia is combined with it I or not. Abscesses merely pushed into the brain, inasmuch as they are not com- monly combined with disease of the sinuses, cause symptoms which are alto- I gether those of an intracranial tumor. Abscesses which are separated from the diseased bone by a layer of brain tissue (often greatly altered), and which are therefore presumed to have originated in the very midst of the lobe affected, are for the most part attended by p3'Eemia, the symptoms being complicated accordingly. But pyemia does not always accompany even these non-peripheral abscesses, and then the difficulty of diagnosis from Tu- bercular Meningitis is very great, espe- cially if we bear these facts in mind : first, that it is not uncommon for otorrhcea to concur with Tubercular Meningitis ; and next, that external otorrhoea, in cases of cerebral abscess due to disease of the pars petrosa, may not set in until a week be- fore death, and may have been preceded by the gravest symptoms of that intra- cranial otorrhcea which destroys the pa- tient. The pulse of cerebral abscess is more persistently infrequent than that of Tubercular Meningitis. 3. Thrombosis of the sinuses of the dura mater, when secondary to neighbor- ing inflammation, does not admit of diag- nosis, unless there be present pyremial symptoms and some obvious possible cause of disease of the sinuses ; caries of the pars petrosa is by far the most com- mon. Thrombosis secondary to debilitat- ' The symptoms are the same as those of epidemic cerebro-spinal meningitis, to the article upon which subject tlie reader is re- ferred, p. 296. 832 TUBERCULAR MENINGITIS. ing causes may be suspected if signs of disease of the ijraiu follow a profuse diar- rhcea or hemorrhage in a young child, but could hardly be distinguished from the simple exhaustion before described; while, on the other hand, I have known a decol- orized softening thrombus to occupy the whole bore of the upper longitudinal sinus, to be attended by large sub-arachnoid hemorrhages, and to have caused no symp- toms during life. 4. Caries of the atlo-axoid joint may cause such brain symptoms as to lead to a suspicion of the possible existence of Tu- bercular Meningitis. It is well, therefore, in a doubtful case, to examine the cervi- cal region carefully, so as to discover any thickening and swelling of the soft parts. 5. Arachnoid hemorrhage, according to Legendre, may simulate Tubercular Me- ningitis. ' This can be only in exceptional cases of the former rare disease. 6. An intracranial tumor at the base of the brain, of the soft sarcomatous kind, which approaches nearest to cancer in general appearance and in rapidity of growth, may cause symptoms which re- semble those of Tubercular Meningitis so closely, that, for a week or two from the beginning of the disease, it may be impos- sible to arrive at a diagnosis. In the case of the tumor, the pyrexia ceases for sev- eral weeks before death, and the disease becomes of a more chronic character. 7. Local hypertrophy of the brain is sometimes attended by symptoms which, at tirst sight, are like those of Tubercular Meningitis. "VVe discover afterwards that the hypertrophy is, comparatively, very chronic. 8. Every practitioner, from time to time, will come across an acute febrile disease, accompanied by symptoms which seem to point unmistakably to some affec- tion of the brain: there being every reason to exclude the notion of suppressed exan- themata or analogous disorders. After one or several weeks of coma, delirium, severe headache, or whatever may have been the prominent symptom, the patient recovers, and we are left quite unable to say what has been the matter with him. To go more into detail, I could not do otherwise than narrate a series of cases which would differ from each other in most important points, and have nothing in common excepting pyrexia and brain symptoms. There is, generally, something wanting which makes us suspect that we have not to do with Tubercular Menin- gitis. Brain fever is as good a name as any whereby to designate these different anomalies ; cerebral congestion, which is more commonly used, involves an explana- tion which is probably often wrong, and certainly never proved to be right. " Eilliet and Barthez, ii. 259. Morbid AKATOjnr. — I shall describe the morbid appearances of Tubercular Meningitis, in that order wherein they are brought under view during a post-mortem examination. Separation of the calvaria is easily effected as a rule. Miliary tubercle of the most undoubted kind was once seen by me upon the inner surface of the dura mater. Slitting up the longitudinal sinus, a pale narrow clot is seen in the posterior half : sometimes the sinus is filled with fluid blood and loose coagula, sometimes with a large black shining thrombus. Removing the dura mater, the great arachnoid sac is found to be destitute of fluid ; the mem- brane itself is dry, and, what is more, sticky to the finger passed over it. Scrape the surface gently with a scalpel and the sticky matter will be removed, minute in quantity, and puriform in appearance. Reddish serosity has been observed in the arachnoid sac by Senn and Becquerel ; transparent or turbid serosity by Eilliet and Barthez. This serosity, was it ob- served before or after the brain had been removed ? If after, the observations are quite valueless, unless indeed certain pre- cautions were taken which probably were not. The ordinary unnatural state of the arachnoid may be looked upon as the sign of a feeble inflammation ; similar sticki- ness is common in incipient pleurisy and peritonitis. Empis once found the arach- noid sac obliterated by old adhesions in a patient who had probably passed through an attack of acute tuberculosis long before. Still more to the point : in Tubercular Meningitis there is almost constantly pre- sent adhesion, more or less firm, of the opposed surfaces of the great longitudinal fissure, especially just above the corpus callosum. The pia mater affords more unequivocal signs of disease. First, as to vascularity. Sometimes there is obvious hypereemia of the whole convexity of the brain : it looks rosy ; examined minutely, the fine vessels are seen to be injected everywhere ; the body having lain on the back, the injection is nearly as well marked over the anterior as over the posterior lobes. More com- monly, the capillaries are not much in- jected ; what color the surface has being derived from large veins full of blood. Sometimes capillaries and veins both are emptied of blood, so that the brain has a most striking appearance, exactly resem- bling in color painters' putty. These dif- ferences depend for the most part upon the amount of pressure from within to which the surface of the brain has been subjected. Secondly, as to oedema. Ex- cess of clear serosity is commonly met with in the meshes of the pia mater be- tween the convolutions ; sometimes the effusion is semi-opaque and lymph-like. Thirdly, as to tubercles. Examine the MORBID ANATOMY. 833 membranes of the lateral region of the brain, corresponding in position to the temporal fossoe, and almost certainly mili- ary tubercles will be seen ; not that they are absent elsewhere, but they are most common at the spots indicated ; they are common at the bottom of the great longi- tudinal fissure also. These tubercles are beneath the arachnoid, often adherent to its under surface ; those exjiosed to pres- sure against the skull are more or less flattened. Alongside the branches of the middle cerebral artery it is common to find a firm, grayish, semi-transparent material, which is probably confluent tu- bercle. Minute opacities of the pia mater are sometimes seen in the same region, most numerous by far in the neighborhood of the miliary tubercles, and possibly tu- bercular in nature, a sort of white " tuber- cular dust." Sometimes the tubercles are yellow at their centre, sometimes all of them are yellow throughout, remaining crude. The number of tubercles present may be very large ; there may be none at all.' Raising the membranes from the surface of the brain, small portions of the brain substance adhere to the membranes so as to be removed with them ; not that this is always the case ; the diflerence depends upon the degree which the soft- ening of the cortex has reached. The amount of vascularity of the pia mater and the degree of cortical softening are not always in direct proportion. The convolutions of the brain are more or less flattened, the intervening sulci narrowed. Proceeding to slice the brain, we perceive that the color of the cortex is increased in depth if the pia mater be liyperEemic, or diminished vice versa, or remains natural. As a rule, the centra ovalia are anasmic, sometimes exceedingly so. Sometimes the texture of the whole brain is obviously softened. "When we reach the lateral ven- tricles, they are found to be distended with fluid, — a colorless serosity, of low specific gravity, mostly clear, but becoming faintly turbid when agitated ; slightly albumin- ous, containing chlorides and phosphates. The quantity of the fluid is from one to four ounces ; sometimes more. In one case I found a drachm of fluid in the fifth ventricle, the septum lucidum being every- where perfect. The foramen of Monro is dilated. The lining membrane (epen- dyma) of the ventricles is toughened, sometimes obviously opacified in places, especially in the sulcus between the cor- pus striatum and the thalamus opticus. Viewing the surface of the lining mem- brane sideways, we see that it looks as if it had been sprinkled with the finest dust. It seems probable that this condition is mostly due to small heaps of cells, a com- [' See the article on Scrofula, in this vol- nine H.] VOL. I.— 53 mencing suppuration of the lining mem- brane ;' sometimes the dusty look," in part at least, is due to a minutely wrinkled state of the ependyma, resulting from the stretching it has previously undergone. Occasionally we see larger granulations than those described, grayish elevations, something midway, in every respect, be- tween the sandy specks and miliary tuber- cles. The whole ependyma down to the fourth ventricle may be thus granular, or this sanded appearance may be quite ab- sent. The vessels of the ventricles, the choroid plexuses and veins of Galen, with their trifjutaries, are sometimes obviously full of blood, but more often not so, and sometimes almost empty, the plexuses be- ing quite pale. Softening of the cerebral matter beneath the ependyma is almost always found ; the septum lucidum and under surface of the fornix are reduced to a pulp ; the corpus callosum, walls of the posterior cornua, and other parts are often similarly affected. The question naturally arises,— What are the causes of these le- sions of the ventricles — the dropsy and the softening ? We cannot suppose that the brain substance will soften by passive im- bibition of fluid ; were it possible, there would be no reason why softening should not occur in health. But is the fluid forced by its excess into the brain sub- stance ? This is not so, because the ven- tricles are sometimes nearly empty when their walls are thoroughly softened. Me- chanical congestion might conceivably be the common cause of the dropsy and the softening ; but, in the great mass of cases, it is impossible to discover any impedi- ment to the return of blood from the ventricles. The blood may be made to flow from the veins of Galen back into the straight sinus with perfect ease ; moreover, as stated above, the plexuses are often quite pale, and the veins nearly empty. It would be difiicult to explain the effusion of serosity into the pia mater, and the cortical softening, by mechanical conges- tion. Inflammation will account for all the conditions. We have already seen that the ependyma presents an appear- ance common in inflammation of surfaces, — namely, proliferation of cells. The con- nective tissue which underlies the epithe- lial layer of the lining membrane is grad- ually lost in the neuroglia or interstitial non-nervous tissue of the brain. And hence, inflammation of the ependyma leads to effusion of serosity both in the ventricles and into the brain matter ; the softening being rendered complete by the mal-nutrition which ensue in consequence of the more or less arrested capillary cir- culation. To proceed : the velum inter- positum is natural, or edematous, or 1 Liischiier and LamM : Aus dem Franz- Josef Kinderspitale, 1860 ; S. 82. Prague. 834 TUBERCULAR MENINGITIS. thickened and somewhat opacified ; stud- ded, it may be, here and there with mili- ary tubercles. The condition of the third ventricle resembles that of the lateral ven- tricles: the distension is ordinarily less because of the resistance of the thalami optici: in front of these masses the dilata- tion sometimes goes so far as to expose the pia mater of the base : the commisura mollis is often more or less torn and speck- led with capillary hemorrhages. The fourth ventricle also is distended. I have several times examined the cerebro-spinal opening in situ, and have always found the niemliranes about it perfectly healthy. When the spinal canal is laid open before the calvaria has been removed, to punc- ture the sub-arachnoid space (internal arachnoid of Hilton) causes the escape of a certain quantity only of fluid, merely the excess in the spinal canal ; when the calvaria has been removed before the spinal sub-arachnoid has been touched, the cerebral ventricles can be drained completely by opening the membranes of the cord. The spinal internal arachnoid is distended with fluid, especially arovmd the Cauda equina. I have never observed any other morbid condition within the spinal canal, but then it has been exam- ined in a minority of cases. Removing the brain from the base of the skull, we occa- sionally find adhesions of the two surfaces of the great arachnoid about the circle of Willis. The memljranes at the base of the hrain are sometimes greatly injected, sometimes much less so. Miliary tuber- cles sometimes swarm in the Silvian fis- sures, interpeduncular space, round the crura cerebri, and on the top of the cere- bellum : ordinarily they are not in very large numbers ; occasionally there is only a tubercle here and there ; still more rare- ly no unquestionable tubercles can be found. Sometimes the tubercle is of the crude yellow variety. Other parts of the membranes of the base than those men- tioned sometimes present tubercles. Be- sides being tuberculized, the membranes (i. e. pia mater, sub-arachnoid) undergo those changes which have caused the name of meningitis to be given to this disease. The meshes of the pia mater are filled with serosity (clear or turbid), or with lymph-like material, or with puri- form : sometimes the membrane seems to be merely thickened, toughened, and opa- cified. The inflammation'of the pia mater is most marked in the interpeduncular space, but tends to spread forwards along the optic and olfactory nerves, sideways into the Silvian fissures, and backwards round the crura cerebri on the upper sur- face of the cerebellum, or right over the pons and as far back, it may be, as the medulla oblongata. There is no propor- tion between the amount of tuberculosis and of meningitis. Softening of the brain cortex is usual ; the under surface of the anterior lobes, and the under surface of the cerebellum, are affected with especial frequency. Softening of the optic com- missure and of the smaller nerves is mostly found. The sinuses at the base present nothing abnormal. The foregoing description applies to the commoner form of Tubercular Meningitis, in which the membranes of the base of the brain are involved. In the less com- mon form of the disease, limited to the convexity of the brain, the morbid changes correspond. The pia mater of the affected part is infiltrated with puriform lymph ; the membranes of the base being spared : there is no excess of serosity in the ventricles. It is obvious to the naked eye that the tubercles are everywhere in the closest connection with the bloodvessels, es- pecially the small arteries. And, in fact, it is in the sheaths of the vessels that the tubercles are formed. Both by their po- sition (being seated upon the vessels), and by their structure, recent mihary tuber- cles of the pia mater have the closest re- semblance to the Malpighian follicles of the spleen : indeed the similarity is so great that when the same bodies, which are recognized elsewhere as being recent miliary tubercles, are found in the spleen, it is often impossible to distinguish them from the Malpighian follicles. There can be no reason for doubting that the men- ingeal tubercles are not of the same na- ture as miliary tubercles elsewhere. It is true that the lymphatic character of the vascular sheaths is very well marked in the brain, but the vessels of many other parts are similarly constructed, to say nothing of the lymphatic tissue which exists beneath the serous and mucous membranes, and in other places. Accord- ing to Dr. Bastian, the new formation in the sheaths of the vessels of the velum interpositum is sometimes so abundant as to cause the vessels to be obstructed. Accidental Lesions. — 1. Masses of yellow tubercle are often met with in examining the brains of children dead of Tubercular Meningitis. Sometimes the tubercle is softened. 2. Capillary hemorrhage coin- cides with the softening of the cerebral matter, when the softening has reached a certain point. Most frequently seen in the soft commissure, hemorrhage some- times occurs in other parts, the brain proper, the pons Varolii, &c., leading to utter disorganization of the tissue. 3. I have seen miliary tuberculosis of the brain substance carried almost as far as can be conceived possible — a whole hemi- sphere of the cerebrum so much softened that it was easy to wash all the brain matter away ; which done, there remained a close network of injected and dilated capillaries studded everywhere with mi- PROGNOSIS AND TREATMENT. 835 liary tubercles. The meningitis in tliis case ran a very rapid course. 4. Menin- geal apoplexy, and a decolorized throm- bus of the superior longitudinal sinus, I observed in one case of tuberculosis of the meninges, unattended with obvious iaflammation of them. Other Orgaius. — Tuberculosis of the lungs, liver, spleen, lymphatic glands, kidneys, and ocular choroid, concurs with the brain disease. The tubercle is mostly miliary, sometimes yellow, crude, or soft- ened. A girl of four' died on the tenth day of Tubercular Meningitis without prodromata ; post mortem we found nu- merous miliary tubercles in the pia mater, great ventricular effusion, very little lymph at the base of the brain, and abso- lutely no tubercle in any other part of the body (which was carefully examined), ex- cepting a small mass of cheesy material in each lung. Tubercular ulcers of the intestines are often present : also intus- susceptions, easily reduced. The children will have frequently preserved a lai'ge amount of subcutaneous fat. Prognosis and Treatment. — The prognosis must always be unfavorable ; and when the disease has passed beyond the invasion period and has become es- tablished, recovery may be deemed hope- less. In the latter case, if we reckon twenty-one days from the invasion symp- toms we shall probably cover the fatal termination. When the disease does not pass beyond what seemed to be the inva- sion symptoms of Tubercular Meningitis, the patient's recoverj' is not always com- plete ; this has been already dwelt upon : moreover, a second attack sometimes ensues. What then, is to be done by way of prevention of the disease ? Tlie prophy- lactics and ordinary hygienics are the same— animal food, change of air, warmth to the surface, moderate exercise ; to which may be added cod-liver oil and cin- chona. The bad prognosis of confirmed Tubercular Meningitis does not belong to acute tuberculosis. No doubt many per- sons recover from acute tuberculosis : knowing this, any patient suffering from what is possibly acute tubercle should be • Under the care of Dr. West in the Chil- dren's Hospital. treated very carefully, so as, if possible, to stop the disease and prevent affection of the brain. If the patient be seen during the invasion period, he should be pu1; into a dark and quiet room ; be carefully and regularly fed ; symptoms should be treated ; constipation relieved ; a convul- sive state diminished by full doses of bromide of potassium. There can be no doubt concerning the powerful depressing intiuence exerted by continuous cold ap- plied to the head : this means should be therefore employed if the disease be seen in its earliest stage. Cod-liver oil may be tried at the same time. Later on there is not much that can be done. Sufficient liquid food should be given to the patient, by means of a syringe placed between the teeth, if need be. Leeches, active purg- ing, blistering, and such-Uke measures, will rather hasten the advance of death. It is best not to shave the head unless it be necessary to apply cold. If the corneas begin to ulcerate, it is as well to keep the eyelids closed by means of a little sticking plaster. [Since the discrimination in the early stage, between simple and Tubercular Meningitis, is not always easy or certain, the good results of active treatment in the former justify the moderate and careful use of similar measures, leeching, purga- tion, and blistering, at that period. After paralytic symptoms appear, all such treat- ment should be discontinued. The follow- ing is abstracted from an account of the case of a man, aged 2.3, reported by M. Dujardin-Beaumetz in Le Progres Medkal., 1879, p. 208 :— "For five days he had persistent cepha- lalgia, which appeared about to usher in anattack of typhoid fever ; coma followed, and from the sixth to the tenth day the symptoms of Tubercular Meningitis, not- withstanding which the man recovered. The patient's antecedents were very un- favorable to this result, his father and mother having both died with phthisis. Examination of the eye-ground had shown exudation with tuberculous granulations. The treatment consisted in blisters, calo- mel, and ice to the head. M. Beaumetz's paper was read before the SocieteMedicale des Hopitaux, and several other cases were brought forward by members show- ing a similar arrest of the disease in ques- tion."— H.] 836 CHRONIC HYDROCEPHALUS. CHRONIC HYDEOCEPHALUS. By J. Spence Ramskill, M.D. This disease is a real dropsy occurring within the cranial cavity. The fluid may be collected in the sac of the arachnoid or in the ventricles of the brain, beneath the arachnoid membrane. The affection may be congenital or acquired. When con- tenital, it is generally, but not invariably, ue to an arrest of development of the cerebral mass, although even in such cases the dropsy has been regarded by Koki- tanksy and Vrolik, whose opinion is quoted and endorsed by Dr. West, ' as not a mere passive dropsy, but as the result of a slow kind of inflammation of the arach- noid, especially of that lining the ventri- cles, which may have existed during life. Such inflammation may also attack the child after its birth, and "each year," says Dr. West, " leads me to estimate more highly the share of inflammation of the lining of the ventricles in the produc- tion of Chronic H3'drocephalus. Acquired hydrocephalus begins to show itself about the period of the first dentition." Ac- cording to Dr. West (p. 124), out of 54 cases, 18 of which came under his own ob- servation, some indications of the disease were obtained in 50 before the child was six months old ; in 14 the symptoms existed from birth, and in 21 more they appeared before the completion of the third month. In some rare cases, the disease attacks children seven, eight, or nine years old, who until then had seemed to be free from all cerebral complaint. In some ex- tremely rare cases, this affection has been known to attack persons of advanced life. Sir Thos. Watson'' cites several instances of the kind, one of which occurred under his own observation. A young and dis- tinguished lawyer of his acquaintance had one or two attacks of rather sudden loss of consciousness, while engaged in the Court of Chancery ; by degrees he became dull, stupid, forgetful, and at length insen- sible. In this condition he died. A large quantity of serous fluid was found distend- ing the ventricles of the brain. No other alteration could be detected. A case of Dr. Baillie's is quoted by the same author, the patient being a man fifty years old. The celebrated Dean Swift died of this complaint at the age of seventy-eight, ' Diseases of Children, p. ]21. ' Practice of Physic, 4th edit. p. 464. three years after the commencement o the disease.' Golis also mentions three instances ii which this aftection began in advance( life : two of the patients were abou seventy years of age ; the third, \\ho wa; a physician at Vienna, likewise died ii the decline of life, having suffered unde the disorder for ten years. When hydro cephalus shows itself some time after tin birth, it is generally accounted for by thi presence of a tumor (cancer, tubercles, o cysts). ' The dropsy in such cases is pro duced, as was pointed out by Dr. Whyt long ago, by the same mechanism ai ascites in cases of schirrus of the liver, o the spleen, or of the pancreas. Any de posit compressing the veins of Galen which bring back the blood from the yen tricles of the brain, is sure to lead to ac cumulation of serosity within those ven tricles. Dropsical effusion within the sac of th( arachnoid is sometimes the result of < former hemorrhage into that cavity, ai pointed out by Legendre, and supportec by Rilliet and Barthez. In some veri rare cases. Chronic Hydrocephalus seen:i to be a result of the acute disease. Tw( cases of this kind are recorded by Rilliet one in his work on "Diseases of Chil dren," p. 162, and the other in the "Ar chives generales de Medecine," for Dec 1847. Dr. West also relates a case ii which the first link in the chain of morbic processes seems to have been an injury ti the head ; the child, when five monthi old, having fallen out of the arms of thi person who was nursing her, and on tin same day she had a fit, and reniaine( stupid and senseless for hours. Anatomical Characters. — 1. Ventricula Hyclrncephalus. — The quantity of fluic varies from a few ounces to a few pounds In a case mentioned by Trousseau," lb head measured a metre (39'3 inches) ii circumference, and about thirty pound of fluid were found in the ventricles. Th same author cites another case fron Franck, in which the fluid amounted t^ fifty pounds. As a necessary consequence of the ac ' Practice of Physic, 4th edit. p. 464. ' Trousseau, Cllnique M^dlcale, 2e Mlt. f 247. CHRONIC HYDROCEPHALUS. 837 cumulation of fluid, the ventricular cavi- ties are considerably enlarged, the open- ings through which they communicate with one another are considerably dilated, although in some instances, from the pour- ing out of lymph, these apertures may get closed, and the fluid may therefore accumulate in one part more than an- other, producing an unsymmetrical en- largement of the head. Thus, Vrolik' has related the case of a young man who died from Chronic Hydrocephalus at the age of twenty, and in whom a false mem- brane had occluded the foramen of Munro through which the two lateral ventricles communicate. The walls of the dilated ventricles may be of normal consistence, or even of greater consistence than normal. Kilhet and Barthez state that they have been able, in some cases, to dissect the con- densed mass into several layers. In other cases the walls felt softer, and osdematous for some Uttle distance. The brain mass above the ventricles becomes thinned and unfolds itself. The convolutions are flat- tened out, and the sulci between them disappear. The cerebral substance looks pale and ansemic. In some cases it hap- pens that the commissures of the brain yield, and that the whole, or a portion of the fluid which it contains, escapes into the cavity of the cranium. This appears to have taken place in the well-known case of Cardinal, whose skull contained seven or eight pints of fluid, while "the brain lay at its base with its hemispheres opened outwards like the leaves of a book. "2 When the accumulation of fluid has resulted from inflammation of the mmbrane lining the interior of the ven- tricles, that membrane is found thickened and rou^h, and in some cases in a granu- lar condition. 2. Intra - arachnoid Hydrocephalus. ■ — When the result of hemorrhage into the arachnoid sac, the fluid is found more or less yellowish in color, and may be even more or less mixed up with thin, serous blood. When it has been poured out to flu up the vacuum in the skull due to de- fective development of the brain, it is perfectly limpid and clear. The sinuses' of the dura mater in this, as in the preced- ing form of hydrocephalus, are either empty, or are found to contain blood, both liquid and coagulated. The fluid of hydrocephalus, when tested by heat and nitric acid, is found to contain albumen ; chloride of sodium, soda, and traces of salts of lime and potash have also been found in it. Urea was detected by Dr. Bostock in his examination of the fluid found in Cardinal's head. ' Traite sur I'Hydrocfiphalie interne. Am- sterdam, 1839. ' Bright's Reports, vol. i. part i. p. 433. Condition of the Bones in Ulironic Hudro- cq3/iate.--They are generally found to be considerably thinned, and transparent; It the union of the sutures has been com- pleted, the bones arc found to be less hrmly united than usual, with less dove- taiUug ; and there are numerous ossa tri- quetra found in the lines of the sutures. In some cases, the bones have been found of normal thickness, and in rarer ones they have been of greater thickness than normal (Rilliet and Barthez), hard, com- pact, and resisting. -Sj/mjjtoms.— When the disease is con- genital, signs of cerebral disturbance manifest themselves very soon after birth. There may be either strabismus and roll- ing of the eyes alone, soon followed by gradual enlargement of the head, or con- vulsions recurring pretty frequently may set in. According to Dr. West,' "enlargement of the head is by no means invariably the first indication of Chronic Hydrocephalus. In twelve out of forty-flve cases, fits, re- turning frequently, had existed for some weeks before the head was observed to increase in size ; in .six, the enlargement of the head succeeded to an attack re- sembling acute hydrocephalus ; and in four other instances it had been pre- ceded by some well-marked indication of cerebral disturbance. In the remaining twenty-three cases no distinct cerebral symptoms preceded the enlargement of the head." Failure of nutrition is almost invariably present, although Rilliet and Barthez assert that " the nutritive func- tions are as a rule well performed in hy- drocephalic children, unless they be in an advanced stage of tubercular cachexia, or chronic intestinal catarrh. Except such cases, the children are plump and well nourished, and even have sometimes an abundance of fat which is certainly mor- bid."^ The cases, however, in which nu- trition is unaffected, form the exception, not the rule. The child sucks well, vora- ciously even, and yet does not grow : he may even waste. His bowels are gene- rally constipated, and his motions are un- healthy. The gradually increasing head soon attracts notice, and the peculiar phy- siognomy and aspect of a hydrocephalic child soon develop themselves. The fon- tanelles enlarge, and the anterior one is seen often to pulsate, and grow tense and prominent ; and at such times there is heat of the head, and the child is more restless than usual. The sutures of the head widen, and the head by degrees as- sumes a gloijular shape. The forehead is round and prominent, the orbital plates of the frontal bone gradually become slanting, and the eyeballs become half 1 Diseases of Children, p. 121, 5th edit. 2 Mai. des Enfants, p. IGl. 838 CHRONIC HYDROCEPHALUS. hidden under the lower ejelid, so that the cornea cannot be seen until this is de- pressed. The parietal bones being pushed outwards and their edges being last to ossify, there is a considerable increase of the sagittal suture, whilst the occiput is driven downwards and backwards, in some cases to such a degree as to be al- most horizontal. On applying the hand over the opened sutures and fontanelles, a distinct sensation of fluctuation is percep- tible. The hair grows very scantily on the head, on which very large distended veins are seen to ramify. The face is small, and contrasts remarkably -with the large size of the head; and looks triangu- lar, with the apex of the triangle at the chin. The child's expression is dull and stupid, and he has a very aged look ; he cannot sit up, or hold up his head, but lies down constantly. As the fluid con- tinues to accumulate, and the disease pro- gresses, the sight becomes impaired, and is completely lost after a time ; the eyes are bright and shining, but restless and oscillating. Plearing is as a rule pre- served much longer, but is lost at the close of the disease. Paralysis often sets in ; contractions and rigidity of the limbs and trunk are not very rare, according to Killiet and Barthez, particularly in very young children (p. 160). Occasional at- tacks of laryngismus stridulus are not in- frequent, and they may even come on be- fore there is mucli enlargement of the head (West). That form of Chronic Hy- drocephalus which results from the trans- formation of a cyst, the result of hemor- rhage into the arachnoid sac, may be recognized, according to Lcgendre, " by its being never congenital ; by generally beginning about the tenth month, that is to say, about the time when the teeth begin to appear. The head, indeed, en- larges gradually, but does not acquire so large a size as in internal hydrocephalus ; while, lastly, it is always preceded by con- vulsions, or by some other form of active cerebral disturbance, which marks the date of the occurrence of hemorrhage.'" At best, however, the diagnosis can be but hypothetical. When liydrocephalus becomes developed after the sutures are -lUiited, the bones, being subjected to pres- sure, become thin, and in some cases the sutures have been known to give way. Such cases are spoken of by Rilliet and Barthez, who also quote from the London Medical Journal (for 1790, p. 56) the case of a child who at the age of nine years, and eleven months before his death, be- came affected with chronic cerebral symp- toms. Nine months and a half after the first manifestation of the disease, the su- tures of the cranial bones, chiefly the ' Legendre, Reclierches Anatomo-patholo- giques, p. 133. coronal, began to open. At the time of his death the distance between the edges of the coronal suture measured half an inch, and at the spot where the lambdoidal joins the sagittal suture there was a i marked opening, so that the occipital bone was completely free. ' As a rule, however, when hydrocephalus begins after the su- tures are united, the head does not enlarge considerably, although it may do so in some rare instances, as in a case men- tioned by Eilliet and Barthez (p. 165), of a child nine years old, who from the age of eight exhibited the symptoms of hydro- cephalus, and whose head became enor- mously enlarged in spite of the ossification of the fontanelles. The size of the head in Chronic Hydrocephalus varies consid- erably ; it has been known to measure two and even three feet in circumference. In the Museum of the Faculty of Medicine of Paris there is a hydrocephalic skull which measures 39 inches round. The shape of the head is generally globular and flat at the top, but in some rare cases it is conical, shaped like a sugar-loaf. The termination of the complaint is generally in death, which occurs either from some intercurrent aflection, h3dro- cephalie children being always weakly and unable to resist diseiise, or from an attack of laryngismus stridulus, or from convul- sions due to passing congestion of the meninges, or lastly from gradual exhaus- tion, from positive asthenia. The disease extends at least one or two years, but it may last from four to ten years. Cases have even been recorded of individuals living to an advanced age who had been hydrocephalic from infancy. Thus Dr. Bright's patient, Thomas Cardinal, lived to nearly thirty. Franck, cited by Trous- seau, ^ speaks of two individuals, the one aged seventy-two, and the other seventy- eight, who had been hydrocephalic from infancy. Strictlj' speaking there is no cure of the complaint, but merely an ar- rest of its progress. Pluid may be no longer poured out, but that which has been already effused is not absorbed. The sutures and fontanelles ossify and close, and a good many ossa wormiana are then found along the lines of union ; these are like nuclei for the formation of bony matter. In some instances it has been said that a real cure takes place ; that there is increased activity of the nutrition of the brain, producing hypertrophy of that organ, the fluid being absorbed and new matter deposited in its stead (Otto).'' 1 Sir Thos. Watson (p. 464, 5tli edit.) also cites two similar cases, one from Dr. Baillie — the patient was a boy, seven years old ; and the other from Dr. Yeats' work on Hydroce- phalus — a boy nine years old. 2 Clinique Mfedicale, p. 247. ' In Rokitansky's Pathologische Anatomie, 1st edit. vol. ii. pp. 749-769. DIAGNOSIS — TREATMENT. 839 Such cases, liowever, must be quite excep- tional, and the rule is that the fluid is unabsorbed and remains in the cranial cavities. The patient's intellect and senses are not perfect it is true, but are still sufficient to enable him to perform tlie ordinary duties of life, although he is apt to be fretful and irritable, and some- what childish in his ways. Diagnosis.— 1st. Congenital hydroce- phalus has to be diagnosed from encepha- locele and perforating fungus of the dura mater. In encephalocele the feel of the swelling is doughy and elastic, not fluctu- ating ; it is local and not general, and it is not transparent. In cases of fungus of dura mater, which has perforated the cra- nium at birth, the general size of the head is not affected, the perforated spot can be easily detected, and it is over the central parts, not near the sutures or fontanclles; the mass feels doughy, elastic, quasi- erectile, and when it is compressed, symp- toms of irritation are produced. Acquired hydrocephalus has also to be distinguished from a merely excessive development of the head apart from any disease. The absence of all cerebral sj'mptoms is suflfl- cient in such cases to establish the diag- nosis. Sometimes hydrocephalus may be suspected where none exists, because of the disproportion between a small, emaci- ated, triangular face and largely developed skull. Eilliet and Barthez candidly con- fess to an error of this kind. 2d. From abnormal thickening of the bones of the skull, which sometimes obtains in rickets. In such cases the diagnosis may be made by a careful inspection and palpation of the bones of the head. The development of the skull is not uniform ; it seems as if flat bumps had been superadded to the centre of the frontal and parietal bones, and we can detect with the finger the ex- act spot where the bone begins to thicken.' The swelling of the articular ends of the bones of the limbs, which is characteristic of rickets, will at once awaken suspicion, for rickets and hydrocephalus do some- times coexist. 3d. From hypertrophy of the brain. This is an exceedingly rare affection, in which the head enlarges with- out exhibiting any symptoms at first ; and when these show" themselves after a time, they run an acute course which soon ter- minates in death. Treatment should be persisted in for a long time, without the adoption of any violent measures. The plan recom- mended by Professor Gblis, of Yienna, seems to be one of the best. He advises the head to be shaved, and a scruple or two of mercurial ointment, mixed with ointment of juniper berries, to be rubbed ' Killiet and Barthez. on the scalp twice a day. The child should wear a woollen cap, to prevent the risk of the perspiration beuig checked by the cold air. From a quarter to lialf a grain of calomel should be administered twice a day ; if it purges too much, the inunction of mercurial ointment must be alone employed. This treatment is to be persevered in for thirty or forty days, when, if there be some improvement, the remedies may be gradually diminished ; but the cap is to be worn alter the inunc- tion has been discontinued. If there ha no marked improvement after six or eight weeks, some diuretic, acetate of potash or squills, for example, may be added ; and a couple of issues may be inserted in the occiput. Blisters to the nape of the neck may be advantageou.-ly substituted for these. Whenever there is heat of head, and the child grows fretful, restless, and irritable, a couple of leeches behind the ears will be found of service. GbUs affirms that under this plan of treatment he has known the circumference of the head decrease by half an inch, or an inch, in a period of six weeks to three months. He thinks that convalescence, when once begun, may be accelerated by small doses of quinine. Dr. Gower's plan of treat- ment, which is said to have been success- ful in many cases, consisted in giving ten grains of crude mercury mixed by rubbing with about a scruple of manna and five grains of fresh squills. This was one dose, and it was to be repeated every eight hours. The medicine induced great prostration of strength, loss of flesh, and profuse action of the kidneys, without ptyalism. Chronic Hydrocephalus has been treated by two mechanical moans ; by bandaging and tapping. Bandaging, which has been particularly advocated by Mr. Bar- nard, of Bath,' seems to be chiefly useful in pale flabby children, whose bones are loose and yielding : strips of plaster, about three-quarters of an inch wide, are made to encase the head ; they are to be applied circularly, transversely, and diagonally. Trousseau, who was at one time an advo- cate of this plan, has given directions for properly carrying it out in the Journal cIp, Medecine for April 1843. But this emi- nent practitioner had good reasons for changing his views, and did not latterly advocate this plan. In his Clinique ]\lei]i- cale, second edit. p. 250, he says that he has given it up completely, since a child a"-ed five months, whom he treated in that way, died suddenly on the fluid making its way through the ethmoid bone and the nasal fossse. The second mechanical mode of treat- ment, namely, by tapping the skull, and ' Cases of Chronic Hydrocephalus, &c., by T. II. Barnard. London, 1839. 840 MENINGEAL HEMORRHAGE. letting out the fluid accumulated in its interior, has been opposed by sucli men as Golis, Eicliter, and Dupuytren. Dr. Conquest has been the greatest advocate of the operation in tliis country, and a paper on the subject may be ibund in tlie Medical Gazette for March, 1838. Sir Thos. "Watson gives the sanction of high autliority to the procedure ; and although Dr. West speaks rather doubtfully on the subject, yet he does not regard the opera- tion as unjustifiable in some cases ; when, for instance, there is good ground for be- lieving that the hydrocephalus is external, or where tlie enlargement of the head has not been attended by indications of active cerebral disease. The operation itself does not seem to be attended with any very great immediate rislc of life, if per- formed carefully. The best spot for puncturing the skull is about an incli, or an inch and a half, from the anterior fon- tanelle, near the edge of the coronal su- ture, taking care to avoid tlie longitudinal sinus, and some of the large veins which empty themselves into it. The trocar should be a small one, and it should be introduced perpendicularly. The fluid should be let out very slowly, a few ounces at a time, and the skull supported by bandages, both at tlie time and subse- quently. If the child turns pale and faints, a few drops of ammonia, or of brandy, will be found useful. If any in- flammatory action should be set up a day or two after the tapping, cold lotions to the head and leeches behind the ears, and small doses of mercury, will be required. The administration of iodide of potassium internally, and of iodine lotions to the scalp, has been advocated by Trousseau ; and, when more active measures may not appear justifiable, some hope in the way of arrest of the further progress of the dis- ease may be entertained from the use; of these remedies. In addition to them I have found great assistance from the use of syrup of iodide of iron, cod-liver oil given in small doses, and bone-earth. The dose of cod-liver oil should be limited to a teaspoonful, the object being not to increase, but to improve nutrition. The iodide of iron is usually very well borne by hydrocephalic children, unless there be a tendency to congestion, or to inflamma- tory action. Amongst the children of the poor the combination of the oil and the syrup of iodide almost always gives the most satisfactory results. Bone-earth mixed with fine sugar, administered with every meal, sprinkled on the surface of nulk, or of other food, has appeared to me to possess a tonic action beyond that pos- sessed by any chemical compound of the phosphates. It has an increased value in cases associated with rickets or imperfect nutrition of the bones ; and a diet, of which lentil flour forms part, has appeared to me highly advantageous. Good food, given in limited quantities, and at small intervals, is absolutely necessary, and I object to the use of stimulants. When the patient appears faint and languid, beef-tea will prove a better and more per- manent stimulant than wine or ammonia. The usual hygienic measures should be adopted, — warm clothing for the extremi- ties, the head being kept cool. Bathing with sea-water is useful, taking care that the limbs are rubbed to produce warmth and redness of the surface after the bath. The patient should, if possible, spend the summer months on the sea-coast, or in some elevated district, and he should al- most live in the open air. me:n"ii^'geal hemoerhage. By J. Spence Ramskill, M.D. The term Meningeal Hemorrhage is used to denote extravasation of blood cither into the cavity of the arachnoid, or beneath this serous membrane, and into the meshes of the pia mater. Ilem- orrhage occurring between the dura mater and the bones of the cranium is extra- nieningeal ; and as it is usually the result of a blow or a fall on the head, in which case it often takes place on the Pide oppo- site to that of the injury, by contre-coup, it comes within the province of the sur- geon and not of the physician. In his valuable work on diseases of the brain, Abercrombie, at p. 238, relates a most curious instance of "extravasation in a cyst, formed by separation of the laminse of the dura mater, from rupture of the middle meningeal artery." The patient, a man aged forty-eight, about the 12th of Kovember, 1814, was assist- ing a neighbor to carry a heavy load up a SYMPTOMS. 841 liigli stair, when he felt a sudden attack of headache. He was from that time troubled with headache and giddiness, increased by stooping ; and after these symptoms had continued rather more than a fortnight, he became sensible of some imperfection of vision. When seen liy Dr. Gairdner, on the 2d of December, he complained of violent headache. The pulse was forty in the minute, and feeble. The pupils were at this time sensible to the light, but after a few days became in- sensible. He sank very gradually into coma, without any remarkable symptom, and died on the 13th. Inspection : On the left side of the head, a cyst was found in the course of the middle meningeal ar- tery, occupying the region of the lower part of the parietal and upper part of the temporal bone. It was formed by a sepa- ration of the laminae of the dura mater, and contained about four ounces of coagu- lated blood. The portion of the dura mater forming the cyst was considerably thickened and very vascular. There was a depression on the surface of the brain, corresponding to the cyst, and the ven- tricles contained a considerable quantity of serous fluid. There was no other morbid appearance. True Meningeal Hemorrhage is an af- fection which is found generally at the two extremes of life, in infancy and old age. It occurs in new-born infants, after severe and protracted labors, and, from the discoloration of the skin attending it, is often mistaken for cyanosis. It may be distinguished from this malformation, however, by the absence of cardiac mur- mur, which is almost always present in the latter. The blood may be diffused, as we have said, into the arachnoid sac itself, or un- der it, and in the pia mater. A third variety has also been described, in which the blood is said to be effused between the dura mater and the arachnoid ; but recent researches have made it more than doubtful that the extremely delicate vis- ceral layer of the arachnoid can be sepa- rated without being torn from the dura mater; and Baillarger' has shown that the error arose from the rapid formation of a false membrane resembling the arach- noid, which isolated the effused blood. An instance of this variety, of traumatic origin, is related by Sir Robert Carswell. A man fell on his head, was stunned for Bome Uttle time, but afterwards went to work as usual. Three weeks afterwards he applied to a hospital, but was refused admission because he had no fever, and he was suspected of malingering. On leaving the hospital he drank some hot spiced wine on his way home, became de- ' Baillarger : Dp Siege dfi quelques H^mor- rhagies des Meninges : These. Paris, 1837. hrious, and died in thirty -six hours. A post-mortem examination showed six ounces of blood efluscd between the dura mater and the araclinoid, part of which was in a coagulated and part in a fluid state. Two cases of the same form of hemor- rhage, but of spontaneous origin, are given by Andral in his "Clinique Medi- cale," occurring in two men, aged respec- tively seventy and seventy-three. Other instances are recorded by Eostan,- Blan- din, Meniere, 2 Cruveilhier.' I-Ieinorrhage into the arachnoid cavity. — This may be traumatic or idiopathic. When the latter, the blood accumulates in the cavity of the arachnoid, and is equally diffused over the brain, not accu- mulated at the base. It is generally more fluid anteriorly, and more coagulated pos- teriorly. The arachnoid and dura mater are colored by imbibition. After a time, the blood is enveloped in a pseudo-mem- brane, and in old cases cysts are found with yellowish contents and smooth walls; in some cases the two layers of the false membrane are found agglutinated, leav- ing no doubt as to the possibility of a per- fect cure occasionally being made. With regard to the source from which the blood comes, there exists a discrepancy of opin- ion. According to most authors, the ex- travasation results from the rupture of a bloodvessel, but Prus' maintains that intra-arachnoid hemorrhage is always the result of exhalation. Hemorrhage by ex- halation is, however, a pathological phe- nomenon not accepted nowadays, and for which cases of molecular rupture of blood- vessels used to be mistaken. Syjdptoms. — In persons of advanced age, there are sometimes certain premon- itory symptoms observed in the shape of drowsiness, vertigo, general malaise, dim- inution of motor power, loss of speech, &c. All these symptoms do not show themselves in the same case, but one or other of them is generally present. Ce- phalalgia is a symptom which is usually met with in old people when hemorrhage has occurred. Some authors regard the false mem- branes as being of "inflammatory origin, and as the first step in the morbid pro- cess—the hemorrhage being only the second.* There may be such cases, ' Rostan : Reoherches sur le RamoUissement du Cerveau, p. 396. 2 Anatouiie Topographique. Paris, 1834. 3 Anatomie Pathologique du Corps humam, livres vi. viii. xvii. » Prus : Memoire sur I'Apoplexie meningfe (M6m. de I'Aoad. Royale de Medecine), Paris, 1845, t. xi. p. 18. 6 Consult Virchow; Die Krankhafteu Gesch- wulste, Berlin, 1863, p. 140 ; and Lancereaux in Archives gfinerales de Mfidecine, Pans, 1862, pp. 526-679, and 1863, vol. i. p. 38. 842 MENINGEAL HEMORRHAGE. doubtless, in the adult and the old, but that they are very rare, in children espe- cially, is sufficiently proved by the sud- denness of the symptoms. There may be sudden paralysis of mo- tion on the side opposite to that of the extravasation ; and when this is consid- erable in amount, both sides of the body may be affected, or paralysis may begin in one side and extend to the other. Sen- sation is rarely affected. Motor paralysis is not a constant symptom, and deviation of the tongue and of one angle of the mouth, and strabismus, are of very rare occurrence in adults, whilst they have never been observed in children : accord- ing to Legendre,' paralysis occurs only in one out of nine cases ; Rilliet and Barthez say, in one out of seventeen.^ Contractions, rigidity of tlie limbs, and convulsions are, on the other hand, almost always present. There is at first somno- lence, which gradually merges into coma; and this, when once established, persists, as a rule, unto the end. About the third or fourth day of the attack, there is in- tense fever lighted up, accompanied by the other symptoms of meningitis. The course of the disease is exceedingly irregular ; death may take place early or not until the end of a month. The prog- nosis is not necessarily fatal, and according to Legendre serous cysts may be formed, which give rise to a form of chronic hy- droceplialus. Hemorrhage may also oc- cur beneath the arachnoid, between it and the pia mater. In some cases, it may take place suddenly; in others, it may be preceded by some headache, drowsiness, redness and heat of the scalp and fore- head. 'When the extravasation has taken place there is generally headache, but not very acute, and having no fixed seat. Paralysis of motion is rare, probably from the thinness of the laj'er of blood effused. It has been said that when the blood is derived from a ruptured artery, motor paralysis is more apt to occur than when it proceeds from a ruptured vein, the dif- ference being explained by the rapidity with which the blood escapes from the artery, and the incidental shock to the brain. Sensibility is not affected as a rule. The intellectual faculties are merely enfeebled, not perverted. After a time coma sets in, which persists until death. On inspection after death, which seems to be an invariable termination of the dis- ease, the blood is found in a liquid state, showing no tendency to coagulate, or to form pseudo-membranes. From the fact ' Legendre : Memoire sur les H^raorrhagies dans la Cavitg de I'Arachnoide (Ilecherohes anat. path, et clin. sur quelques Maladies de I'Enfance). Paris, 1846, p. 130. 2 Maladies des Enfants, p. 257. that no old cysts are ever discovered be- tween the arachnoid and pia mater, it is inferred that sub-arachnoid hemorrhage is invariably fatal. In his memoir on "Diseases of the Lateral Sinuses," Ton- nele' has related instances of rupture of a sinus giving rise to sub-arachnoid extrav- asation of blood. ■ In a case reported by Dr. Mullar,^ the blood came from the right lateral sinus, which was ruptured at its point of entrance into the torcular Herophili : death occurred in twenty-four hours, the symptoms preceding it having been those of cerebral hemorrhage. Ac- cording to Aitken, arachnoid hemorrhage occurs when the extravasation bursts through the pia mater and arachnoid into the space between the membranes ; and he says such an affection cannot be distin- guished from ventricular extravasation. If, however, the extravasation is inmie- diately arachnoid at first, and of limited extent, it may be approximately diag- nosed : first, by the nature of the symp- toms having partaken of meningeal in- flammation, such as by severe pain in the head, with impaired intelligence and loss of power of movement; second, the attack is less sudden than in cases of congestion or of cerebral hemorrhage, and the symp- toms are progressively developed. The following are the combinations of symptoms which indicate sub-arachnoid hemorrhage : — i^irst.— Complete and profound coma without paralysis, or with general paraly- sis slightly developed. Second. — Complete loss of consciousness without paralysis, but combined with rigidity or clonic contraction of limbs. Third. — Paralj'sis of hemiplegic distri- bution, as regards the limbs ; but without deviation of the features, the muscles of the face not being implicated. Fourth. — An apoplectic attack without anaesthesia. Fifth. — Imperfectly developed coma with general paralysis. Sixth. — An apoplectic attack, of which the symptoms are somewhat interchange- able or remittent.^ The Treatment of arachnoid hemor- rhage must be guided by symptoms pres- ent. When there is perfect coma with full, hard pulse, which is possible, a hot head, flushed face, turgid veins of the neck, and a hot general state of surface, with a slow, deep respiration, we may open a vein and take away ten ounces of blood with advantage ; but in by far the majority of cases there will be no such ' Journal hebdomadaire de M^decine, Paris, 1829, tome v. 2 The Lancet, June, 1849. ' Reynolds : Diagn. of Dis. of Brain, &c., p. 101. ADVENTITIOUS PRODUCTS IN THE MENINGES. 813 opportunity. If the tendency be to death by syncope, the pulse small or feeble, the surface cold, the face pale and head cool, if there be signs of disease of the aortic or mitral valves, of kidney disease, or a general appearance of anteiiiia, we should do mischief by abstracting blood. The administration of a turpentine and castor- oil enema, and the application of an ice- cap or cold lotion to the shaved scalp, will generally limit our power of treat- ment, until the period of shock has passed away, or until consciousness has returned. Then the propriety of applying leeches must be measured by the degree of pain in the head, and of heat of the scalp. In the majority of cases even this will be found unnecessary. Pree purgation will always be advisable, and the continued application of cold to the head. After a time, if the patient survives, the continued administration of the iodide of potassium promises the most hope of good. With respect to the abstraction of blood, it is right to say that the most eminent au- thority in Paris, Professor Trousseau, never saw any reason to order it. He denied the slightest advantage to be gained by it, either in arachnoid or in any other cerebral hemorrhage. ADVENTITIOUS PRODUCTS IN THE MENINGES. Under the heading of Syphilitic Menin- gitis the presence in the dura mater of so-called gummata has been adverted to. Calcareous deposits are also found some- times in the substance of the dura mater ; in some cases the falx cerebri has been found completely ossiiied. HEMATOMA OF THE DURA MATEE IS hardly recognizable during life. The symptoms, according to Aitken, extend over several months, and consist in gen- eral weakening of memory and of intel- ligence, the occurrence of giddiness, and local pain in the head. A chronic form of idiopathic inflammation of the dura mater is set up. At a later period an aggravation of all the symptoms occurs, with transitory losses of consciousness. Somnolence and apathy prevail, and gen- erally one-sided paralysis of the extremi- ties, which may soon disappear ; eventu- ally the case terminates with symptoms of apoplexy. On post-mortem examina- tion, sanguineous and flattened masses, composed of fine layers of fibrine, spread to a greater or less extent over the dura mater, are discovered, accompanied by small extravasations which are converted into pigment. By repetition of the pro- cess, numerous layers come to be deposited one on the other. Numerous and larger bloodvessels form in these layers ; and from these vessels renewal of the hemor- rhage occurs (Virchow, Weber). Tlie lesion is sometimes described as due to iutra-meningeal apoplexy, with false membranes on the dura mater ; but the false membranes, which are the result of chronic inflammation, precede the apo- plectic phenomena. The hematoma often attains considerable size. It may be four to five inches long, by two and a half broad, and one-half to three-quarters of an inch thick. It is generally of a flat- tened circular form, with a central eleva- tion. The long diameter is parallel to the falciform process. The tumor gener- ally occurs on one side only, or if bilateral, one is more developed than the other. The affection occurs only in the adult, and usually after the age of fifty. It has been clearly made out that the hemor- rhage which gives rise to the formation of the hsematonia takes place between the layers of false membrane, and be- comes encysted there. Treatment must be tentative. Iodide of potassium is our chief remedy. Any symptoms which in- dicate a recurrence of the chronic inflam- mation must be met by the application of cold to the forehead, by purgatives and revulsives. If we can succeed in pre- venting the recurring attacks, there is fair ground for believing the newly-formed membranes may undergo a retrograde change and finally disappear. Tumors have not been unfrequently found springing from the dura mater, varying as to their character and the na- ture of their contents. They are some- times fatty and eticysted, and have been known to contain hair ; and Morgagni (in Epist. Anat. xx.) speaks of an adipose tumor with hair in the substance of the tentorium. But sometimes a^o the tumor is of cancerous nature, constituting what has been termed "fungus of the dura mater." The celebrated French surgeon, Louis, has written a most important series of essays on the subject, published in "Mem. de 1' Academic de Chirurgie," vol. V. p. 1, Paris, 1774. The cancer may be of the encephaloid or of the scirrhous va- riety : the former is the more frequent of the two, and indeed, when tumor has made its way outwards by perforating the bones of the skull, it has often been mis- taken for hernia cerebri. The tumor may spring from the outer or the inner lamina of the dura mater, and in some cases there may be tumors co-originating on both surfaces of the dura mater, as in cases reported by Chelius and by Dr. Bric^ht. When they spring from the mner surface of the dura mater, they have a tendency to grow inwards and depress the surface of the brain. But in compara- tively rare cases they press on the skull, cause absorption of its substance, and protrude externally. In one case, de- 844 CONGESTION OF THE BRAIN. scribed by Cruveilhier, protrusion liad ac- tually occurred ; in another, perforation was in progress. In connection with the dura mater are sometimes also found fi- brous tumors, which, on microscopical ex- amination, are seen to possess the same curvilinear stromal arrangement as the common uterine fibrous tumor. The bony plates found on the inner side of the dura mater have by some been re- garded as growth belonging to the arach- noid, but that they are not so is suffi- ciently proved both by the position in which they are found, and by the property of periosteal tissues, to which class the dura mater undoubtedly belongs, to gene- rate bone. In connection with the choroid plexus (that intra-ventricular appendix of the pia mater) the adventitious products found have been indurated yellow bodies, the remains of former hemorrhagic effusions, and more frequently round or oval bodies of a yellowish tinge, apparently formed of concentric laminai, which only become more apparent on the addition of acetic acid. Tliey are generally microscopic, but sometimes accumulate into masses of the size of a pea or small nut. They have been called by Virchovv corpora aniylacea, and by Dr. H. Jones concentric corpuscles. Small cysis are also pretty frequently found on the choroid plexus, which have by some been erroneously spoken of as hj'datids, but there is no evidence to show that they belong to those parasitic forma- tions. They rather seem to be due to a condensation of the epithelial covering of the plexus, and an accumulation of fluid beneath it, limited by an effusion of plas- tic matter. CONGENITAL MALFOEMATIONS OF THE MENINGES. The dura mater is the one generally affected, and such cases are of extremely rare occurrence. Sometimes the falciform process is entirely or partially deficient, as is also the tentorium. The falx is, of course, absent when the cerebrum is undivided ; or if the cerebrum be single in front and divided behind, the falciform process begins to appear where the division is, namely, at the coronal su- ture. In monsters, in which the posterior lobes of the cerebrum are deficient, the tentorium is also deficient. In a girl, seventeen years old, who was idiotic and motionless from birth, the hinder part of the tentorium was deficient.' The Re- ports of the Pathological Society, 1847 and 1848, p. 178, contain the account of a very rare defect of the falx cerebri exhib- ited by Mr. Shaw. Dr. Bright also gives a similar case, in which no trace of the process was visible anterior to the tento- rium, and it was assumed that the defect, which occurred in a lady of tnirty years of age, had existed from birtli. CONGESTION OF THE BEAIN.^ By J. Russell Reynolds, M.D H. Charlton Bastian, M.D , F.R.S., AND F.R.S. Under this name there are to be in- cluded several forms of disease very dif- ferent from each other in the general character of their symptoms. In one of these the patient is feverish, and his attack is sometimes regarded as "brain fever ;" in another the case is described as an "apoplectic" or " paralytic stroke ;" in a third, as a fit, or seizure of " convul- sions ;" and in a fourth, as an attack of "delirium," or of "wandering." Pa- tients taken with symptoms of disturb- ance, in any one of these forms, often die ; and upon post-mortem examination there may be found but one departure from healthy appearance of the brain, viz., congestion. We cannot but suspect that in many cases there have been altera- tions of nutrition which have escaped our notice, and that the locality and nature of such alterations have determined the form that the malady has taken. We may infer in others that, if the congestion has been the sole cause of symptoms, the character of the symptoms which accom- panied it was determined by the situation of the excess of blood. But we cannot ' Gilbert, in Edinburgh Medical and Surgi- cal Journal, No. 95, April, 1828. 2 The sections on Pathology and Morbid Anatomy are written by Dr. Bastian. SYMPTOMS. 845 yet demonstrate the truth of these sur- mises or inferences, for we cannot see the brain while the symptoms last, and the most characteristic often pass away before the patients die. The premonitory, and even the earlier developed symptoms of cerebral congestion may be closely similar in many cases ; they then speedily pass into one or anotljer of the several groups enu- merated above, and from the special cha- racters which they then present the cases derive their names : but if the morbid state continue, and advance towards a fatal issue, the distinctive features of these several forms pass away ; convulsion, deli- rium, and febrile action cease ; and pa- tients, who a few days before presented very wide symptomatic diiferences, look much like each other, and die in a similar manner. Such being the case, we should expect to find the traces of that which existed only a short time before death, and to fail in discovering evidences of those localized changes which must have determined the character of the previous symptoms. It will be convenient therefore to de- scribe first the premonitory symptoms of cerebral congestion, viz., those which are or may be common to its several forms ; then to detail under four distinct catego- ries the developed symptoms, with their modes of termination in recovery ; and lastly, to describe again generally those which are final, and into which any one of the four varieties may pass by a rapid or a gradual progress. Symptoms. — A. Premonitory. — There is often a mixture of two classes of symp- toms — those which indicate both over- action and the reverse ; sometimes the two coexist, at other times they alternate ; in one case the former group is predomi- nant, in another the latter ; whereas in a few all the symptoms tell in the direction either of inaction or of undue excitement. It is possible sometimes to foretell, from the nature of these symptoms, the form which it is most likely that the disease will hereafter assume ; but such forecast is uncertain in all cases, and useful in only a very small proportion. The mind is changed in such manner that there is diminished intellectual power; thought becomes confused, and memory treacherous ; the individual may be irri- table, "put out about little things," wor- ried, fanciful, peevish, or depressed ; sleepy, and especially so after meals ; at times in- different and sluggish ; he complains that he "cannot think," and that the forced effort to do so makes him worse ; he talks at random, using wrong words — some- times noticing his blunder, correcting it, and expressing his annoyance ; sometimes not observing that he was wrong, and being greatly annoyed with any one who should attempt to set him right. He is usually worse after being in the recum- bent posture, and after sleep ; his sleep is heavy, and disturbed by dreams and nightmare ; sometimes there are transient delusions— one person is mistaken for an- other—the past and the present are curi- ously intermixed, and the conversation is like that of a dream, a dream which goes on while the patient is awake, but from which he may be awakened still further by a loud voice or any other strong ap- peal to the senses. The senses are dull : hearing is defect- ive, and there are rumbling "noises in the head ;" the sight is dim, and "black specks" appear before the eyes ; some- times diplopia is present ; there is giddi- ness, and a feeling of oppression and ful- ness in the head, with " stupid headache," made worse by lying down. There is rarely "pain" in the head, but, as the patients say, " a confused, uncomfortable feeling." The limbs feel heavy, and there is often numbness or "pins and needles" in the toes and fingers. These sensations come and go, but between the periods of their recurrence there is a sense of general discomfort which it is often quite impossible for the patient to de- scribe. Often it is that of "oppression about the breathing ;" and great difiiculty from this source is experienced in walk- ing upstairs, uphill, or even a little more quickly than usual on level ground. Some- times "feelings of faintness" are com- plained of, and with them nausea and increased vertigo. The power of movement is diminished, and with it yet more notably the readi- ness of action. The limbs are dragged along sleepily, or sluggishly ; the step loses its elasticity, is shorter than in health; the " general bearing" is changed; and sometimes, but rarely, the alterations in power and activity are observed on one side of the body more distinctly than on the other. The patient simply leans for- ward, and appears weak and lethargic ; or he may lean to one side, hold one shoulder half an inch or an inch higher than the other when standing, and when sitting, collapse, as it were, on the lower side. Friends of such patients say, " He seems to go down on this side," and,""\^^e are afraid that he will fall off his chair, or off the pavement," but the physician may observe no paralysis ; for the stimulus given to voluntary effort by his presence is often enough to remove the trifling want of symmetry. The features are regular, the tongue is straight in its pro- trusion, and the grasp of the hand and the movements of the feet are as pro- nounced on the one side as on the other. There are other symptoms than those of direct change in the nervous functions, such as redness, and often dusky redness, 846 CONGESTION OF THE BRAIN. of the lips, conjunctivae, face, and scalp. Tlie head is hotter than the cheeks, the jugular veins are distended, and the neck appears thick. On stooping, sneezing, or cougliing, the veins of the forehead are too full, and the heat of the carotids is too distinct. The pulse is slow and labored, or quick and feeble ; the tongue is foul, the urine small in quantity, and often loaded with lithates ; the bowels are con- fined, and the extremities are cold. The heart may be found dilated, and there may be tricuspid regurgitation, shown by the pulsation of the jugulars, and systolic murmur at the ensil:brm cartilage. These premonitory symptoms may exist for very variable periods of time ; may appear and disappear ; or may gradually increase and pass into one or another form of malady already hinted at, but now to he described. B. Developed Symptoms. — 1. Apoplectic form. — The attack usually takes place during some muscular exertion, such as lifting a heavy weight, blowing the nose, coughing, sneezing, straining at stool, or stooping to pick up something from the floor. Sometimes it cannot be traced to any one of these. But it rarely occurs during sleep; patients do not wake up and find themselves in a state of what is called " congestive apoplexy." Tliey are more commonly doing their ordinary work, or trying to do a little more than they are able to accomplish, when the attack is made. Consciousness, sensation, and power of motion seem to be lost, and the patient is said to have "an apoplectic stroke ;" but these faculties are not alto- gether lost, or if they are, it is for a few moments only, and the physician usually finds the following conditions : — Tlie 7nind is not in complete abeyance. There are indications tliat the patient knows, although but imperfectly, what is said to him ; he makes scmie attempt to respond to questions, and to do what he is asked to do. He starts at a loud and sudden noise, looks round him, and gives signs of annoyance when he is disturbed. If at the moment of seizure he should ap- pear to be in profound coma, this coma is of short, almost of momentary duration, and soon there are signs of returning con- sciousness : there is confusion of thought, bewilderment, and dulness of apprehen- sion, passing sometimes into a mild deli- rium, but more often into a heavy sleep. The senses, obtuse for a moment, are rapidly restored to a certain point. The patient shrinks from strong light, groans when pinched, starts when spoken to, hut yet takes little or no notice of ordinary impressions. The power of motion is so diminished that the patient falls down, and the limbs when raised fall heavily. All of them ap- pear equally weak; but, in a few moments. occasional voluntary movements may be seen in them, and these are commonly more distinct on the one side than on the other. There are slight twitchings of the muscles, but there is no rigidity. The features are usually symmetrical, or if drawn to one side are speedily set straight again. There is no stertor in the breath- ing ; the speech is clumsj', the words are clipped, and wrong words are used ; but this is for a short time only, and the sphincters very rarely fail in tlieir action. The pulse at the moment of attack is sometimes suspended at the wrist, and the In'eathing is arrested ; but soon tlie pulse is felt to be heavy and labored, and the respiration becomes tumultuous ; and again, in a few seconds, both pulse and respiration go on as thej^ did before. There is an exaggeration of the previous vascular fulness of the face, neck, and head; sometimes a bloodshot eye, or epis- taxis ; not unfrequently vomiting, with apparent faintness and a condition of col- lapse. The symptoms of a first attack usually abate quickly : they may last for a few minutes, or for several hours, but most commonly they disappear within an hour; and the patient, although languid and perhaps alarmed, may feel better than he has done for some days before. Upon the repetition of seizure, however, the dura- tion of symptoms is prolonged ; the re- covery of consciousness, sensation, and movement is less complete ; drowsiness is more marked ; and if there be some mo- mentary awakening, it is momentary onlj' ; fresh attacks supervene, and each leaves the patient lower than he was be- fore. The apoplectic form of cerebral conges- tion is most common in advanced life, and has usually been preceded, and tliat to a marked degree, by the "premonitory" symptoms that have been described. 2. The convulsive form. — The paroxysms that occur have the general features of epilepsy (see Part I. ) ; but they differ from the attacks of that disease in their general history and mode of onset. Con- gestive convulsions may occur at any pe- riod of life, but they are most frequently met with at the time of full maturity, or when that stage is passed. There are usu- ally the premonitory signs of congestion, but these may be very slight ; there may be no forewarnings, and the patient may be seized during sleep, or while making some unaccustomed effort. When the attack occurs during sleep it is difficult, and sometimes impossible, to say in what manner it commenced ; but when it has come on while the patient is awake and friends are about him, it has been usually observed that much discomfort has pre- ceded it, for a few seconds, minutes, oi hours. A tight cravat, worn while making SYMPTOMS. 847 some undue exertion ; a sudden alarm ; or an indigestiljle meal, rapidly swallowed, may be the immediate antecedents. The patient, more or less suddenly, becomes confused, then apparently half uncon- scious, makes some unintelligible sounds, turns red and then blue in the face, stag- gers for support, looks round him wildly or imploringly, and then sits down, or falls down, convulsed, and a paroxysm, epileptiform in character, supervenes. From this he recovers partially, exhibit- ing great confasion of mind, headache, muscular feebleness, and sometimes par- ' tial paralysis of one side, or of one limb. The attack is occasionally followed by quasi-maniacal excitement, lasting from half an hour to three or four hours"; after which, the patient becomes exhausted and falls into a heavy sleep. From this state he may recover, or during sleep a second or third attack of convulsions may come on. When congestion of the brain has as- sumed this convulsive form, the patients, so far as my own experience extends, have usually been in middle life, and have recovered. But in other instances, when the age has been further advanced, the attacks have recurred more frequently, the intervals between them have become of shorter duration, and the patients — less sensible and less reasonable after every paroxysm — have presented the appear- ance of those whose attacks have been apoplectiform at their commencemeiit. 3. Delirmm may be the most marked symptom of congestion of the brain in certain cases. This is observed almost exclusively in those who are of an ad- vanced age, but it is not absolutely limited to the period of senility. It may occa- sionally be met with in middle or even early life, and is then commonly accom- panied by some change in blood-quality. The attack may come on suddenly, may be induced by a fall or a fright, but when occurring spontaneously is first observed towards evening. Sometimes the attack is preceded by "depression of spirits;" the patient, after some hours or even days of undue taciturnity, becomes cheer- ful, or gay, and hilarious ; he talks loudly and incoherently, but rarely exhibits any violence. He gets out of bed, wanders about his room or ward, opens drawers, puts on his dress, and is bent upon doing something which he cannot explain, or which, if expressed in words, is unneces- sary, unaccustomed, and absurd. He is under a delusion, of no fixed character ; and can usually be directed and managed without much difficulty. Sometimes, and this is especially observed in the aged, there may be hysterical crying ; or, still More rarely, great irritability of temper and some attempts at violence. The lat- ter occur almost exclusively as the result of bad management and rough thwartino^ of the delusive purpose. ° The patient may complain of pain in the head, or of uneasy sensations in the limbs ; and there may be twitching of the mus- cles, or weakness of the extremities. But none of these are complained of while the delirium lasts, although weakness and clonic spasm may be observed at the time of its occurrence. It is when the delirium has completely or partially subsided that these things are noticed, and that the general phenomena of cerebral congestion, viz., those which are described as pre- monitory symptoms, may be observed. Durand Fardel states that it is common to find "a mucous secretion, clear and viscid, produced on the eyelids, or in the interior of the mouth, and sometimes in extraordinary abundance, running over the whole face ;'" but this is very com- mon in other diseases of old people, and has no special relation to mere congestion of the brain. The recurrences of delirium may be very frequent or very occasional : some old people present them nightly for many weeks, and know nothing about them on the following days ; while others exhibit them after nmch longer intervals, and only when "upset" by the little occur- rences of the day. The tendency, how- ever, is towards increase — not so much in degree as in persistence of mental change — and the patients become gentler, but less rational. The mind is weakened at each onset of delirium, and does not re- cover itself; there is drowsiness in the daytime and wandering talkativeness at night ; but the intellectual powers are seen to be failing day by day ; the physi- cal energy diminishes, and the patient keeps his bed, and gradually passes into the state hereafter to be described. 4. Febrile Form. — In the earlier periods of life, and especially in infancy and childhood, congestion of the brain may occur with marked elevation of tempera- ture, a dry skin, thirst, and the restless- ness and malaise of a pyrectic state. There is headache, not of great intensity, but of dull, oppressive character ; the head is unduly hot, the cheeks and conjunctivae are flushed, while the extremities are cold ; the mental faculties are obscured, and the sleep is broken by dreams or transient and mild delirium. Usually there has been some distinct cause for such disturbances ; there is no marked prostration, no initial rigor ; there may be some vomiting, but it is not persistent, nor are the bowels obstinately confined ; there is no photophobia, no intolerance of sounds, no eruption on the skin ; the secretions may be foul, but they present no indications of organic disease ; and the • Maladies des Vieillards, p. 27. 848 CONGESTION OP THE BRAIN. patients usually recover speedily. Re- covery is, however, not always observed ; the distress may persist ; there may be, alternately, convulsions and delirium, or there may be the changes from over- excitement to drowsiness, the latter grad- ually becoming relatively more marked, until the patient passes into a state of stupor from which he may never rally. C. Final Symptoms. — Under whatever form congestion of the brain may pri- marily appear, its tendencj', unless speed- ily recovered from, is to produce a condi- tion of torpor and inactivity. The mind becomes a blank ; there is sometimes pro- found coma, stertorous breathing, and involuntary evacuation of both bladder and rectum ; sensibility both general and special is lost, and voluntary muscular power reduced to a minimum. Convul- sions may occasionally disturb the calm, or there may be fitful and momentary muttering of unintelligible sounds, but usually, in this latter stage, the patient lies quietly, with labored pulse and breath- ing, and with flickering contractions of the muscles of the limbs, until he dies. Causes. — Among the predisposing causes must be reckoned such physical conformations as should impede the re- turn of blood from the head, and the most important of these is a morbid con- dition of the heart. Dilatation of the right side of the heart, with loss of both power and valvular competency, are commonly found, during life and after death, in those who succumb to cerebral conge'ition. It is in old age that such changes are usually discovered, and hence advanced age appears a predisposing cause. It is more common to find severe cerebral congestion in men than in wo- men. Sedentary occupation and short- ness of neck have been reckoned among the predisponents, but I think with in- sufficient reason ; for attacks of cerebral congestion often occur in those of active habits and of healthy build, and indeed sometimes the worst forms of seizure that I have witnessed have been in persons of great mental and physicial activity, in those who have been overwrought, and who have continued in forced exertion beyond the bounds of reason and habitual practice. The determining causes are to be found in all those conditions which entail sud- den changes in the circulation. These are exposure to extreme heat or cold, and especially to the direct infiuence of the sun's rays ; blows upon the head or trunk ; violent exertions, such as make it neces- sary to "hold the breath ;" rarefaction of the air, such as is encountered in balloon ascents, and in some mountaineering ex- peditions ; violent emotion, or prolonged mental effort ; an overloaded state of the stomach, and this especially after undue abstinence ; the ingestion of large quan- tities of alcoholic stimulants ; a sudden change of posture, such as stooping or lying down with the head too low ; and tightness of the dress around the neck. Besides the so-called predisposing and exciting causes of cerebral congestion, there are two general conditions of the organism which may have some causative relation to the symptoms, although neither of the preceding words fully con- veys the nature of that relation. A full- blooded, lax-fibred, and fat man, in middle age, represents one of these conditions ; a thin, pale, wiry old person, with rigid vessels, is an example of the other. Both are prone to suffer from disturbances, ir- regularities, inequalities in the circula- tion ; and in either there may be cerebral congestion in a grave or fatal form. If these conditions be regarded as " predis- ponents," it must be remembered that they have no special relation to this lo- cality of congestion, and further that the mode in which the one operates is quite distinct from that in which the other leads to its results. In the former cere- bral congestion is but part of a general condition, and some accidental posture may determine that the brain shall be the organ upon which the weight of the bur- den falls ; in the latter, feebleness of cir- culation power, and locally increased re- sistance in the walls of vessels, may be the main factors in the production of such partial congestion of tlie brain as shall give rise to an apoplectiform seizure. Diagnosis.— Remembering the general character of the symptoms which were described as "premonitory," there can be but little difficulty in carrying the diagnosis up to a certain point, and in explaining them by the fact of congestion ; but when the malady passes into either one of the four forms of " developed" symptoms, the diagnosis is sometimes difficult, and it is therefore necessary to consider it in detail with regard to each. The apoplectic form of congestion re- sembles cerebral hemorrhage, acute soft- ening of the brain, urineemia, and syn- cope. From hemorrhage, it may be distinguished by the facts of its less sud- den onset ; its occurrence while the pa- tients are awake rather than when asleep — patients do not wake up in the morning and find themselves paralyzed on one side, as they often do in cases of hemor- rhage ;— the attack of "congestive apo- plexy" occurs during the day, and its onset is marked by the absence of the phenomena of shock ; by the equality of disturbance usually noticed in regard of mind, sensation, and motility at the com- mencement of the seizure — each of them is affected generally, and to nearly the PATHOLOGY. 849 same degree, but in no one direction is there entire and absolute loss of function except for a few moments ; by the subse- quent relative proportion of symptoms, such for example as partial paralysis of all the limbs with imperfectly developed coma, a combination not to be observed in hemorrhagic apoplexy ; by the speedy restoration of the mental faculties ; and by the equable and usually simultaneous Temoval of other symptoms. From softening of the brain in its acute form, congestive apoplexj' cannot be al- ways distinguished at the outset, for in some cases of the former the attack is in reality due to the occurrence of the latter. The diagnosis can only be made after some little time has elapsed, and then it will turn upon a recognition of the follow- ing points : In congestion the mind speedily recovers, in softening it does not ; in the former there is widely distributed but imperfect paralysis, in the latter limited, but more complete, loss of power ; iu the one the patient is generally power- less, in the other he is hemiplegic ; in the one there is flaccidity of muscle, in the other there is rigidity ; in the former the premonitory symptoms have been those of congestion of the brain, in the other those of chronic disease elsewhere and loss of power. From urinfemia, the attack may be dis- tinguished by regard to the premonitory symptoms ; by the absence of oedema of eyeUds or of lower extremities ; by the absence of albumen from the urine ; by the absence of marked rigidity of mus- cles ; by the nature of the coma, its mo- mentary profundity, rapid diminution, and want of that peculiar character which often attaches to blood-poisoning, viz. its apparent profundity in strong contrast with the ease with which tlie patient may be awakened up to a certain point ; and further by the absence of a peculiar va- riety of stertor, occasioned apparently in tlie mouth or at the palate. From syncope, congestive apoplexy may be distinguished by an examination of the heart, and the pulse at the wrist, the car- otids, and the temples ; by the color of the face and head ; the premonitory symptoms, and the conditions which led to the attack. The convulsive form of congestion may be confounded with epilepsy or with eccentric convulsions. From epilepsy the diagnosis may be made by a consideration of the previous history : in the one there liave been the premonitory symptoms of congestion, in the other no such phe- nomena have presented themselves ; in the former the patient is usually of middle or advanced age, in the latter he is young, iiud is either under twenty years, or has not far exceeded that period of life ; in tlie one the period of most marked con- VOL. I.— 54 gestion is at the moment of onset of the seizure, in the other congestion of the face and head is most marked as the attack is passnig olf; in the former there may be some moaning sound, in the latter the " epileptic cry ; " in the one there is the sudden onset of an acute disease, in the other the attack of a chronic malady. From eccentric convulsions it is possible to distinguish congestive convulsions by regard to age and attendant symptoms. Eccentric convulsions are observed in infancy and early life, and when some definite source of irritation can be dis- covered in certain organs of the body; they are found most commonly in the weak, irritable, and nervous subject, and they are attended by no premonitory symptoms of congestion, and by little or no evidence of its presence during the attack. There is but trifling somnolency, and the seizures differ from those of epi- lepsy and of congestive convulsion in not passing through the stages which were described as proper to the former, and which are closely simulated by the latter. Congestion of the Brain in" the form of delirium is met with almost exclusively in old age ; and it is necessary only to men- tion delirium tremens in order to prevent the possibility of their being confounded. From senile softening of the brain, when this is accompanied by recurrent delirium, the diagnosis may be made by regard to the intermediate state ; for when only congestion is present the patient returns to his normal condition in the intervals of wandering, whereas when the brain tissue is" undergoing degeneration, and is the cause of delirium, no such recovery is possible. There is, moreover, a progres- sive enfeeblement of all the nervous func- tions, and a general condition of depraved nutrition such as is not necessarily found in cases of congestion. The febrile form of congestion may be distinguished from meningitis by the ab- sence of acute pain, and of intolerance of sensorial impressions ; by the milder cha- racter of the deUrium, the dilatation rather than contraction of the pupils, the absence of persistent vomiting and of obstinate constipation, the generally milder charac- ter of the symptoins, and their early ces- sation. Pathology.— The circulation through the cerebral vessels has been supposed to present certain peculiarities owing to (he inclosure of the brain within an unyield- ing case, and its being, therefore, beyond the influence of atmospheric pressure. This was first alluded to by the second Monro. It was thought that no great alterations could take place in the total quantity of blood within the cranium at different times, although there might be an altered ratio as regards the respective 850 CONGESTION OP THE BRAIN. amounts of arterial and venous blood. It was even held by Dr. Kellie, that in ani- mals which have died from hemorrhage there is no lack of blood in the brain ; that where, on the contrary, we should expect ,to find a condition of cerebral hy- pera3mia, we do not meet with it ; and that the quantity of blood in the cerebral vessels is not aft'ected l:)y gravitation, and thus is uninfluenced by the position of the head with respect to the body. These views were also supported by Dr. Aber- crombie and by Dr. John Reid ; ' though they have been ably opposed by Dr. Bur- rows^ and by Donders,^ many of whose experiments go to establish the direct re- verse of the results arrived at by Kellie. It seems by no means satisfactorily demon- strated that the contents of the cranium are so entirely removed from the influence of atmospheric pressure. Dr. Burrows says: " The numerous Assures and fora- mina, for the transmission of vessels or nerves through the bones of the cranium, appear to me to do away with the idea of the cranium being a perfect sphere like a glass globe, to which it has been compared by some writers." And the other dogma on which this hypothesis rests, and which Dr. Abercrombie supports when he says, "We may safely assert that the brain is not compressible by any such force as can be conveyed to it from the heart through the carotid and vertebral arteries," seems to be directly contradicted by a considera- tion of other facts.* The observations of Kobin,^ and of His, ^ who have discovered a system of lymph- atic sheaths inclosing spaces around the cerebral bloodvessels, are of great import- ance, and reveal a structural adaptation which seems especially calculated to per- mit of varying amounts of fulness of the cerebral vessels, within certain limits, without injury to or compression of the surrounding nerve pulp. Professor His has succeeded in injecting this system of perivascular canals, and has found them most obvious in the gray matter of both brain and spinal cord. He has found that the injections at first reach the sur- face of the encephalon and cord, and fill a vast system of lacunse situated between the pia mater and the surface of the nervous centres ; while, if pushed still further, he has found that they fill the ' Physiolog. Anatom. and Path Researches. No. XXV. 2 Lumleian Lect. 1843, and On Disorders of ■the Cerebral Circulation, &c. 1846. 3 Nederland. Lancet, 1850. ■• Andral's Clinique M^dicale. * Brown-S^quard's "Journal de Physiolo- gie," 1859, p. 527. ^ Zeitsch. fiir wissen. Zoolog. 1&65, Bd. xv. and The Journal of Anatomy and Physiology iCambridge), No. 2, p. 347. lymphatics of the pia mater itself. Thus there is, as it were, a second series of ves- sels inclosing and surrounding with a fluid medium all the ramifications of the cere- bral and spinal vascular system, whilst these two sets of vessels, containing and contained, are lodged in definite cylindri- cal canals permeating the nerve substance in all directions. The lymphatic sheaths are in contact with, though in general are easily separable from, the walls of these canals through the nerve substance. The diameter of the canal (and therefore of the lymphatic sheath) may be seen, in trans- verse sections, to be generally twice, and sometimes three or four times, as large as that of the contained bloodvessel. It will be easily understood that these two sys- tems must have such a complemental relationship to one another, that an extra fulness of the one set of vessels will corre- spond with diminished fulness of the other set. That is to say, in order to make room for an increased amount of blood in the cerebral vascular system a correspond- ing amount of fluid must be driven out of the enveloping lymphatic vessels ; ' whilst, when the vascular supply is again dimin- ished, a proportionate amount of fluid re- enters the cerebral lymphatic canals. Thus, we believe that the amount of blood existing within the cranium may be subject to great variation, and that the peculiarities of the cerebral circulation have been much overrated. The conditions capable of bringing about a state of cerebral congestion are very various, and so also is the degree of hypersemia met with, and the extent of its diffusion over the encephalon. In one class of cases, the congestions seem to be most obviously mechanical phenomena, due to some impediment to the proper re- turn of blood from the brain, owing either to diseases of the heart or lungs, to pres- sure upon the great veins by turners, or to their obliteration by thrombosis. In other instances, however, the condition of hyperaemia seems a more purely vital phenomenon, as when it is the result of prolonged study and over-mental work, or when it has an irritative origin, and is set up around some old clot, bony exos- tosis, or adventitious product in the brain. Then, too, alcoholic intoxication, great elevations and alternations of tempera- ture, exposure to the sun's rays in hot summer weather, and the suppression of accustomed fluxes, whether menstrual or other, are all looked upon as occasional causes of cerebral congestion. In connec- tion with inflammation of the meninges, congestion of the convolutional gray mat- ter is doubtless the initial stage of what afterwards becomes diffuse superficial ■ Cambridge Journal of Anat. and Physiol., No. 2, p. 351, note 2. MORBID ANATOMY. 851 cerebritis. Well-marked Congestion of the Brain is also met with very fre- quently in persons who have died whilst suffering from symptoms of delirium or coma during the course of the acute spe- cific diseases, and in whom there may be no trace of meningeal intiaramation. This is more especially common in typhus fever. From observations wliich I have made on the bodies of persons who have died from this disease, and also from the minute examination of the brain of a man who died delirious whilst suffering from acute phlegmonous erysipelas of the head and neck, I have been led to believe that these minute and wide-spread congestions are often due to embolism or thrombosis of the minute arteries and capillaries of the brain.' Wide-spread obstructions in the small vessels, however brought about, would cause much of the propulsive energy of the heart to be wasted and a consequent lagging of blood in the venous radicles. Cerebral congestion Is very intimately related to cerebral hemorrhage on the one hand, and to inflammation on the other. Hemorrhage is most likely to be associated with the congestions of mechanical origin, especially if these are brought about rap- idly; and altliough such cerebral condi- tions generally give rise to well-marked brain-symptoms, still the groups of S3'mp- toms previously described are often re- lated to congestions of a more active kind —such as are commonly spoken of as 'de- terminations' of blood to the head — and which may be said to commence rather on tlie arterial than on the venous side of the circulation. In these cases, perhaps by virtue of certain changes occurring in tlie nerve tissue itself, an increased flow of blood takes place to the brain, which may subside after a variable time and after the production of a certain set of symptoms, or which may occasion the death of the patient owing to the super- vention of symptoms of a graver type. In certain other cases the congested condi- tion of the membranes and cortical sub- stance may gradually lapse over into a state of inflammation, and it will then be associated with tissue changes of a more marked character. Morbid Anatojiy. — Congestion of the braiu tissue itself is almost invariably as- sociated with a similar condition of the pia mater, and the amount of cerebral congestion is often judged of, in a loose Way, by the degree of fulness of the ves- ' "On the Clogging of Minute Vessels in the Gray Matter of the Brain as a cause of Delirium and Stupor in severe Febrile Dis- eases ; and on other Symptoms of the ' Ty- phoid State:'" Brit. Med. Journ. Jan. 23, sels of this membrane. AVhat many per- sons would consider to be a state of con- gestion is, however, natural to the vessels in this situation. Hasty opinions on tliis subject should, therefore, be especially guarded against. This fulness of the ves- sels of the pia mater is most notable in the occipital region, whither the blood gravitates, for the most part, after death. Occasionally, however, as suggested by Laborde, this occipital congestion may take place during the last days of life, so as to place it in the same category with hypostatic congestion of the lungs. In some cases, where there has been every reason to believe that a state of congestion existed during life, it must be confessed that little or no traces of it can be recognized after deatli ; though, on the other hand, when it has existed for some time and has been carried to an extreme degree, or when it has been often repeat- ed, undoubted evidences of the present or previous existence of such a condition may be met with. In a young and mid- dle-aged subject, in whom no atrophy has taken place, but whose brain has been subjected to an extreme degree of conges- tion during life, the organ frequently seems, after the removal of the calvarium, to be in a swollen condition. The dura mater is tightly stretched over the organ, and after its reflection the convolutions appear broad and flattened, with sulci less obvious than natural, owing to the efl'ects of pressure against the interior of the skull. Then, there is not only the usual fulness of tlie large veins of the pia mater, but also a more tortuous and even varicose condition of these trunks, to- gether wdth a more complete injection and turgescence of the smaller vessels than is usually encountered. The membranes may be stripped off the surface of the con- volutions without tearing the gray mat- ter, and on section this appears darker than natural, and dotted with bloody points in the situations of its loaded ves- sels. The white substance also shows an abundance of a certain number of the red points, which are usually gorged vessels pulled out for a certain distance so as to lie on the cut surface. These are only comparative signs, however, and their true value must be estimated accordingly, since all intermediate conditions may be met with between the ordinary healthy amount of fulness and the most marked degree of hyperemia. It is extremely difficult to draw the Hue and say what is morbid and what is consistent with healtli. If, however, the congestions have been often repeated or have lasted for any length of time, microscopic examination does enable us to discover evidence of this. The capillaries, and more particu- larly those of the gray matter, become 852 CONGESTION OF THE BRAIN. twisted and varicose, displaying partial dilatations, or real aneurismal swellings, implicating either a part only of the cali- bre of the vessels, or dilating them in numerous adjoining parts in their whole extent, so as to constitute "I'etat monili- forme" of Laborde.' But a still more certain mark of old congestion is afforded by the presence of a quantity of blood pig- ment (hsematine) surrounding the vessels, though inclosed within the lymphatic sheath described by Robin. It is met with in the form of more or less rounded simple or molecular grains, mostly of large size. They may measure as much as 5bV(i" ill diameter. They are usually of a dark olive or amber yellow color, and are sometimes composed of a number of mi- nute pigment granules aggregated into small spherical masses. The pigment re- mains quite unaltered after the applica- tion of ether, alkalies, or the strongest acids. The crystalline form of blood pig- ment (hfematoidine) is not met with, since this seems to be produced only in places where an actual extravasation of blood has taken place, whilst the pigment in the granular and amorphous condition seems to result from stasis of blood, and more or less transudation of coloring matter, or hsematine, through the walls of the ves- sels into the surrounding lymphatic ca- nals. It seems impossible otherwise to account for what I have seen. I have found, for instance, this matter in great abundance around almost all the small vessels and capillaries that were examined belonging to the brain and spinal cord of two individuals. Both were lunatics ; the one an epileptic and chronic maniac, sub- ject to paroxysms of great excitement, and the other a chronic maniac of the most violent and excitable disposition, whose fits of passion were both frequent and long-continued. It was during the examination of the brains of these indi- viduals that this granular blood pigment, surrounding the vessels, first attracted my attention. I have since found that a similar condition had been noticed and ' "Le Ramolliss. et la Congest, du Cer- veau," Paris, 1866. These irregular aneuris- mal dilatations of thin-walled capillaries must not be confounded with the distinct though microscopic aneurisms, occurring on some of the smallest arteries after they have undergone a process of fibroid thickening in different parts of the brain in old people. We have previously hinted at the occasional con- nections between cerebral congestion and cerebral hemorrhage, and now we may state that the links which bind the two together are frequently the aneurisms just mentioned. Congestion may have something to do with their formation, as it certainly has to do with their final rupture, leading to effusion of I'liiod. (Trans, of Path. Soc. vol. xviii. 18J7.) described by Robin, and I can endorse his statement that a few such nia^-ses of pigment are usually to be met with, here and there, on the cerebral vessels of even young and healthy subjects. It is, there- fore, the abundance of this matter only which is to be looked upon as an index of disease ; and the duration of past conges- tions may be roughly guessed at by the more or less excessive accumulation of pigment around the vessels. Occasionally, however, an actual rup- ture of one of the minute vessels may take place under the increased strain upon its walls in cerebral congestion. This is all the more likely to occur in elderly people whose vessels have been weakened by fi- broid or atheromatous degenerations. In such cases I have not unfrequently found, after careful preparation, evidences of past capillary hemorrhages on several of the smallest vessels of the same brain. Af- ter the brain substance has been washed away, and when the vessels are floated in water in a shallow dish, one or more little orange-cfilored specks may be seen, even smaller than a pin's head. On examina- tion with the microscope these are found to be accumulations of altered blood pig- ment in the form of amorphous canary- yellow colored flakes, interspersed with distinct crystals of hsematoidine, situated around one of the minute vessels, and dis- tending its sheath in a more or less obtuse fusiform manner. In these cases the pres- ence of the perivascular sheath seems to have limited the amount of blood eft'used. As soon as the sheath became distended in the immediate neighborhood of the rup- ture, the pressure so produced would tend to close the aperture in the ruptured vessel. Lastly, there is to be mentioned that condition of certain parts of the brain which was spoken of by Durand-Pardel' as "I'etat crible," and which he and others regard as an evidence of previous dilatation of the vessels from long-con- tinued congestions. This condition is oc- casionally well seen, more especially in old people, in the white substance imme- diately beneath the gray matter of the convolutions. On section a number of round or oval apertures appear — some large enough to admit a pin's head — and within eacli may be seen the cut extremity of a vessel. In these situations the canals in the nerve substance have become en- larged by pressure, and the lymphatic sheaths have been dilated to a similar extent, whilst in the space between the sheath and the much smaller bloodvessel a large quantity of pigment granules is generally met with. This dilatation of the vascular canals sometimes reaches an extreme degree in the corjiora striata and ' Loc. cit. p. S7. PROGNOSIS — TREATMENT. 853 in the optic thalami, and the same con- dition may be eucouiUered, thougli to a less extent and le^s frequently, in the sub- stance of the pons Varolii. Whenever the granules are met with, however, the structural conditions and the mode of ori- gin seem to be the same. Durand-Fardel says :— " Tantot I'etat crible du cerveau so trouve repandu dans une grande eten- due des hemispheres, tantot on ne I'ob- serve que dans un espace circonscrit. " This condition may be met with at all ages, though it is found more particularly in old people : and in them, the same writer tells us, the canals are sometimes so large and numerous in the corpora stri- ata, that these bodies may seem to have lost nearly half their substance. It seems most probable that these canals have been produced by the dilatation and pressure exercised by congested vessels, though their method of pathogenesis cannot be said to have been ascertained in a thor- oughly satisfactory manner. Prognosis. — In cases of cerebral con- gestion regard must be paid to the age of the patient, the form of his attack, the severity of the symptoms, and the fre- quency with which the symptoms or the attack of symptoms may have occurred. Age cannot be fairly estimated by the mere duration of life, for some men are "older" at fifty-five than others are at seventy years, and are so without any necessary coexistence of exhausting or definite disease. The apparent age is a truer guide than the real age in the mat- ter of prognosis. Baldness, gray hair, rigid vessels, a weakened heart, arcus senilis, and enfeebled powers, must be taken into more serious account than the date of birth ; and judged by such tests, the prognosis is unfavorable in proportion to the oldness or agedness of the indi- vidual. The form of attack is worthy of most grave consideration. That which is of the worst omen is the apoplectic ; next to this is that characterized by delirium ; after it the convulsive form ; and least serious of all is the febrile, or quasi-febrile. The severity of symptoms is of much value in relation to the apoplectic form ; the danger being in direct proportion to the profundity of coma, and its duration. It is of but little moment when delirium is the most prominent symptom, and the value that it possesses is in inverse rather than direct ratio to the force of the dis- turbance ; the prognosis is worse when the delirium is mild, muttering, and con- tinuous, than when it is noisy, or even violent, and — as is usually the case — of short duration. When convulsions occur, it is not safe to base any prognosis on the mere fact of their severity ; for often pa- tients recover after tbe most frightful seizures, whereas others succumb to much milder paroxysms. The degree to which, in the intervals of seizure, the mind is re- stored to its normal state, is a fairer cri- terion of the amount of danger than is the violence of the convulsion. In the febrile form the prognosis is bad in direct pro- portion to the intensity of the symptoms. When the disturbance is slight, confident hopes of recovery may be entertained ; when it is severe, there is room for the apprehension of ulterior and "inflamma- tory" changes. Congestion of the Brain is rarely fatal at its first attack ; it becomes dangerous in proportion to the frequency and'readi- ness of its induction ; and this is true with regard to each form in which the symp- toms may be developed. The other conditions by which the prognosis must be determined are those of organic disease or degeneration in any of the important vital organs. It is obvious that the heart, the vessels, the kidneys, and the liver should be examined with care, and that the opinion formed as to the future should be guided by the kind and amount of disease that may be found in them. The prognosis, however, when such diseases are discovered, is not that of cerebral congestion only, but of those complicated morbid conditions of which it is but one form of expression. It may be that Congestion of the Brain is likely to prove the cause of death, but the nature of the disease which leads to such conges- tion furnishes the material, by a consider- ation of which the probabilities may be estimated. Trbatmbxt. — As there are two dis- tinct, practically opposite, conditions of the body under ^vhich cerebral congestion may occur, so there are two different lines of treatment to be adopted. If the brain congestion be but one of many symptoms of a general plethora, much may be gained by either general or local blood-letting ; if it be but the outcome of weakness and vascular obstruction, then sucli measures may increase the evil. The previous habits and health of the patient, the present state of his integuments, — their warmth, vascularity, and color, — the state of the pulse, of the heart and vessels, will furnish the guides in this important mat- ter. A man in middle age who has over- strained himself, or placed his head in some dependent position, and who is at- tacked by violent convulsions, character- ized by great turgescence of the skin, bloodshot eyes, and a full but labored pulse, may be relieved, and greatly re- lieved, by venesection to the amount of six or ten ounces. But such cases occur rarely, and in the majority of instances no man would at the present day think of bleeding from the arm. When, however. 854 CEREBRITIS. there is distinct general weakness, and, witli this, lieat of liead, oppression, con- tinuous headaclie, and a tendency to drowsiness, niucli relief may be obtained by the application of leeches to the tem- ple, or by cupping to three or four ounces at the back of the neck. When there is no such heat of head, and no flushing of the face, but when the diagnosis of cere- bral congestion maj' still be made — per viam exclusionis — and when the vital powers are low, the pulse small, feeble, irregular, or intermittent, even a small abstraction of blood locally may be fol- lowed by the worst results. It is when attacks of congestion are frequently re- peated, and other measures have failed to relieve them, that local depletion may be found of signal service. It is well to raise the head, to apply cold water or ice to the forehead, and to place the feet and hands in hot baths. If the stomach be overloaded, an emetic of mustard or ipecacuanha may be given ; and often with the discharge of the stom- ach the symptoms pass away. This is especially useful when the attack has fol- lowed a full but hastily taken meal. It is of great importance to empty the rectum, and the most efficient means for doing this is the administration of an injection of warm water. Should there be any sus- picion of the existence of hardened masses of feces, the injection of a large quantity of warm olive oil will prove niore useful than that of water. AVhen the tendency to cerebral conges- tion is noted, rather than any marked sj'mptomsof its presence to a high degree, the secretions must be carefully regulated ; and among these one of the most impor- tant is the urinary. Many cases of threat- ening aspect are to be relieved by saline diuretics ; and I have known a copious flow of urine to be followed by the remo- val of symptoms which had existed in spite of free purgation and other treat- ment. There are many cases occurring in ad- vanced life in which the congestion is of onh- momentarj- duration ; and the pa- tient, when seen by the physician, is simply bewildered, pale, and with a cool, moist skin, and feeble pulse. Under such circumstances the cautious administration of stimulants is called for ; and of these sal-volatile and wine are the most useful. It is well to combine with them carbonate of potash, or of soda, as there is often considerable "acidity of stomach," and the discharge of flatus by the mouth, which results from such administration, is often followed by a complete remission of the symptoms. As precautionary measures, quiet of mind, and gentle exercise of body, with the careful avoidance of either fatigue, sudden change of posture, or strain, should be enjoined ; and much relief may be ob- tained by insuring a position during sleep which shall prevent not only the head, but the head and shoulders, from sinking down to the level of the body. This may be easily obtained by a simple contrivance placed under the bed or mattress upon which the patient lies ; such an arrange- ment being much better than a mass of pillows, which shift their places, and often maintain the head in a condition of undue heat. [In patients who have been subjected to the influence of malaria, special care is sometimes needful in diagnosis, in order for the proper adaptation of treatment. A lady was placed under my care who, without any distinct chill, became coma- tose, and continued so for about twelve hours. Her age, over sixty years, made apoplexy not improbable. Her pulse, however, was feeble, as well as mode- rately slow ; and her respiration was not stertorous. She was known to have just visited a malarious region. Ordinary de- rivative measures were used, and, as soon as she was able to swallow, quinine was given, a grain every hour, watching its effects. Under this treatment she re- covered. — H.] CEEEBRITIS. By J. EussELL Reynolds, M.D., F.R.S.,' and H. Chaelton Bastian, M.D., F.R.S. _ It is probable that general inflamma- tion of the brain never exists alone, but that it is invariably associated with men- ingitis. The terms encephalitis, meningo- cerebritis, and phrenitis, which have been employed to denote the condition now referred to, are sufficient of themselves to > The section on Pathology is written by Dr. Bastian, CAUSES — PATHOLOGY. 855 point out this constant association. Never- tlieless, in some cases tliere is to be found, during life, the predominance of a class of symptoms which simple meningitis will not account for ; and, after death, the presence of such changes in the cerebral tissue, as do not necessarily accompany the meningeal inflammation. It would seem, therefore, that the brain substance is not only susceptible of morbid change of an inflammatory type, but that the presence of such change may determine the clinical history of the case. We may, in particular instances, refer some of tlie symptoms of a complex encephalitis to in- flamniation of the membranes, and others to an implication, in like change, of the cerebral tissue. Meningitis has already been described, and it remains for us, in this place, to de- scribe only those symptoms which mark the extension of the malady to the brain itself. All that relates to that which has been described as local Cerebritis, or lim- ited softening of the brain, will be found under the articles on Abscess of the Brain and Softening of the Brain. Causes. — The most common causes are injuries to the head ; such as violent contusions, wounds, diseases of the bone, and insolation. It would appear, how- ever, that sometimes prolonged mental exertion or moral excitement have led to the development of this disease. In rare cases there has been no distinctly recog- nizable cause, the symptoms having ap- peared in the absence of any one of the conditions above mentioned. Symptojis. — These are, of necessity, associated with those of meningitis, but sometimes they are the earliest to appear, and are predominant throughout the case. Thus, some mental change may be the first evidence of disease ; it may be very slight, and maybe mistaken for " hyste- fia," "stomach disturbance," or some such vague malady. In one case, which I saw several years ago, there was a mere confusion of ideas, and a worried manner, with misuse of words, and this for two or three days before other phenomena ap- peared. Usually the patient is sullen, and the faculties are obscured ; there is a confused, "muddled" state of the intellect, sometimes merging into mild delirium, sometimes, when meningitis is present, alternating with, or superseded by, violent excitement. There is deep-seated, oppressive pain in the head, described as sometimes shoot- ing from the centre to the vertex, the temples, eyes, or ears ; and this pain is persistent, and is out of all proportion to the p3Texia, which is often very slight. Except in dependence upon meningitis, there is no intolerance of light or sound, but there may be obscurity of vision, di- plopia, and failure of sight, together with ringing noises in the ears, and some diffi- culty in hearing. There is general muscular lassitude, but neither dettnite paralysis nor spasm ; the limbs are weak and aching, but they may all be moved. Such symptoms may continue for two, three, or four days, and then a violent convulsion may occur, followed by coma, from which the patient never thoroughly recovers. There is, however, partial re- covery sometimes, and then more or less general paralysis is discovered. The patient is stupid, sleepy, comatose, and lingers for a shorter or longer time, in proportion to tlie amount of nourishment that can be gi\en and retained by either stomach or rectum. Convulsions, some- what epileptic in character, usually recur, and in their intervals there is to be ob- served a gradual dymg out of the vari- ous functions of the brain. Mind, sensa- tion, and voluntary power are lost, and the patient lives a mere vegetative life, disturbed occasionally by slight spasmodic movements, or rigid contraction of the muscles. The convulsions are often of long duration, involve the limbs especially, and are not marked by notable asphyxia. The general symptoms arc, as a rule, so slight that they attract no notice. There is no fever, little or fio vomiting, and no obstinate constipation of the bowels. Yery often the sphincters are relaxed quite early in the history of the case, and no- thing abnormal can be discovered in the evacuations. Diagnosis.— That which gives to the diagnosis of meningitis its gravest ele- ment is the recognition of coexisting Cerebritis, and hence the diagnosis is val- uable as an aid to prognosis. Cerebritis may be inferred when there is a rapid transition from the excitement of menin- geal inflammation to the marked loss of function which is characteristic of cere- bral change. "When the signs of menin- gitis are unusually severe, the pain deep- seated, and followed after twelve or twenty-four hours by convulsions, coma, and paralysis, there is commonly Cere- britis of considerable extent. Pathology.— Of uncomplicated Cere- britis wc have no knowledge. "When inflammation of the brain substance ex- ists, it is either associated with a more marked change of the same kind m other parts, such as the meninges, m ^vhich case it is treated of as a concomitant con- dition, and not as a primary morbid affec- tion; or else it speedily lapses into other distinct pathological states, such as ab- sce.ss or softening, which, on account ot their importance, are usually described as independent affections of the bram Two kinds of Cerebritis are usually de- 856 SOFTENING OF THE BRAIN. scribed, namely, the diffuse or general form, and local Uerebritis, which liy most recent writers has been held to be synon- ymous with "red softening" or "acute ramoUissement" of the brain. The diffuse form, or general Cerebritis, is a more or less wide-spread affection of the cortical substance, or gray matter of the convolutions, and is always associated with inflammation of the meninges. It may be met with in surgical cases, from injury to the skull ; when, conjoined with it, there is inflammation of the dura mater and arachnoid, together with the formation of purulent lymph within the arachnoid cavity, and also beneath the visceral layer, into the meshes of the pia mater. Cerebritis may also be met with in the more limited meningitis, such as occurs when the disease is not of trau- matic origin, and which, affecting the pia mater principally, is not accompanied by any purulent ellusion in the sac of the arachnoid. In these cases there is ex- treme ^•ascularity of the cortical gray substance, which is also more soft and pulpy than natural ; and it is frequently adherent to the meninges, so as to be torn when these are stripped off. For further particulars we must refer to the articles "Meningitis" and "Tubercular Menin- gitis," under which heads these morbid conditions are more fully described. It should be stated, however, that many pathologists of the French school look upon general paralysis of the insane as a disease due in part to a species of chronic Cerebritis. The same adhesion between the gray matter and meninges is frequent- ly met with in this disease ; but' for fur- ther information we must refer to the article on this subject. "With regard to local Cerebritis, we think with Lebert and other pathologists that this may be the antecedent condition and proximate cause of abscess in the brain; and we do not den}', also, that some acute softening of the brain may have an inflammatory origin. ^Ye do, however, strongly object to the view that all "red softenings," or "acute ramollissements, " have to acknowledge this method of path- ogenesis. We believe that most of the softenings hitherto placed in this category have been brought about by embolism or thrombosis, owing to the interference with the crebral circulation thus induced; and that the characters usually considered as diagnostic of their inflammatory nature are capable of receiving a totally different interpretation, as may be seen on refer- ence to the article "Softening of the Brain." In this view we are supported by many recent writers on the subject. With regard to the occasional existence of softening of the brain of inflammatory origin, we do not altogether disbelieve in its occurrence, only we plead ignorance as to the characters by which such soften- ings are to be distinguished from others of a degenerative nature, due to arterial or venous obstruction. We certainly think it is a pathological condition which occurs very much more rarely than the state- ments of some ijathologists would lead us to imagine. It may, perhaps, be looked for most confidently in cases of wounds or injuries to .the brain, or around adven- titious products, as centres of irritation. Prognosis. — The prognosis is as bad as it is possible to be. There is no prob- ability of recovery when symptoms such as those above described have been de- veloped. Trbatmekt. — Only palliative mea- sures can be used with any advantage. We have never seen any good result from mercury given by the mouth or by inunc- tion ; nor from blisters, cupping, or other modes of blood-letting. Pain may be re- lieved by the apphcation of ice ; and spasmodic movements may be limited by sedatives, such as belladonna and Indian hemp ; but beyond such relief of symp- toms therapeutic art has failed. SOFTEi^ING OF THE BEAII^. By J. Russell Reynolds, M.D., F.R.S., and H. Charlton Bastian, M.D., F.R.S.i Definitiok. — A disease characterized during life by impairment of mind, sensi- bility, and motility, and after death by diminished consistence and degeneration of the cerebral substance. The disease now to be described is that which has been known as white or non- • The sections on Pathology and Pathologi- cal Anatomy are written by Dr. H. C. Bastian. ACUTE SOFTENING OF THE BRAIN. 857 inflammatory softening : ramollissement blanc, or ramollissemeut nou-intlamma- toire. Causes.— Tliere is little that is satis- factory wliicli can be said with regard to the remote etiology of Softening" of the Brain. Among the conditions which predispose to its occurrence the most im- portant is age, or agedness. Softening of the Brain is essentially a manifestation of decay, and this may be either the natural result of the wear and tear of a long life's work, or it may be the early outcome of excessive strain. The real cause is that waste of tissue which is unbalanced Ijy repair, and this may come from the long continuance of work, — old age, — or the unhealthy severitjf of work, and its undue relation to rest. The proximate causes may be resolved, — as will appear in the section on "pathology," — into mor- bid conditions of the vascular system. Neither sex, constitution, nor season of the year has been shown to exert any marked predisposing influence, nor has any distinct relation been made out be- tween any one particular condition of the heart and cerebral softening. Degenera- tion of the kidneys and impaired nutri- tion of the heart and vessels are among the conditions which frequently accom- pany ramollissement ; but these ought to be regarded as certain parts of a general change of which the cerebral softening is but another or counterpart, rather than as predisposing causes of its existence. Vegetations on the valves of the heart may become detached and may block up one of the cerebral arteries ; and thus their presence on tlie valves miglit be re- garded as predisposing to Softening of the Brain. But it must be remembered that such vegetations when in situ, i. e. uude- tached, do not specially predispose to Softening of the Brain, that they may lodge in other vessels than those of the cerebrum, and that when they are carried from the heart to the cerebral arteries they become determining and not predis- posing causes. If we may employ the term "predisposing cause" under these circumstances, we should do so to the general or constitutional state that has led to the production of vegetations rather than to the vegetations themselves. There is nothing definite to be said with regard to exciting causes. Attacks have sometimes followed violent mental or moral excitement, anger, abuse of alcohol, over-fatigue, or local injuries ; but in the majority of cases no such conditions have been present, and in very many there has been a singular immunity from all appa- rent causes of disturbance. Exposure to cold has been followed by an apoplectic seizure, and one of the more frequent de- termining causes of an attack has been too free a purgation of the bowels. Symptoms. — Softening of the Brain may occur as either an acute or a cln-onic disease. It wiU be well, therefore, to de- scribe the allu(.'tion under two general headings, and first : — Acute Softening of the Brain. 1. Premonitm-y Symptoms. — These may be absent altogether, but such complete innnunity is rare ; for Softening of the Brain most frequently occurs in those whose health has been for some time lie- low the average, and very frequently in others who are the subjects of some dis- tinct chronic and exhausting diseases. There is nothing so special in the charac- ter of the general condition which may precede Softening of the Brain as to ren- der it of much value in the forecast of a patient's chances. There is often an en- feebled condition, with impaired nutritive power, shown in the general bearing of the patient, and more distinctly in the weakness of cardiac impulse, rigidity of arterial vessels, and local ineciualities of temperature. These facts may be noticed for months or even years, but there is no- thing in tliem that points specially to the brain as the organ which is likely to give way. In combination with symptoms of cerebral failure they are, however, of great significance. The symptoms which, when thus com- bined, are premonitory of softening, are often those already described as charac- teristic of impending or actually devel- oped congestion of the brain. {See p. 845, article "Congestion of the Brain.") They are — headache, more or less con- stant in duration, and usually "dull" in character, dulness of sight or hearing, numbness, obscure pain, weight, or an indescribable sensation of "something wrong" in the extremities, slight con- fusion of thought, sleepiness, weakness of purpose, hesitation in judgment, irritabil- ity of temper, diminished control of emo- tion, deficiency of muscular power, a stoop- ing gait, and tendency to cramp in the limbs. Sometimes the face assumes a dull, expressionless aspect when the pa- tient is at rest, and he may pass hours in a state of apparent indiflerence to all around him ; but when called upon to ex- ert himself is able to resume his habitual manner, and do his accustomed work, al- though with some heaviness of manner and apparent eflbrt. There may be occa- sional and slight symptoms of faintness, the face becoming pale, and the limbs cool ; and such occurrences are of much significance. It sometimes happens, more- over, that the altered sensations aliove described are noticed more on one side of the body than on the other ; and the fact of this limited distribution is highly iudi- 858 SOFTENING OF THE BRAIN. cative of impending evil. Tliere may be a little dragging of one leg, or oulj- a ten- dencjf to lean to one side when either walking or sitting ; and this, when con- stant iu its locality, is of much graver meaning than is a mucli greater amount of weakness when variable in its seat. Such symptoms may continue for a shorter or longer time, and may precede either acute or chronic softening, and there is nothing in their nature, when ex- isting only to the degree described, and which can only be regarded as ' ' premoni- tory," that furnishes any clue to the form which the developed symptoms are likely to assume. 2. 37(6 developed symptoms may occur in one of three distinct forms. The patient may either have an apjolectic seizure, be taken with convidsim^s, or may pass into a state of delirium ; and it will be conven- ient to describe these forms separately, premising that sometimes they pass into one another, and that occasionally mixed cases are observed, in which stupor, de- lirium, end convulsions alternate. (a) The (ipoplcctkform may be very grad- ual or very sudden in its onset. When the former, there is an increase of the premonitory sjanptoms for days or weeks ; when the latter, there may have been no special premonition, but the patient sud- denly falls down in what is termed an "apoplectic fit," and he is said to have had "a fit," or "a stroke." Very commonly the attack occurs after too loniT an abstinence from food, or when the patient is fatigued by too long a walk, or too protracted an effort ; sometimes when, as in congestion of the brain (see page 845), he is making an excessive ex- ertion. It is not common, so far as my experience extends, for patients to wake up in the morning and find themselves paralyzed on one side of the body, a mode of attack by no means uncommon in the case of cerebral hemorrhage. The condition of the mind is highly sig- nificant. Transient excitement, talkative- ness, irritability, or wandering of thought, amounting sometimes to mild dehrium, may occur for a few minutes. The patient says or does something quite out of rela- tion to his surrounding circumstances or previous conversation ; speaks as if to some person he may not have seen for years, asks a question which refers to events long since passed, or in some other manner shows that he is " not quite him- self;" is bewildered and "queer," vexed or pathetic ; he makes some effort to get up and do some extraordinary thing which no one can understand, is impatient of attempts at dissuasion or control, looks faint, and becomes more or less insensi- ble, sometimes falhng to the ground, some- times voluntarily sitting or lying down, as if merely fatigued, or disgusted with the stupidity of those around him, who do not understand what it is he wants to do. The patient may for a few minutes be completely insensible, and when he is so, it is probably due to sudden congestion of brain, or to equally sudden anajmia of brain, either of which may be recovered from in a few seconds or minutes. "When, however, the physician sees the case, he rarely finds absolute loss of consciousness. The patient lies quietly, in apparently profound sleep, snoring, and taking no notice whatever of the questions that friends ask in anxious and beseeching tones ; but if spoken to sharply, told to put out the tongue, open the eyes, give the hand, or do any other simple thing, he responds at once, usually makes an awkward failure, and then relapses into his former state ; if asked a question, he makes some inarticulate or unintelligible sound in reply, and again falls back into his heavy sleep, sometimes muttering to himself, but more commonly snoring con- tinuously, or occasionally interrupting the rhythm of his snore by a long-drawn sigh. In such a state the patient may con- tinue for hours, days, or even weeks. There is often suflScient intelligence re- maining for him, when roused, to swallow food, to recognize friends, to make efforts to say something ; but so much dulness of apprehension, and so much difficulty of expression, that the real life is " hidden," and it is impossible to know that we are on such common terms with it that we can understand its meaning. In some cases there is after a longer or shorter period marked improvement, the faculty of articulation returns, and a cer- tain amount of conversation is possible to and with those who will give pains to learn the language that is spoken. The names of common objects are forgotten, or are confounded with those of others ; and this, sometimes with such constancy that friends may understand what is intended, sometimes with such thorough want of uniformity that the meaning is unintelli- gible. Notwithstanding this great ob- scurity of expression, it may be perfectly clear that the patient himself knows dis- tinctly what he means, is aware that he is wrong in his use of words, is vexed at his blunders, and ingenious in contriving means to counteract or avoid them. For example, he may know so well the words which he wants, and which he supplies by others in ordinary conversation, as to write down lists of words, and point to one or more of them in order to make up his sentences, or correct erroneous expres- sions. ( See page 85.5. ) Occasionally, after being even pro- foundly affected, the mental condition may undergo great improvement, and the patient, although not perfectly restored, be carried back again to the point de- SYMPTOMS. 859 scribed in the notice of premonitory symp- toms. But far more commonly there is no real restoration ; some confusion may dear away, the stupor may be lessened ; but •vvhcu these improvements have oc- curred the mind is found to be dulled and incompetent, and in a state of gradually increasing deterioration ; week by week, and month by month, the patient is further and further removed beyond the reach of intercourse, until the attempts to talk with him are given up so gradually by the friends that they are scarcely aware of the change, and so imperceptibly to the ■weakening mind of the patient that he takes no notice. In this way a sudden attack of softening may pass into what is termed "chronic softening, " the patient becoming imbecile of mind, and powerless in body. In a certain number of cases, the course is rapid, the apoplectiform attack is re- peated, and at the end of two or three days there is profound coma, passing into the sleep of death ; in a much smaller number, the symptoms are very transient, and the recovery may be complete. For example, a young lady, set. twenty-two, in her first attack of acute rheumatism, marked by considerable swelling and red- ness of knees, wrists, and ankles, and a recently developed systolic murmur at the base of the heart, received a visit from some friends, was excited in conversation, and had palpitation of the heart. A few minutes after her friends had left her she grew faint, looked pale, became uncon- scious, and remained so for two or three hours. At the end of that time she was confused, unable to utter any intelligible sentence, clipped her words, made some sounds that were quite inarticulate, and had marked right hemiplegia, the features being drawn to one side, the right arm being completely, the right leg incom- pletely, paralyzed. At the end of three aays speech was perfect ; and at the end of a fortnight the hemiplegia had disap- peared. The most rational interpretation of such case is, that an embolus blocked up the left middle cerebral artery, and led to impaired nutrition of the brain, which equals the first stage of softening ; but that, owing to either" the re-establishment of the circulation by the breaking up or removal of the embolus, or to the perfect establishment of the circulation in the col- lateral vessels,, the nutrition was restored to its ordinary condition. Sensibility is sometimes quite destroyed at the time of attack, and for some few minutes afterwards ; but in the greater number of cases it is only dull or impaired, and subsequently changed. While_ the patient is lying apparently unconscious, or only half conscious, it is often obvious that some sensibility is present, for he moans, moyes about uneasily, puts his hand to hi.s head, and starts or draws away some one or other of his limbs if the skin Ije scratched or pinched. It is pro- Ijable, from the frequency with which the hand is put to the head, that there is headache, or an uneasy sensation in the head ; and a general feeling of distress, with, very frequently, some distressing sensation in one or more of the limbs. Often before the patient is able to speak, he is evidently unea.sy in some of the ex- tremities, and these are usually on one side of the body, and are paralyzed ; he looks inquiringly at them, or rubs them, moans at them, and cries out if they be either moved or touched. When suffi- ciently conscious to make himself intelli- gible, the patient often complains of cold- ness, or numbness, or " queer feelings" in the arm or leg of one side ; of headache, or discomfort in the head not amounting to pain ; of a bewildered feeling, and some vertigo. There is occasionally hypcras- thesia, and its occurrence in the limbs affected by a stroke of hemiplegia is thought to be highly characteristic of acute Softening of the Brain. It would appear, however, that, instead of true hypersesthesia, there is a modified sensi- bility, such as that described above, and that it renders ordinary impressions pain- ful. Sometimes these modifications pre- sent very curious features ; the patient feels distinctly and painfully any impres- sion on the skin, but is unable to refer it to its proper locahty. For example, a pinch on the sole of the foot is referred to the inguinal region, while similar irrita- tion above the knee may be felt in the shoulder, or side of the neck ; and some- times the sensation may be referred to the wrong side of the body. In the majority of cases the sensibility of the limbs is, after an apoplectic attack of softening, speedily restored to its nor- mal condition. The special senses are, as a rule, unaf- fected except in the earliest stage of the attack, when all of them may be in abey- ance. There is not rarely some complaint of tinnitus, and of muscffi, or of dulness in hearing, or mistiness of sight, but there is no one change which is characteristic of softening. The optic disk is often paler than natural. The vessels are extremely small, and either white or gray atrophy may be apparent. The outline of the disk is sometimes very sharply defined, and its shape distorted ; but there may be integ- rity in the appearances presented by the eye when there are unequivocal indica- tions of Softening of the Brain. There is often to be observed some marked pecu- liarity in the eyebahs and in the pupils, which being, however, illustrations of al- tered motility rather than of sensibility wiU be described under the following heading : — 860 SOrTENING OF THE BRAIN. The symptoniR cliic to changes in motility. — It has been oi'teu observed that the eye- balls are directed to one side, and that the head is turned in the same direction, so as to give the idea that the patient is making an eflfort to look at something by the side of him, and usually on the oppo- site side to that of the paralysis in limbs. If carefully examined it may sometimes be shown that the patient does not see at all, and that the retina is quite insensible to light ; while in other cases the patient sees distinctly, and may, by an effort of the will, bring the eyeballs to the middle line or even beyond it and to the opposite side. In one curious care, under my care in University College Hospital, this sy- nergic condition of the eyeballs was ob- served for nearly a fortnight, at the end of which time the patient died. The pa- tient was, when roused, sufficiently sensi- ble to give a cohenmt account of himself, his sight and hearing were good, he could distinguish not only objects but colors, and seemed rather amused at being put , through an examination on such points ; yet while talking to me the eyeballs were constantly turned towards the right side, and so much so as to hide a considerable portion of each iris beneath the lids at the left inner and right outer angles. The patient often fell asleep, and began to snore while the students were standing round his bed ; and what was very inte- resting to observe was this, that at the moment of doing so the eyeballs returned to the middle hne. Upon touching him, or speaking to him so as to rouse him a little, the synergic movement again in- stantly appeared. Owing to the ease with which the transition from sleeping to wak- ing could be effected in this case, the above oliservation was repeated many dozens of times, and always with a simi- lar result. The eyeballs are usually, ex- cept at or soon after the occurrence of the attack, unaffected. It is the rare excep- tion, and not the rule, to meet with stra- bismus even to a slight degree. There is nothing characteristic in the condition of the pupils ; they may be found in almost every degree of either dilatation or con- traction, and they are usually equal on the two sides in case of acute softening. Their relation to light is determined by the general sensorial condition rather than by any special involvement of their own motor centres. It has been said that oc- casionally the pupils dilate vipon expo- sure to light and contract upon its with- drawal, but there has been, I believe, a fallacy in such observations which it is very easy to correct. The facts as they have been witnessed bj^ myself in many cases are these : that tlie patient is found asleep, or in a state of half-unconscious- nc'ss, with contracted pupils ; a strong light is brought before him, or the eyelids are suddenly raisrd, and then immediately there is dilatation ; left to himself, again the drowsiness comes on, and the pupils pass into the state of contraction. The pupils dilate because the patient is roused, not because they are exposed to light; the contraction and dilatation that have been observed have had no relation to light or darkness, but simply to the facts of sleeping and of waking. This I have shown again and again by gently raising the lids of such a patient, and exposing the contracted pupils to the light without arousing him ; there is then no dilatation nor change of any kind : but if he be addressed loudly by name, or if his toe be pinched so that he is awakened, the pupils instantly dilate. The features are sometimes quite sym- metrical, both when at rest and when in motion ; but commonly there is some de- viation, noticed most distinctly in the lower part of the face at the angle of the mouth when the patient speaks or laughs; and sometimes it is so trifling that it may escape observation unless the patient smile, or make a forced effort to exhibit either the upper or the lower teeth. In other cases there is marked paralysis of the face on one side, and dragging of the features towards the other, with deviation of the tongue ; but let it be remembered that this paralysis does not, as a rule to which there are very few exceptions, in- volve the muscles of the forehead, eye- balls, eyelids, or pupils. The patients can equally raise the eyelids, open or close the eyes, and there is neither ptosis nor strabismus. The speech is commonly interfered with, not only at the moment of attack but for a long time afterwards, and sometimes persistently. It may be so thoroughly abolished that no intelligible sound is ut- tered, although it is obvious that ideas of some kind are passing through the pa- tient's mind ; it may, on the other hand, be so slightly affected that alteration is observed only in the articulation of certain sounds, such as those of the letters I or r. Between these two extremes there is al- most every variety of degree in the im- pairment of speech as a mechanical act, and there is also every shade of difference in the precision with which it expresses mental processes. Some patients car read with ease and correctness, articu- lating every sound distinctly : and yef they cannot construct for themselves a sentence of half a dozen words, so as tc answer intelligibly the simplest question. Such patients, arihough able to hold a pen and copy sentences, or sometimes tc write a few words from dictation, cannoi compose anything for themselves. Ir such instances language is interfered will on its intellectual side. Other patient: can write well, when not flurried, can tall SYMPTOMS. 861 for a little time so as to be understood, can help to convey their meaning by signs and gestures ; but when "excited," or sometimes even when not disturbed in such jnanner, they can make no such suc- cession of articulate sounds as shall be in- telligible. Here speech is interfered with on its mechanical side. In the former group of cases there is usually paralysis on the right side of the body : in the lat- ter there is not any constancy in such as- sociation. It is to the former class that the terms "aphasia" and "aphemia" have been applied ; and it is not rare to meet with cases which illustrate either it or the opposite condition : it is exceed- ingly easy to recognize intellectually the difference between the two extremes of symptoms, or between them as conjoint elements in a particular case ; but by far the most common event is to meet with such combinations of the two that it is by no means so easy to say how nmch is due to the one failure and how much to the other." As the words aphasia and aphemia have now passed into frequent use, and the conditions described by them have become not unfrequently the topics for medico-legal investigation, it is desirable that some further attention should be di- rected to them, or to what they mean. Aphemia was the word constructed by M. Broca ;' and aphasia, an old Greek word, signifying the dumbness occasioned by strong emotion, was that used by M. Trousseau^ to denote the same thing, viz., the loss of speech or of articulate language, when occurring as a symiitom of disease. The condition now well known as apha- sia was observed by the older writers on medicine, some of whom appear to have recognized the distinction, and others to have failed to do so, between it and a more general condition of injury to the nervous centres. But the special patho- logical significance of the loss of language has been demonstrated within a recent period. Dr. Gall was the first who sought to discover the locality or seat of what he, in accordance with a certain school of philosophy, was led to regard as the sep- arate faculty of language, and he arrived at the conclusion that this faculty had its place in those portions of the anterior lobes of the brain which lie upon the supra-orbital plates. The idea of Dr. Gall was taken up an_d strongly advocated by M. Bouillaud,^ who distinguished, with care, between the recollection of words and the power of producing distinct sounds for their ex- ' Sur le Siige de la Facult On this subject Dr. Kirkes wrote: "Al- thougli by the arrangement of the vessels composing the circle of Willis ample provision is made against obstruction ensuing in any of the main arterial channels on either side previous to their arrival at the circle, there is comparatively little provision for an obstruc- tion ensuing in any of the main branches into which this arterial circle breaks_ np. This remark applies chiefly to the middle cerebral artery, which, if plugged at its ori- gin, becomes at once altogether useless as a bloodvessel, for nearly all its divisions, espe- cially those for the central parts of the brain, proceed to their several destinations without receiving any anastomosing branch from the other divisions of the circle of Willis." — Med.-Chir. Trans., 1852. 870 SOFTENING OP THE BRAIX. trunk also exists at some point before it aives ofl'the branches for this anastomosis. Obliteration of the trunk of the carotid alone is not sufficient, under ordinary cir- cumstances, to produce cerebral soften- ing, as may be seen from a resume by M. Ehrmann,' of cases in which, the carotid arteries having been tied, the operation was followed by cerebral disturbance. The symptoms of cerebral mischief at first set up gradually disappeared when the circulation was re-established by means of the circle of Willis ; and where softening did actually occur, this was due either to the extension of a clot upwards, beyond the circle, into one of the cerebral arteries, or perhaps, as M. Ehrmann sug- gests, to some unusual distribution of the arteries themselves at the base of the brain, preventing the establishment of a collateral circulation, such as ordinarily takes place. The seat of the softening also corres- ponds with the anatomical distribution of the branch occluded, though the two are never coextensive. Usually the brain in the peripheral portions of the vascular department is healthy, owing to this por- tion of its tissue being nourished by the collateral capillary circulation, whilst the central portions of the vascular region are principally affected : thus, as Lancereaux points out, in cases of obliteration of the Silvian artery, softening of part of the corpus striatum and of the neighboring white substance is generally observed, whilst the gray matter of the convolu- tions as well as the walls of the ventricle are often intact. It has been suggested by Durand-Fardel that the obliteration of the arteries is secondary to the softening, and not the cause of it ; but, in reply to this, it is only necessary to state that the actual seat of arterial occlusion is almost always outside the softened tissue, and in these cases, as well as in those in which there is obliteration of the arteries within the softened patch itself, an examination of the vessels will either show degenerated and roughened walls together with the presence of an adherent clot within, or else it will establish the existence of a small obstructing mass, differing from re- cent fibrine in composition and appear- ance, and unattached to the walls of the vessels. 2. Obstruction of Capillaries. — In certain cases, by the rupture of old clots of the heart having softened centres, or by rup- ture of the inner coat of the aorta over large softened atheromatous patches, a mass of granular debris is carried into the cerebral arteries, whilst, from the minute size of the particles of which it is com- posed, these penetrate to and block up the minute arteries and capillaries of the part. ' Theses de Strasbourg, 1859. If the quantity of matter thus carried to the brain be considerable and widely dis- persed, death may rapidly follow before there is time for definite alterations of the cerebral tissue to take place, and owing to the extent of the capillary obliteration the brain, it is said, may present an anse- mic appearance. Such was frequently found to be the case by MM. Prevost and Cotard, when they injected fine lyco- podium powder into the carotid arteries of dogs. When a smaller number of ca- pillaries are obliterated, either by athero- matous matter, by small particles of fibrine, or by pigment granules,' local patches of softening may be produced, having the usual characters of Softening of the Brain due to arterial obstruction. 3. Obstruction of the Veins and Sinuses. — The general causes favorable to the production of thrombosis have already been mentioned. The cases of oblitera- tion of the cerebral veins and sinuses are in part due to some of these, though, just as frequently, they are the sequences of blows on the head, or of inflamma- tory conditions of the scalp and cranial bones. Indeed out of the seventy-four instances of thrombosis in the cerebral sinuses which have been recorded by Lancereaux,^ and other observers, such as Tonnele,' Eilliet and Barthez,'' Lebert,' Gerhard, ° and Von Dusch,' thirty-nine are found to belong to this latter cate- gory. Amongst these, in no less than thirty cases it was due to caries of the bones of the skull ; in so large a propor- tion as twentj'-four of these cases it was the temporal bone that was affected as a result of otitis. [Dr. Lidell has given the history' of 130 cases of cerebral thrombo- sis. Of these, 86 were inflammatory in origin, 38 marasmic or due to debilitative causes, and 6 traumatic. Among the in- flammatory cases, facial carbuncle was the most frequent cause. Otitis and erysip- elas preceded thrombosis in a few cases. — H.] Both the lateral sinuses are sel- dom implicated at the same time in these secondary thromboses, and the longitudi- nal sinuses are even more rarely affected from such a cause ; whereas in those cases in which the thrombosis proceeds from more general causes, such as alterations in the quality of the blood or slowness of cir- culation, its almost habitual seat is found ' Lancereaux, loc. cit. p. 106; Frerichs, Traits des Maladies du Foie, p. 264; and Charcot, Gaz. Hebdom. 1857, p. 659. ! Loc. cit. p. 116. 3 Journ. Hebd. de Med. 1829, p. 337. » Malad. des Enfants, t. i. p. 161, 1853. 5 Virch. Archiv, Bd. ix. p. 381. 6 Deutsche Klinik, 1857, No. 45. I New Syd. Soc. vol. xi. p. 81. [' American Journal of Med. Sciences, Jan. and July, 1874.] PATHOLOGY. 871 to be the superior longitudinal sinus, from wtiich the thrombus frequently prolongs itself down to the torcular Herophili and then on each side into the lateral sinus. It is in this latter class of cases, moreover, that cerebral softenings are associated with the thrombosis. These are of a pe- culiar kind, consisting principally of a number of small patches of red softening, oueupying chietly the gray matter on the upper surface of the brain ; and they are often distributed symmetrically over both hemispheres. Occasionally, softening of a portion of brain tissue of considerable extent has been noted. Besides such pe- culiarities in the seat and distribution of the softened patches, we usually meet, in these cases, with serous effusion into the ventricles and beneath the arachnoid, or more rarely with an actual effusion of blood in tliese situations or into the sub- stance of tlie brain itself, together with many minute patches of hemorrhage in the gray matter, such as have been de- scribed by Cruveilhier under the name of " apoplexie capillaire " The actual com- i bination of these conditions met with in j individual cases depends upon the seat of [ the obstruction, the rapiditywith which it is brought about, and the condition of the ; vessels themselves. In the secondary thromboses, on the other hand, there is often evidence of more or less circum- scribed inflammation of the meninges, although the cerebral softenings and ex- travasations of blood very rarely occur. This, according to Von Dusch, is owing to tlie fact that in these cases tlie tlirombo- sis starts from the veins in communication with the inflamed spot, and reaches the sinus only after the collateral circulation has had time to establish itself, instead of forming at once in the sinus, and before a collateral circulation has been set up. 4. Alterations in the walls of the Capilla- ries. — Fatty degeneration of the walls of the capillaries has been described by Hughes Bennett,' Paget,^ Todd,' Moos- herr,* and Charles Robin. ^ This altera- tion is most frequent in old age, and is said to be especially common in indi- viduals suffering from Bright's disease, or from other maladies producing a low cachectic state of the system. In some of these cases such changes may supervene at a much earlier period than is usual. It is thought that such changes may not only favor the occurrence of cerebral hemorrhage, but that they may also lead ' Edin. Med. and Surg. Journ. 1842. " Medical Gaz. 1849, and Surg. Pathol, (revised by Turner) 1863, p. 106. ' Clinical Lectures on Paralysis, &o. 1854. • Ueber das Patliolog. Verhalt. der Klein. Hirngef. Wurzburg, 1854. ' Compt. rend de la Soc. de Biolog. Paris, 1855, p. 142. to softening when the changes are univer- sal and well marl^ed in the capillaries of a certain area. Such degenerations of the walls of the capillaries nmst not however be confounded with the accumulation of fat granules and of granule corpuscles on the walls of capillaries' which are situated in the midst of softened brain substance. The tirst state may possibly be a cause of softening, but the second condition is always a consequence of it.'' The obser- vations of Moosherr and Eobin, more par- ticularly, have shown tliat a certain num- ber of fat particles may almost invariably be found within the slieaths of many of the small arteries and capillaries of the brain when this is quite healthy, and that, too, even in children. In many cases it is extremely difficult to discriminate be- tween small fat particles and calcareous granules' in the walls of the capillaries, without submitting them to the action of dilute hydrochloric acid. This calcareous degeneration of the capillaries is more rare tlian the ordinary fatty degeneration, though when it exists in an extreme de- gree, it is also capable of giving rise to Softening of the Brain, as may be seen by the perusal of a remarkable case reported M. Delacour,'' in which the small arteries and capillaries were completely calcified. In these cases, as well as in those of fatty degeneration, the softening is brought about by a gradual diminution in the nu- trition of a portion of the brain, the capil- laries of which have been altered in struc- ture so as no longer to permit the osmosis of a quantity of blood plasma sufficient to maintain the ordinary balance of nutrition in the surrounding tissue, and to prevent it from undergoing processes of degenera- tion. In addition to the various softenings of the brain, which may be produced by the influence of some of the conditions already mentioned, and otliers of trauma- tic origin, which are mostly "red," owing to effusion and dissemination of blood, there are also secmvlnry or consecutive forms of softening, which may be classi- fied under two heads, viz. : 1. Softenings set up around tumors and adventitious products generally, in the brain. 2. Atro- phic softening due to the separation of nerve fibres from their ganglionic com- munications. The first variety of second- ary softenings will be referred to elsewhere (Art. "Adventitious Products"). Tho'^e coming under the second head are by no 1 "Wedl, Patholog. Histol. (Syd. Soc.) p. 291, flg. 64. ! Billroth, Arohlv der Heilkunde, Drit. Jahrgang, p. 47. 3 Jenner, Med. Times and Gaz. January 31, 1862. 4 Gaz. des Hopitanx, 1850, p. 107; also Wilks, Journ. of Ment. Sc. vol. xi. p. 131. 872 SOFTENING OF THE ERAIN. means frequent ; the lesion resulting from tlie separation of a tract of nerve-fibres from their central ganglionic connections beino; usually a simple atrophy or slow wasting. Although the method of de- generation, in this condition and in soft- ening, has been proved to be identical, nevertheless actual cerebral softening does not usually occur, apparently because the atrophic change is brought about rather more slowly and without the occurrence of obstructions in the vessels of the part capable of producing cedema. Still, soft- enings from this cause have been met with. This kind of atrophic change was pointed out by Cruveilhier' in the cerebral peduncles, the pons, and the medulla ob- longata, and since his time our knowledge of the process has been greatly advanced by the investigations of Turck,^ Waller,' Van der Kolk,* Phillipeaux and Vulpiau,'' Gubler,^ and Bouchard.' Laborde* has, moreover, quite recently stated that in cases where there is softening of the cor- pus striatum or of the optic thalamus, a similar process is also set up on the sur- face of the hemispheres in some related portion of the superficial gray matter of the convolutions. These softenings of the convolutional gray matter are stated to be always on the same side of the brain as the lesions in the central ganglia, and La- borde says he has also ascertained that a relationship exists between the particular convolutions affected and the particular portions of the central ganglia which have been destroyed, so that where softening of the anterior portion of the corpus stria- tum or optic thalamus exists, the same process occurs on some portion of the an- terior convolutions ; with destructions of the central portions, the middle convolu- tions are affected ; and with destructions of the posterior portions of either of the central ganglia, a corresponding change is set up in some of the posterior convolu- tions. Should future observations confirm the opinions of Laborde, these changes would seem to be related to the secondary atrophic degenerations, and would be most interesting in a physiological as well as a pathological point of view : it is well to mention, however, that MM. Vulpian and Charcot maintain' that the coexist- ence of these peripheral and central ' Anat. Patliolo Arch. GSn. de Med. 1863, p. 281. says : "Independently of the fatty gran- ules contained in the altered tubes, a great number were free between the tissue elements, and, at certain points, aggre- gated together into masses, so as to con- stitute what are known as the 'corps granuleux' of Gluge." In the same case, the vessels presented on their surface heaps of molecular fat particles, or even a complete envelope of these, so as to render the vessels black and opaque under the microscope. Here, then, are produced, without the intervention of inflammation, all the appearances which have been sup- posed to be characteristic of inflammatory Softening of the Brain. Dr. Hughes Bennett says:' '■'■Exudative or inflamma- tory softening always contains granules and granule cells, which are numerous, according to the degree of softening. The granules are for the most part seen coating the vessels, and the cells also may occa- sionally be seen there in various stages of development. In the demonstrations that are made under the microscope, the3' are frequently seen diffused among the tubes, which, according to the severity and ex- tent of the lesion, are easily separated from, one another, or broken up in a variety of ways." MM. Prevost and Cotard have found from their experiments on dogs, that at the end of the first twenty-four hours after the obstruction of an arterj- there was red pulpy softening, with slight dimi- nution of consistence, and, on examina- tion with the microscope, there were seen broken-up fragments of nerve tubes, drops of myeline, blood corpuscles, and peculiarities of the capillaries, though no granules or granular corpuscles were at that time visible. As early as the third day, however, they have found granule corpuscles formed, and an abundance of granular matter lying amongst the tissue elements, as well as more especially ag- gregated along the walls of the vessels. These results are quite in accordance with our own observations, since we lately met with an instance of traumatic softening in which a few fully developed granule corpuscles, and very man}- in a less ma- ture state, were seen, which must have been produced in rather less than two and a half days.^ Bouchard believes that these granule corpuscles may result from the " granulo-graisseuse" degeneration of drops of myeline, and Prevost and Cotard ' Clinical Lectures. Fourth ed. 1865, p. 354. * The man on whom this observation was made fell down an area and fractured his skull. He was admitted into St. Mary's Hospital on September 7, 1866, at 4 P. M., immediately after the accident, and died on the 10th of the same month at 3.10 A. M. The exact interval was, therefore, 2 days, 11 hours, 10 min. MOKBID ANATOMY, 87T also think they may result from the ag- gregation of granules originally separate. We have, ourselves, never been able to substantiate either of these modes of ori- gin, and we agree with Virchow' in the opinion that they mostly originate from the fatty degeneration of the cells of the neuroglia, since granule corpuscles are commonly met with in the midst of the white matter of the hemispheres, having a more or less distinct cell wall, and which show a large nucleus in their in- terior after staining with carmine.^ The cells of the neuroglia are the only ele- ments existing in this situation capable of giving rise to such bodies.'' They are also to be seen in the gray matter lying between the ganglion cells, which, in old age, undergo more or less of the pigmen- tary degeneration, and always present quite a different appearance. Bobin formerly held that these granular corpus- cles were produced by the degeneration of pus cells ; but pus cells in their natural state are never met with in simple Soften- ing of the Brain, and it seems scarcely tair or reasonable to assume that they should be seen only in a state of degenera- tion. In cases of softening of the convo- lutional gray matter or of the central ganglia, a degeneration of the proper nerve cells takes place, which become filled with dark-colored granules. These are generally at once distinguishable from ordinary granule corpuscles by their ir- regular, angular shape, and by the pres- ence of the stumps of one or more cell prolongations. At the same time that these bodies are forming in the degenerat- ing tissue, granules collect along the walls of the capillaries, partly in an alto- gether irregular manner, and partly in the form of more or less spherical aggre- gations. Some of the capillaries become completely covered in this way ; but the collection of granules is on the walls of the capillaries, and is a consequence, not a cause of the softening. It must not be confounded with fatty degeneration of these vessels, in which the granules are imbedded in the walls of the capillaries. There are other alterations of the capil- laries met with, especially in red soften- ings, which have been particularly dwelt upon by Laborde.' At first, ])artial dila- tations of the walls of the capillaries are seen, like minute aneurismal swellings, or, in other places, little ampulliform di ' Wiener Medicin. Wochenschr. January 19, 1861. ' Case of Concussion Lesion, Med.-Cliir. Trans. 1867. ' Corpuscles almost precisely similar are ■net with in other organs, whose tissues are in a state of degeneration, which undoubtedly originate from the fatty and granular degen- eration of pre-existing cells. * Loc. cit. p. 114. latatious including the whole circumfer- ence of the vessel, and constituting what he describes as the moniliform condition of the capillaries. At a later stage, com- plete as well as partial dilatations of the capillaries are to be seen, together with actual ruptures here and there, and mi- nute extravasations of blood. Still later, the capillaries become enormously dilated^ : and their walls thin and granular from ' degeneration. The punctiform hemor- rhage, to which Cruveilhier gave the name of " apoplexie capillaire," is some- times due to minute extravasations from rupture of the capillaries, sometimes to the extreme dilatation of capillaries gorged with blood, and often to the pro- duction of what has been wrongly called "dissecting aneurism," occasioned by rupture of the proper wall of a minute artery and an efl'usion of blood into the lymphatic sheath which surrounds it. The blood remaining in the capillaries, and also that efl'used externally amongst the nerve elements, shows, for certain time, traces of the individual blood cor- puscles, more or less decolorized and yel- low, as well as flattened and pressed together ; whilst mixed up with them are reddish or reddish-yellow flakes of tissue, stained by the transuded hfematiiie. In those minute patches of extravasated blood, in which the coloring matter exists in some quantit}^, we afterwards find it in the form of amorphous, yellow or orange- colored granules or flakes, intermixed with the characteristic orange or ruby- colored crystals of hasmatoidine. These are very minute, and of an oblique rhom- boido-prismatic form. It is not known exactly in how short a time these crj'stals may appear in extravasations of blood in the human brain. Dr. Wilks' has, how- ever, met them as soon as three weeks after such an occurrence, and Cruveilhier found the "coloration jaune orange" de- veloped after twenty-five days in the seat of an hemorrhagic efliision into the brain. Once formed, the hsematoidine crystals remain as indelible evidences of past ex- travasation of blood. In the extreme stage of softening, the fluid matter occupying its site no longer presents the slightest trace of nerve struc- ture — the degeneration is complete, and nothing can be recognized by the micro- scope save granules and granule cells, mixed up with the various kinds of blood pigments, amorphous fragments of tissue, and the deljris of degenerated vessels. When we have to do with the last stage of red softening, and especially when this is situated in the corpus striatum or optic thalamus, the contents of the softened centre may present a brownish or even chocolate hue. ' Leot. on Path. Anat. 1859, p. 133. 878 SOFTENING OF THE BKAIN. Fatty degeneration of the tissues being complete, the process of repair begins at a variable period — probably in from one to two months after the commencement of the degeneration. These alterations have been fully described by Durand- Fardel,' and differ according as they are situated at the surface of the brain, or in its central parts. In the former situation the process results in the formation of the so-called "plaques jaunes," and in the latter it is accomplished by what Durand- Fardel calls "infiltration celluleuse. " These so-called ' ' plaques jaunes, ' ' which have been well represented by Cruveil- hier,^ exist in the form of yellow or ochre- colored, rounded patches. They may be confined to a single convolution, or may extend over several, at the same time dip- ping down into the sulci. The pia mater over them may sometimes be easily strip- ped off, whilst at other times it is closely adherent to the tissues beneath. The substance of the patch, though pliable, is tough and resists the knife ; it usually implicates the cortical gray matter onl}', and its circumference is pretty sharply defined from the surrounding healthy tis- sue. More rarely, however, it is separ- ated, as well circumferentially as beneath, from the healthy brain substance, by a layer of softened tissue. Histologically, these patches are composed of connective tissue containing an abundance of nuclei ; also of intermingled hsematine granules and crystals of hsematodine, together with fatty particles, a few granule C(3rpuscles, and some degenerated vessels. Rokitan- sky' denies that these yellow patches are the sequelae of softening of the convolu- tions, and looks upon them as changes resulting from superficial hemorrhage. But the result of a recent experiment Dy Prevost and Cotard goes strongly to sup- port the view of Durand-Fardel. They found a well-marked yellow patch on the middle lobe of one of the hemispheres of a dog, which is in every way similar to those met with in man ; and the corres- E ending middle cerebral artery of this dog ad been obliterated, thirty-five days be- fore the death of the animal, by the injec- tii in of tobacco seeds into the carotid artery. From what we ourselves have seen, how- ever, we are inclined to think that super- ficial extravasations of blood into the pia mater may also, as Eokitansky says, give rise to yellow patches, though of a dif- ferent kind from the "plaques jaunes" described by Durand-Fardel. In cases where a superficial hemorrhage has been the antecedent condition, the coloration is almost entirely due to an accumulation 'Malad. des Vifiillards, Paris, 1854, p. 72. ' Anat. Path., Livraison a3, pi. 2. ' Patholog. Anat. (Syd. Soc), pp. 394 and 416. of blood pigment in the meshes of the pia mater, with atrophy of the subjacent con- volution, rather than to a flbro-cellular conversion of the substance of the gray matter itself. When a focus of softening in the midst of the white substance of one of the hemi- sheres begins to undergo the process of repair, the walls of the softened cavity become bounded by a pulpy tissue of a white or grayish color, which, on micro- scopical examination, is found to be con- tinuous with the neuroglia of the contig- uous healthy portion of the hemispheres. Tissue of the same kind also extends across the cavity in different directions, breaking it up into divisions or compart- ments, in the meshes of which may be found a whitish liquid containing frag- ments of nerve substance which have not yet completely undergone the fatty meta- morphosis. This fluid holds in suspension, also, fat particles, and a number of cor- pora amalacea. The formation of the vascular and nucleated connective tissue constitutes the " infiltration celluleuse" of Durand-Fardel. Though met with prin- cipally in the white substance of the hemi- spheres, it is also seen more rarely in the central ganglia. When situated in the corpora striata, the walls, instead of being white, are often of a yellowish or ochre color, which makes the identity of this process with that which gives rise to the " plaques jaunes" of the convolutions all the more evident. The fluid contents of the cavity gradually become absorbed, and its walls close in and contract in the same way as do those of an apoplectic fit. In- deed, in these last stages there may be some difliculty in discriminating be- tween the two. In the remains of the apoplectic cyst, however, more coloring matter is usually found ; its walls are also generallj' more dense and contractile, and a more complete obliteration of the old cavity is said to follow. Lastly, there is a condition of the cen- tral ganglia of the brain, more particularly of the corpora striata, which has been described by Durand-Fardel ' under the name of "etat crible." On making a section of these central ganglia, small pisiform cavities or lacunte are occasion- ally seen, which sometimes seem bounded by a distinct membrane. Similar cavities may also be seen, though more rarely, in the pons Varolii. These are regarded by Laborde ^ and others as minute apoplectic cysts, resulting from slight eff'usions of blood, whilst others again look upon them only as dilatations of the lymphatic canals, > Who, however, attaches little importance to this condition, and looks upon the little cavities as the results of dilatations of the vessels, owing to long-continued congestion. 2 Loc. cit. p. 94. MORBID ANATOMY. 879 in which, as pointed out by His,' the cere- bral vessels are contained. Laborde, how- ever, thinks there is another and more important modification of this condition, in which no lining membrane is to be met with, but in which the little cavities are somewhat larger, so as to be even capable of containing a good-sized pea. These he looks upon as the result of " une desor- ganisation partielle et progressive," and as true, though minute and circumscribed, softenings of the parts in which they are found. ^ [In regard to localization of ce- rebral lesions, see the article on Cerebral Hemorrhage and Apoplexy, in this vol- ume.— H.] It only remains for us now to notice the softenings which have a post-mortem origin, and to point out how these may be distinguished from those having a real pathological significance which we have hitherto been considering. Ordinary post-mortem" softening of the brain is due to the combined influence of two causes; namely, putrefactive changes, and the maceration of the cerebral tissue from absorption of fluid. ^ This is com- monly met with on the surface of the thalami and in the parts bounding the posterior portions of the lateral ventricles, in all those cases where an interval has existed between the death and the au- topsy, and more particularly when the atmospheric temperature has been high and the ventricles have contained an ex- cess of fluid. In these cases the surface of the parts affected is broken up, and presents an irregular appearance, whilst the tissue itself is in a more or less difflu- ent condition. The fornix also frequently shares in this change. It has been a sub- ject of dispute as to what is the nature of the process which gives rise to the soften- ing of the central parts of the brain in acute hydrocephalus — whether, in fact, it has been produced by inflammation, or is merely the result of maceration ; and in the event of the latter method of patho- genesis being the real one, whether this maceration has occurred during life or after death. Doubts have been expressed ' Zeitsch. fiir Wissen. Zoolog. 1865. Bd. xii. ^ Laborde says: " Nous poss^dons plusienrs obsarvations de ces curieuses desorganisations partielles si6geant au centre de la protuberance annulaire et paraissant rfipondre au point de vue symptomatique, k certains oaa de paralysie diffuse, ggngralisfie, dans laquelle s'fiteignent progressivement un grand nombre de vieil- lards."_p. 95. ' Dr. Bennett calls attention, in his "Clin- ical Lectures," to the softenings which may be produced by mechanical means, owing to the clumsy use of instruments in removing the bialn and spinal cord from the body. This mode of origin should also be borne in mind. by many pathologibts as to whether such a process of maceration ever occurs during life.' When merely macerated ner\e tissue is examined by the microscope, broken up and dissociated nerve elements only are met with, and none of the grarmle corpuscles or other appearances charac- teristic of real softenings that have been produced during life. Examined by the specific gravity apparatus also, we have several times found the actual density of the altered tissue the same as that of con- tiguous unaltered portions. This is some- what remarkable and becomes very char- acteristic ; since if a portion of brain tissue having a similarly diminished con- sistence, brought about by a pathological softening rather than by a post-mortem maceration, had been examined, the specific gravity would have been found lower than that of similar healthy tissue in the same brain by from eight to ten degrees of the hydrometer scale. The specific gravity test thus becomes a most important auxiliary to the microscope ; and we have several times found it most useful in examinations of the spinal cord. Thus,, a short time since, on making sec- tions of a cord through the cervical, dor- sal, and lumbar regions respectively, the surfaces exposed were quite pulpy and irregular in the two former regions, whilst in the lumbar portion the surfaces were firm and smooth. Yet the specific gravity of portions of the cord from the dorsal re- gion was the same as that of other por- tions from the lumbar region, whilst in the cervical region the specific gravity was even slightly higher. Microscopical ex- amination, moreover, yielded no evidence of a pathological change in any portion of the'cord. We have found much the same state of things also in other cases. Di- minished consistence or diffluence, there- fore, must not be confounded with dimin- ished density or specific gravity ; and it ' The impediment to the return of blood through the vense magnse Galeni, owing to thrombosis in these vessels, to which the col- lection of fluid in the ventricles is in part due, also gives rise to a condition of cederaa in the walls of the ventricles themselves, and is followed by a true degenerative softening of the brain tissue. (Pathology of Tuberc. Mening., Edinb. Med. Journ., April, 1867.) Respecting this condition of cedema of the brain, however, which it may be presumed occurs occasionally in heart disease and other conditions impeding the return of blood from the head, we have no very definite knowledge. It seems doubtful whether any amount of serous infiltration would be capable of pro- ducing actual softening during life, or do more than make the brain appear flabby— a little moister and softer than usual— and, at the same time, slightly lower its specific grav- ity. The brain is usually said to be "wet" when in this condition. 880 SOFTENING OF THE BRAIN. Rhould be remembered that it is tlie com- LiuatioQ of the two, associated with cer- taiu microscopical cliauges, wliich are the characteristics of real pathological soften- ing of the brain. Diagnosis. — 1. Acute softening may, in its apoplectic form, 1)e confounded with congestion of the brain, with hemorrhage, or with urinsemia ; but by regard to the mode of onset of the symptoms, and to their proportion inter se, a diagnosis may be established in the majority of cases. At the onset of attack it may be impossi- ble to distinguish the nature of the malady, but after a few minutes, or perhaps only after two or three hours, it is possible to aim at something like certainty. From congestive apoplexy softening may be distinguished by the longer duration of mental obtuseness ; and by the distinct limitation of intellect in one or two direc- tions, when the general obscuration of the "fit, "or "stroke, "has passed away. At the onset of attack in congestive apoplexy there may be complete loss of conscious- ness, and the same thing may occur at the commencement of acute ramollissenient, and for precisely the same reason, viz. the presence of congestiou. In the former case, however, the mind rapidly recovers, and is restored to its previous condition ; in the latter all that was due to mere con- gestion is speedily removed, but there re- mains the impairment due to softened tissue. This may be aphasia, or some other special alteration in the mental powers, such as have been described in the section upon symptoms. Attacks of softening differ still more distinctly from those of congestive apoplexy, when they are unattended by any of the phenomena of hypersemia, and occur after middle life, and especially in advancing years. The patient becomes more or less suddenly confused, but does not lose his conscious- ness ; he may wander in his talk, utter some exclamation of alarm, or may simply look distressed and as if about to cry ; he knows what is said, and makes signs to those about him ; is obviously aware that something very wrong has happened, and continues in this state of mental impair- ment for hours, weeks, or months. The diflference from congestion is seen in the primary absence of general mental change — loss of consciousness — and in the per- sistence of limited intellectual failure. The two classes of change in function, now described with regarcl to mind, are to be observed also in respect of sensation and motility. There may be, at the mo- ment of attack, general anaesthesia and general paralysis ; but if so, they are due to congestion or to shock, and they, with either of those conditions, soon pass away; leaving behind them, however, impaired sensation in one or two limbs, and with this, localized paralysis. On the other hand, there may be no general change in the power of feeling or of motion— there may be neither congestion, nor sufficient shock — the patient feels some numbness, coldness, or deadness, together with weak- ness of one or two limbs, and these condi- tions pass on into hemiplegia, i. e., loss of power, and loss or diminution of sensibil- ity in the arm and leg of the side opposite to the lesion. Beyond these facts there is not unfrequently some hypersesthesia or morbid sensibility of the paralyzed limb, and this is much more common in cases of softening than in those of congestion ; and, again, there is twitching of the limbs, or rigidity of those that are paralyzed. The general aspect of the patient differs from that of tlie person struck with con- gestive apoplexy. There is, unless con- gestion be present as a transient condition, pallor instead of dusky redness, coldness of the head instead of heat, and a faint look in the place of bloated suffocation ; there is often some sweat upon the brow ; the patient is spare in habit, and the attack occurs when sitting quietly at the desk or when making no such exertion as could tax the physical powers. Beyond these general conditions there may be ob- served rigidity of arteries, an irregular, weak, and often intermitting pulse, a fee- ble heart, arcus senilis, and irregular dis- tribution of bodily warmth. Prom hemorrhagic apoplexy acute soften- ing may be sometimes distinguished by the following considerations : — in hemorrhage there is often some evidence of either con- gestion or of shock ; in softening there may be an entire absence of both. In hemorrhage the attack frequently occurs at night ; the patient goes to bed appar- ently well, and wakes in the morning feel- ing as usual, but on attempting to move finds that one side is paralyzed. In hemorrhagic apoplexy the attack is often absolutely instantaneous, in softening it is gradual. In the former there may be not the least — even momentary— confu- sion of mind, whereas in the latter there is distinct mental jjerturbation and insuffi- ciency. In hemorrhage, when the intel- lect is profoundly affected, as it sometimes is at the onset of attack, there is often a rapid restoration, and in the course of a quarter of an hour the patient's mind is as clear as it was before ; in softening jjer se there is less distinct mental obscuration at the commencement, and little or no subsequent recovery. In hemorrhage there is sometimes alarm, and not unfre- quently anxiety and depression, whereas in softening there is more commonly too nmch confusion of thought for any definite apprehension to be entertained, and some- times there is transient excitement or mild delirium. Sensibihty is often unaffected inhemor- DIAGNOSIS. 881 rhage, it rarely escapes altogether in an attack of softening. In tin' former there is, as a rule, unilateral anaesthesia, which rapidly diminishes or disappears ; in the latter there is dulness of sensation, -with morbid feelings of coldness, nmubness, tingling, &c. , which persist. The paralysis in hemorrhage is, typi- cally, hemiplegic ; in softening it is more irregular, and sometimes more closely limited. In the former there is neither rigidity nor convulsion unless the coma be profound, and the paraljsis extensive ; in the latter there is often cither twitch- ing or tonic spasm even when the paraly- sis^ is slight, and the mental perturbation comparatively trivial. In hemorrhage there is very frequently hypertrophy of heart, with granular de- generation of the kidneys ; in softening tliere is very commonly a weakened heart, with valvular disease. ' Hemorrhage may occur in a person of strong limb and gen- eral good health, whereas softening is more common in the aged, the enfeebled, and those who have suflered from exhaust- ing diseases, or still more exhausting cares. From urinmnia as a cause, ^:»er se, of an apoplectic seizure, softening may be dis- tinguished by the fact that in the former, convulsions of some kind and to some de- gree almost invariably precede the coma ; and that these have followed premonitory symptoms of drowsiness, oppression, and headache. The coma exhibits in a marked manner the features sometimes observed in acute softening of the brain, viz., an apparent profundity, with susceptibility of being roused, tlrinasmic patients lie in apparently profound torpor, but they may be roused by a touch or a word, and may appear in possession of all their facul- ties ; left to themselves they relapse al- most instantly into the state of stupor. In softening, if the coma be highly marked tlie awakening is less distinct, and the answers are less rational. In urintemia there is often amaurosis, and a generally obtuse condition of sensibility, neither of which is frequent in ramollissement. There is much twitching of the limbs, and often marked rigidity in the former case, but the locality of these symptoms changes from side to side, and is not accompanied by fixed paralysis ; there may be twitch- ing or rigidity in the case of softening, but these are found in tlie same limbs day after day, and are attended by distinct and persistent loss of power. The stertor in urin^mia is unhke that of softening, be- ' Dr. Kirkes found the heart hypertrophous in thirteen of twenty-two cases of cerebral hemorrhage, and in all of these the kidneys Were diseased, being for the most part granu- lar and atrophous. (Medical Times and Ga- zette, Nov. 24, 1855.) VOL. I. — 56 ing oral rather than guttural ;' the pulse- respiration ratio is much changed, being sometimes 5:1 f sensori-motility and irri"^ tability of muscles on percussion are often notably increased. Beyond these features there are the signs of chanicteristic debil- ity and cachexia, the pale waxy skin, with vomiting and diarrhcea ; and above all the oidematous condition of the eyelids and ankles, together with albuminous urine. In cases of acute cerebral soften- ing, all these symptoms may be absent. The two diseases are frequently combined, but when they are so it is not impossible to determine how much is due to the one, and how much to the other condition. When Softening of the Brain occurs in a convulsive form, its diagnosis is to be established by regard to the symptoms already described, p. 863. It is by a con- sideration of the prodromata and of the after-phenomena that the distinction may be made from epilepsy ; it is by a similar process that tumor of the brain or of me- ninges may be diagnosticated.' That which is characteristic of softening is not the fact of the convulsion, nor the form which the convulsion takes, but the grad- ual development of intellectual, sensorial, and motor failure, such as has been de- scribed in the section upon symptoms ; and the absence of those general and spe- cial changes which are characteristic of tubercular, carcinomatous, or other mor- bid growths. The form of softening which is marked by ddirium is not likely to be confounded with any other malady. It is essentially an affection of old age, and may be dis- tinguished from simple senile congestion by the persistence of its symptoms, and by the speedy development of those signs oif failure in nerve-po-sver, to which so much attention has already been di- rected. 2. Chrome softening, when its course has been chronic throughout, has to be distinguished from tumor and from me- ningitis ; and although the distinction is not possible in all cases, approximation to certainty may be attained in the ma- jority by regard to the following consider- ations. In tumor there is pain, intense in de- gree, subiect to violent exacerbations, limited to and fixed in one locality ; the special senses are affected, so that there is blindness or deafness, or the two com- bined, on one side generally, but some- times on both ; there are local paralyses and epileptoid convulsions ; but, _ apart from the convulsions, unimpaired intelh- 1 Addison, Guy's Hospital Reports, 1S39, vi. 2 Marc^, Schmidt's Jahrb., Nov. 1P55. 3 See articles Epilepsy and Adventitious Products in the Brain. 882 SOFTENI>;a OF THE ERATN. gence. There is often marked disturb- ance of the stomach, obstinate vomiting, and constipation ; and there may be the signs of the tubercular, carcinomatous, aneurismal, or sj^phihtic dyscrasise. In chronic meningitis, there is pain, generally distributed over the whole head, not very severe in degree, and, although varying in intensity, not subject to the parox- ysmal exacerbations observed in tumors ; there may be local paralyses, and these are especially observed in the muscles of the eyeball ; there is much but intermit- tent mental excitement and irritability of temper alternating with marked depres- sion ; there are disorderly spasms and paralyses of the limbs together with fre- quent but irregular accessions of fever ; there is often a syphilitic taint, but there may be an entire absence of that dyscrasia, and the symptoms may liave dated from a blow or fall. In chronic softening there is dull head- ache, and gradual impairment of intelli- gence, motility, and sensibility, together with advancing years or a prematurely aged appearance, a feeble heart, rigid vessels, and most commonly some disease of old standing in such important viscera as the kidnej's, heart, or liver. Thus, to resume, the characteristic fea- ture of tumor is pain, that of softening is failure of power, that of chronic menin- gitis is the mixture of excited with de- pressed functional activity. It is the pro- gressive deterioration of cerebral faculty which marks out the disease we are con- sidering ; the patient begins to die, as it were, before his time, and his death begins in the highest element of his organism. Pbogttosis. — Occasionally there is com- plete recovery after an attack of acute softening ; for example, apoplectic seiz- ures have occurred, which have been fol- lowed by hemiplegia and mental dulness of many months' duration ; these symp- toms have passed away entirely, and upon post-mortem examination, after a number of years have elapsed, the signs of old softening have been distinctly discernible. It is possible, of course, that the softening may have originated in or around a ''clot," but that possibility does not affect the general question of prognosis. Again, there may be improvement, but not com- plete recovery; a patient may suffer a sud- den apoplectic seizure, and may lie for days in a state of profound danger, the mind almost a blank, and the limbs hemi- plegic ; but after a time he may improve, and his improvement may continue for months, slowly going on from week to week; he becomes able to understand wliat Is said, to speak or to make intelli- gible gestures, he may walk, or may even regain the use of his hands, and may re- main more or less aphasic for an indefinite period. He may have a second attack, and one so characterized as to ^how that the other side of the brain has been af- fected, and he may be partially restored from this. At length a third or a fourth seizure comes, from which there is no re- covery. Upon post-mortem examination in such cases distinct softenings may be found in such situations as to relate them to the first or second attack, and the cati^e of such softenings may be discovered in the obstructed arteries. The prognosis of softening, therefore, although unfavora- ble, is not necessarily fatal. The prognosis is relatively favorable when the patient is young, and has been previously healthy; as, for example, when an apoplectic attack occurs during the course of rheumatic endocarditis in a young subject. It is unfavorable when the patient is old, or is affected by chronic disease of the kidneys, liver, or heart, when the arteries are rigid and the circu- lation low. It is favorable when the soft- ening is, as it were, the result of acci- dental interference with the supply of blood ; it is unfavorable when that inter- ruption of the arterial circulation is but part of a general organic change. The severity of an attack is to be judged of by regard to its mode of onset. If ac- companied by either much congestion or by profound collapse, the symptoms, al- though ver3' highly marked and widely distributed, may pass away; whereas the same amount of symptoms occurring with- out evidence of congestion or collapse would indicate, in direct proportion to their severity and extent, the gravity of the lesion. Cactcris jjarlbits, the lesion is in proportion to the extent of the symp- toms ; and tlie prognosis is worse when the mind, sensation, and motion are all slightly impaired, than it is when either one of them alone is profoundly affected. If the patient be young, and if there be no signs of general impairment of nutri- tion, hopes may be entertained that there will be some recovery of mental and motor power : but if the patient be old, or if there be weak circulation, and rigid vessels ; and if the attack has had many forewarning symptoms, such as occasional forgetfulness, numbness of the extremities, and the like, the probability of restoration is very small, while the likelihood of in- creasing mischief or of renewed seizure is very great. The prognosis of approaching death after an apoplectic or convvxlsive seizure is based upon the increasing rapidity and feebleness of pulse, the involuntary pas- sage of the urine and feces, and the gene- ral flaccidity of the limbs. Treatment. — Attacks of softening may be postponed by attention to the ADVENTITIOUS PRODUCTS IN THE BRAIN: SYMPTOMS. 883 following points : 1. The maintenance of an even temperature in the body : the feet and hands when chilly and blue should be put in hot water, or wrapped in aad rubbed with warm tlannels, and the patient should be placed in the recumbent posture, with the head only slightly raised. 2. The avoidance of long inter- vals between meals ; food, easy of diges- tion should be given frequently, and "the patient, if old, should not be allowed to pass the night without nourishment. 3. The ready administration of some gentle stimulant when there is any tendency to occasional pallor or faintness. A glass of wine, or some sal-volatile and water, should always be at hand, and should be given, not recklessly, but fearlessly if the premonitory symptoms become threat- ening. 4. Direction of the mental habits ; easy and pleasant occupation of the mind, with careful abstinence from lazy inaction on the one hand, or violent excitement on the other. 5. Careful attention to the excretions, the skin, the kidneys, and the bowels. Exposure to cold is very preju- dicial, and, although constipation and straining at stool are to be strenuously avoided, nothing is much more mischiev- ous than the relaxation of close and too warm rooms, and the production, by medicines, of anything approximating purgation of the bowels. When the premonitory symptoms are those of much headache and drowsiness, obvious relief may be gained by warmth to the extremities and by the use of such diuretics as the liquor ammoniEc acetatLs, with infusum scoparii, nitrate of potass, and spirits of nitric ether, or of juniper. When there is the tendency to noctur- nal delirium, a judicious administration of hquid nourishment, with very small quantities of wine, may suffice to give relief. Should this fail, the most useful medicine that I know of is the Indian hemp, in doses of a quarter to half a grain of the extract _; and next in value is the chloral hydrate in doses of five or ten grains. If there are marked symptoms of spas- modic or convulsive character, bromide of potassium in doses of from five to fifteen grains may be given three times daily with a bitter infusion and some diffusible stinmlant, such as chloric or nitric ether. On the occurrence of an attack, either apoplectic or convulsi-\'e, there is but little that can be done beyond the regula- tion of temperature and of secretion that has been already described ; but when the attack has passed away something may be gained by the administration of cod- liver oil, hypophospliite of soda, and vegetable tonics. In many cases of chronic softening marked improvement follows the exhibition of cod-liver oil, and I am disposed to regard this as the most valuable agent in the treatment of the malady. It should be administered in conjunction with a fully nutritious but easily digestible diet, and with free expo- sure, without fatigue, to fresh air. It appears to me highly doubtful whether under any circumstances of softening of the brain the smallest good has followed either general or local blood-letting, the application of blisters, the administration of mercury or of iodide of potassium. When recovery has advanced to a con- siderable degree, and some limbs remain paralyzed, good has distinctly followed the exhibition of iron, and of strychnia in exceedingly small doses, and the cautious application of galvanism to the weakened muscles. ADVENTITIOUS PEODUCTS IN THE BEAIN. By J. Russell Reynolds, M.D., F.R.S., and H. Charlton Bastian, M.D.,' F.R.S. In this chapter is included a descrip- tion of many diseases differing widely from one another in their pathological character, but agreeing in this, that they lead to the development within the cra- nium of some abnormal physical condi- ' The section on Morbid Anatomy is written l)y Dr. Bastian. tions, the nervous symptoms of which may bear close resemblance, inter se, during life. Symptoms. — It has sometimes hap- pened that, on post-mortem examination, tumors have been found in the brain, the existence of which had never been sus- pected during life. The patient may have 884 ADVEXTITIOUS PRODUCTS IN TPIE BRAIN. presented no sign of cerebral disease, and may have died from an affection of tlie lungs or other organs ; and, with the help conferred by post-mortem discovery upon the direction of questions as to past his- tory, no evidence can be obtained of any symptom which can be referred to the brain. Such a case occurred to myself some years ago ; several large hydatid growths being found in the brain of a young girl who had never suffered in any such way as to lead to the suspicion of cerebral mischief These facts should be borne in mind when dealing with certain cases where signs of cerebral disease are present, but the diagnosis is obscure. When it is said that "a tumor cannot exist because of the absence of this or that symptom," it should be replied, that a tumor may exist without any symptoms at all. There may be very highly marked symptoms, and yet these may be of such a character as to mislead. Dr. Abercrom- bie' has related exauiples of disease within the cranium, the locality and nature of which had been unsuspected during life, the patient's history having been such as to lead to a diagnosis of some affection of the stomach. Cases of the kind described by Dr. Abercrombie are rare, and it is probable that they will be rendered more so, as clinical examination becomes more minute. The fact, however, remains, that ; the complaint of a patient may be so marked with regard to dyspepsia, vomit- ing, constipation, and the like, and so trivial in respect of headache, giddiness, or other morbid sensations, that, although he has a tumor in his brain, no suspicion may be entertained of its existence, and the diagnosis that is arrived at may be malignant disease of the pylorus, or the liver. In other cases the symptoms of intra- cranial tumors are highly characteristic, and the diagnosis of their existence, their exact situation, and anatomical nature nlay be sometimes made with a precision and minuteness such as is scarcely attain- able with regard to any otlier diseases. The intellectual faculties may be quite unaffected ; indeed, they very often are retained in their integrity when other functions of the brain are seriously im- paired. The changes they present are of two kinds : there may be on the one hand great irritability of temper, a condition totally different from the previous habit of the individual, and with this, but very rarely, some mild delirium, or confusion of thought ; on the other hand, there may be loss of memory, and general impair- ment of intelligence, with depression of spirits and listlessness. When convul- sions occur, as they frequently do, during ■ Practical Researches, p. 337. the few days that precede death, there may be profound coma as their sequel ; but the convulsions which exist in the earlier period of the growth of tumors are often accompanied by only partial loss of consciousness, and are followed by none of the stupor which is so commonly ob- served in epilepsy. Sensation is altered in various manners, but by far the most characteristic change is that of pain. Headache is often slight at the commencement, but afterwards it arrives at gxeat severity ; it is usually confined to a definite point or region of the head, and persists in that locality ; it undergoes occasional exacerbation, and sometimes the suffering seems almost intolerable, and elicits from the patient agonizing cries ; it is, however, rarely absent altogether during the intervals of paroxysm ; it is increased by intellectual and physical exertion, by emotional dis- turbance, by sensational impressions, and by forced respiratory movements. It is sometimes almost the only symptom, but in rare cases it is absent altogether. The aggravation of pain which is occasioned by light, or noise, or movement, is such as to make a patient hold his head stead- ily between his hands, or bury it in the bed-clothes ; and this intolerance has sometimes been regarded as hypersesthe- sia, from which it differs widely. The sight and the hearing maj' be dull, but yet sensorial impressions intensify the headache. The sense of sight is often lost in one eye or in both ; or there may be simply some mistiness or imperfection of vision, with dark or bright spots before the eyes. The iris does not often lose its irritability, but it is often found dimin- ished ; whereas, in some cases of complete blindness, it contracts readily on the ad- mission of even a feeble light. Various changes may be observed in the ophthal- moscopic appearances, but that which is, perhaps, the most characteristic of tumor — although by no means constantly pre- sent — is enlargement of the veins, an en- largement sometimes to be observed in one eye only, sometimes in both. [The importance of this appearance, of choked disk, has been differently estimated of late years by leading authors ; but statistics show' that in about ninety-five per cent, of cases of intra-cranial tumor, either this appearance or that of descending optic neuritis is found when sought for with the ophthalmoscope. Turck first called at- tention to retinal signs of brain disease, in 1853. Von Graefe, in 1860, pointed out the existence, in different cases, of two conditions ; the one, of great engorgement \} Anmiske, Reich, Longstreth, &o. See a paper by Dr. W. F. Norrls, and a discussion in Pathological Society of Philadelphia, in Philada. Med. Times, Aug. 30, 1879.] SYMPTOMS. hSo of the intra-ocular end of the optic nerve (stasis papillse or choked disk), and the other, of interstitial iutlanunation of the optic nerve, descending from meningeal inflammation (descending optic neuritis). Both of these conditions are followed by atropliy ; and the difficulty of discrimina- tion between them, and of separating them from simple atrophy of the optic nerve, be- comes greatest in their later stages. Since 1860, Bouchut, Allbutt, Hughliugs Jack- son, and others have given much attention to this aid in diagnosis. Annuske found that, in 920 cases examined, nearly all brain-tumors were attended either by optic neuritis or choked disk. The location of Fig. 51. Choked Dislc. {After Liebreicli.) the tumor does not seem to be at all constant in its relation to these results. Xeithcr do large tumors more constantly produce them than small ones. Some marked cases of brain-tumor, moreover, have been proved to be entirely without ophthal- moscopic indication of their presence. Hence Becker (1868) and Schweigger (1871)' have denied the practical import- ance of the coincidence when it occurs. We must conclude, however, that at least an important negative value belongs to it ; viz., that, when tumor of the brain is sus- pected, but not proven, the total absence of ophthalmoscopic changes makes such a diagnosis much less probable than if they are ascertained to exist. The ophthal- moscope should be used, therefore, in every douljtful case, even if there be no observed defect in the patient's vision; since it has been found^ that sight may be apparently good, and yet examination will show decided alterations to have com- menced in the optic disk.— H.] Hearing [' Norris, loc. citat.] [2 Shakespeare, Phila. Med. Times, loc. citat. j ! is less commonly impaired, but it may be lost completely on one side without 1 havmg attracted tlie attention of the pa- [ tient ; noises in the ears are common, I either with or without any diminution of ' the faculty. Numbness, tingling, creei)- ing feelings, sensations of heat or coiu, may exist in the limbs, or in certain tracts of skin over the trunk, and sometimes there may be distinct anisstliesia of parts. Vertigo is frequent, and often most dis- tressing ; usually it is reheved by closing the eyes and maintaining perfect rest ; but sometimes it is aggravated by dark- ness, and the patient has to maintain a fixed gaze in order to ward off the feeling. Commonly tlie vertigo is of such a Ivind that the patient feels as if rolling over, or swimming along in space ; and it is com- paratively rare to hear complaint of the apparent rotation or motion of surround- ing objects. Aflections of the siglit have been found most frequently when the tumor has occupied the anterior lobes of the brain, and least frequently when in the posterior lobes or cerebellum. In the cases which have been placed on record, conndsions have occurred more frequently than jjoi-fil/ysw, and among those which have presented the latter, one-half have exhibited the former. Con- vulsions, of epileptic form, often occur during the few days that precede death ; but in certain kinds of tumor or of ad- ventitious product in the brain, epileptoid convulsions may exist for years, and the cases presenting them may be termed "epileptic." When no general parox- ysms occur, there are, ver}^ frequently, clonic spasms or tonic contractions of tlie muscles. As the result of an examina- tion of a large num'ber of cases, it may be stated that convulsions are most common when the disease is situated in the pos- terior lobes of the brain, or in the cere- bellum, and least frequent when the an- terior lobes are affected ; the distribution being exactly the reverse of that which pertains in regard of amaurosis.' Paralysis is sometimes observed in one muscle of one eyeball, such, for example, as the external rectus, leading to con- vergent strabismus ; or in all the muscles supplied by the third nerve on one side, so that ptosis and divergent strabismus, with dilated pupil, are the results. The speech may be also affected, the patient being unable to articulate certain sounds ; the facial muscles may be so paralyzed as to produce every degree of deformity, or the paralysis may be more widely dis- tributed, and be hemiplegic, or, but more rarely, paraplegic in its form. Sometimes the lesion may be of such kind, and in such degree and locality, as to affect the ' Vide Auct., Diagnosis of Diseases of the Brain, &c., p. 186. ADVENTITIOUS PRODUCTS IN THE BRAIN. nutrition of muscular and otlier textures. For example, in a case under my own care, where a tubercular mass involved the seventh nerve, and also the deep ori- gin of the fifth, not only was there loss of sensibility on one side of the face, but the temporal muscle was much wasted, the conjunctiva and cornea became sloughy, and the mucous membrane of the mouth was aphthous and studded with vegetable parasites. The paralysis of cerebral tumor is developed— as a rule — slowly and in- sidiously ; and when it occurs in one of the limbs, is sometimes preceded by pain or some other alteration of sensibility ; but in a few cases it is produced as an "apoplectic" phenomenon, and may be the first symptom to attract the notice of either patient or physician. The general symptoms of tumor of the brain vary almost indefinitely, for they may be simply those of reflex or direct disturbance of the stomach and other vis- cera, when hydatid or fibrous growths are their producing cause ; or thej' may he the special features of carcinoma, tubercle, or syphilis, when any one of those dyscrasise is the primary fact in the formation of the adventitious product. Thus they may, on the one hand, be all-important, and may partially conceal the cerebral disease; on the other they may be so trivial as to awaken no attention ; while in an inter- mediate group they may have such cha- racter and relation as to render it possible to make an accurate diagnosis of the na- ture of the lesion. Thus there may be tumors on the scalp, or, in other regions, glandular swellings of strumous charac- ter ; or there may be distinct evidence of syphilitic deposit, of carcinoma, or of aneurismal dilatation of the vessels. Tu- berculosis gives rise to the most common form of tumor in the child or 30ung adult, and syphilis is the next in frequency in early life or middle age ; while carcinoma is prevalent in direct proportion to ad- vancing years. Sometimes there is obvi- ous alteration in the general contour of the head, but such change is almost con- fined to the period of growth ; whereas in later years there may be gradual promi- nence of one eyeball, or the distinct pres- sure of a growth through the bones. Un- der such circumstances the diagnosis is tolerably easy. As a rule the commencement of symp- toms is insidious, and their progress slow ; but sometimes after a few premonitory phenomena there is a sudden attack of convulsions, or an apoplectic seizure. Under such circumstances a diagnosis is possible only by consideration of the sub- sequent history. Diagnosis. — In some cases it is impos- sible to gain even a hint of the nature of the malady, while in others the diagnosis is as certain as that of any disease with whicli we are acquainted. It will be con- venient to speak first of the diagnosis of tumor generally, secondly of the diagnosis of the locality of growtlis, and thirdly of the recognition of particular forms of morbid product. 1. If convulsions be the prominent fea- ture of the case the diagnosis is to be made from eji'ihpf>y, and here the distinc- tion depends vipon the recognition of symp- toms over and above those of the latter disease. The convulsions are commonly epileptiform in type, but very often they present these diflerences — they are irregu- lar in development, there is not absolute loss of consciousness, there is little or no asphyxia, and no subsequent stupor, while the spasmodic movements are more mark- ed on one side than on the other, they last for a longer time than is observed in epi- lepsy, and frequently terminate without being followed by anything like epileptic coma. In many cases the age at which the}- commence is so far advanced as to make epilepsy improbable, and there are symptoms.— such as pain, affections of the senses, and paralysis — which do not occur in simple epilepsy. Again, the mental state in a person the subject of tumor may remain quite intact, and may fail to present the peculiar sluggishness which is often, although by no means in- variably, the concomitant of repeated epi- leptic seizures. Epilepsy is essentially a chronic disease, the commencement of which dates in a large proportion of in- stances from or soon after the period of puberty ; it is characterized by fits of a peculiar type ; and when uncomplicated it exists for years, and in the. majority of cases without entailing any ulterior change in the functions of either brain or spinal cord. Tumor in the brain is of compara- tively rapid development ; it begins, as a rule, — to which there is the one exception of tubercular growth, — after adult age has been reached, and most commonly when the period of middle life is passed ; and when convulsions are present they are by no means the prominent symptoms of the malady, for, although often severe, they may be cast into the shade by the violence of pain and the loss of special senses. It is possible that the early and even some of the advanced symptoms of tumor in the brain should be confounded with, or passed over as, hysteria. Such mistake can only arise through carelessness, or through a prejudiced mode of dealing with the obscure affections of women. Not long since a lady consulted me, who was supposed to be hysterical, and who had been treated upon that supposition. Yet her symptoms had not commenced until after thirty years of age ; she had violent paroxysmal headache^ was blind of one DIAGNOSIS. 887 e3'e, and deaf of one ear, and the amaur- osis and the deafness had crept on slowly. The distinction from hysteria may he made hy regard to age, afli^ctious of the special senses, the absence of the peculiar mental condition of the hysteric patient, and the nature of the paroxysms. Chronic meningitis may he of such cliar- acter that its physical conditions become identical witli those of morbid growths, and its symptoms pass then into those of tumor. This is the case, for example, when there is syphilitic thickening of the membranes, which may at ain' time be- come so complicated by nodular thicken- ing of either of the membranes or the bones, as to give rise to the special con- ditions and symptoms of a tumor. Again, a tumor, of fibrous or carcinomatous char- acter, the growth of which is habitually slow, may sometimes set up, in its neigh- borhood, chronic meningitis, so that the symptoms of the two morbid processes may be found in association. Under either set of circumstances the diagnosis is possible by a regard to the mode of de- velopment of, and relative proportion between, the symptoms. As already stated (see p. 881), the distinction between tumor and chronic meningitis lies here — that in the former the characteristic feat- ures are violent pain, marked diminution, .or loss, of one or more of the special senses, limited paralysis, integrity of mind, and occasional epileptoid convulsions; whereas in the latter the pain is slight, the special senses are perverted but not lost, the mind is damaged, and the convulsions are less distinctly epileptoid. In the former there is the predominance of pain, in the latter there is no such predominance, but a mixed condition of excited and dimin- ished action in mind, sensation and mo- tility. In the case of chronic syphilitic meningitis the diagnosis may be assisted by the history of syphilis, or by the pre- sence of its symptoms in a tertiary form. It must be remembered, however, that the diagnosis may often be carried to this point, — the obvious presence of chronic meningitis, and the probability of tumor ; but this latter cannot be affirmed to exist because of the absence of its special symp- toms (see page 884). On the other hand, in certain cases, there may be no doubt of the existence of a growth, when paroxys- mal pain, &c. , occur in a patient exhibiting the features of the carcinomatous cachexia. Trom chronic softening of the brain., the diagnosis is to be made by recognizing the absence of the characteristic features of that malady, viz. loss of mental power, of sensation, of motility. Certain cases of tumor may be taken for examples of chronic softening, and they are such as have been marked by a small amount of pain, by repeated convulsions, and gradual failure of intelligence. It would be im- possible under such circumstances to make an accurate diagnosis. ± The diagnosis of the particular locality of a tumor may sometimes be very minute and accurate, but in other cases vague, and not unfrequently erroneous. The side of the brain aflected is usually, but not invariably, the same as that upon which the pain is felt, and on which the special senses and the muscles of the eyeball are aflected ; it is the opposite to that upon which spasm or paralysis occurs in the limbs. Again, the locality of pain may be taken for a guide as to the situation of a tumor in the anterior, middle, or poste- rior lobes. Such guide, however, is not always trustworthy, for frontal pain may be the result of a cerebellar tumor. Upon analyzing a large number of cases, I find that convulsions are most frequent in tumors of the cerebellum, and that they diminish in frequency as the seat of lesion advances forwards, ('. e. through the poste- rior and middle to the anterior lobes of the cerebrum ; and that amaurosis, im- paired articulation, and intelligence ob- serve a contrary relation to those lobes, being most common when the tumor is in the anterior cerebral lobes, and relatively less frequent as the seat of tumor retro- grades. Eomberg has suggested that the position of a tumor on the upper surface or at the base of the brain might be deter- mined by an observation of the etfect pro- duced on pain by forced inspiration or expiration : the pain of tumors, when seated at the base, being aggravated by inspiration, that of those on the upper sur- face by expiration, sneezing, or coughing. This Eomberg explains by the rising and falling of the brain during the respiratory movements, and the consequent pressure of the mass against the upper or lower bony walls.' I have met with several cases which confirm Romberg's statement, but several others in which no reliance could be placed upon the test. The par- ticular portion of the brain involved in a tumor may be sometimes determined by a careful consideration of the distribution of all the symptoms; such diagnosis, how- ever, requires merely the application of anatomical and physiological knowledge, and needs no further notice here. .S. A diagnosis of the nature of a tumor is always of great importance both in re- gard of "prognosis and of treatment. Some- times all that can be accomplished is a guess, but sometimes tolerable certainty may be attained. Under certain circum- stances we may distinguish between tu- bercle, syphilis, lead-poisoning, aneurism, hydatids, carcinoma, and hypertrophy. Tubercle is the most common form of tumor in the child or young adult, and Syd. I Manual of the Nervous Diseases. Soc. Trans, vol. 1. p. 159. 8SS ADVENTITIOUS PBODUCTS IN THE BRAIN. we might infer its presence if, in addition to a tubercular family history, there were the obvious features of the tubercular con- stitution, marked wasting of the body, to- gether with an elevated temperature, and the presence of tubercular disease in the lungs or bronchial glands. It is some- what curious to oljserve that the tempera- ture of cases of cerebi'al tuberculosis is not raised to the degree, nor with the persist- ency, that is to be noticed in regard of tuberculosis elsewhere, hut of all cerebral growths that which exhibits the greatest amount of elevation of temperature is tubercle. After pulierty an examination of the chest is of great hnportance in the diagnosis, since it rarely happens that a healthy state of the lungs is found co- existent with tubercular disease of the cranium. iSi/philis may occur in such locality as to produce any of the varied symptoms which have been enumerated ; but there are certain features which help to distin- guish it from other forms of adventitious products in the nervous centres. Head- ache is rarely intense, but is prone to undergo nightly increase ; actual loss of sight or hearing is not common ; but im- plication of the third or sixth nerve is very frequenti)' observed, so that patients exhibit ptosis, dilated pupil, and divergent strabismus, or more commonly inversion of the ej-eball; there is often much depres- sion of spirits, and further a wide extent of symptoms, the spinal cord as well as the encephalon being involved in the mis- chief. The characteristic features of this disease are, however, to be sought else- where, in the presence of periosteal thick- ening, eruptions on the skin, and such other phenomena as have been described in the article on Constitutional Syphilis.' The intnxiciitinn of lead ma)' be followed by such induration of brain substance as shall produce the symptoms of tumor; but the diagnosis turns upon a consideration of the previous history of the case, and the discover}' of exposure to lead by trade, accident, or medicine; the previous occur- rence of symptoms of lead colic ; the pre- sence of general cachsemia, of a blue line on the gums, and of lead in the secretions. The extensors of the hands and fingers are the most frequently paralyzed ; the extensors of the toes, the tibialis anticus, and peronfei are not rarely affected ; the paralyzed muscles become much impaired in their nutrition, and exhibit marked diminution, even extinction, of both con- tractility and sensibility on the apphcation of powerful faradization ; but yet they may respond readily to a slowly inter- rupted batterj'-current of moderate power. It has been further observed that this loss of contractility to faradization sometimes • Part i. p. 423. persists after there has been restoration of voluntary power. I)idunai(iii of the brain may occur in scorbutus, in rickets, or in epilepsy, but the diagnosis of its presence in either con- dition would be attended with much diffi- culty during hfe. Dr. Cohn observes that in one case there was, in the instance of rickets, an entire want of intellectual dis- turbance ;' whereas in epilepsy — as de- scribed by Bouchet and Cazauvielh, and as observed by myself— the presence of induration might be inferred from the progress of general intellectual decay; at- tention, apprehension, memory, and judg- ment failing ; the patient becoming gra- dually incoherent, and general paralysis creeping on, while the tits increased in frequenc}' but diminished in violence. The anewismal nature of a tumor could be guessed at onl}' per vium exclusionis, or rendered probable by the observation of disease of similar kind in other portions of the arterial system; for it has been only in very rare cases that an aneurismal bruit has been discovered in the head during life ; similar remarks may be made with regard to hydatid growths, and it must be remembered that hydatids in the brain may exist ivithout isroducing any symptoms whatever. The presence ot carcinoma would be in- ferred only upon the recognition of the cancerous cachexia ; and here age would be an important element in the considera- tion. Lancinating pains in the limbs are not, as Rostan supposed,^ of any diag- nostic value ; but the diagnosis must rest upon the discovery of the carcinomatous dyscrasia, and the coexistence of tumors elsewhere, and especially of such as affect the integument and bones of the skull. Hi/pertrophy of the brain, although not an adventitious product, is best described in this place. It may be met with in young children ; but the only character- istic feature of the disease is enlargement of the cranium. Dr. West observes that this is "first apparent at the occiput, and the bulging of the hind-head continues throughout especially striking. The fore- head may, in the course of time, become prominent and o\'erhanging, but the eye remains deep sunk in the socket, for no changes take place in the orbitar plates, such as are produced by the pressure of fluid within the brain.'"' There is no prominence, but actual depression, of the fontanelles and sutures; the general nutri- tion of the child is imperfect, but there is ' See Cohn, in Gunsb. Zeitsohr. v. 35, 1854; Sclimidt's Jahrb. Bd. 86, 1855, No. 6, p. 322; and Bouchet and Cazauvielh, De I'Epilepsie dans ses Relations, &c. ' Recherches sur le Ramollissement, p. 404. ' Lectures ou Diseases of Infancy and Childhood, p. 9. MORBID ANATOMY. 889 nothing special in the cerebral symptoms •which would lead to the diagnosis of this particular form of malady. Partial hyper- trophy of the brain may be attended by no disturbance of the cerebral functions ; the morbid condition, under such circum- stances, can be recognized only by post- mortem examination.' Morbid Anatomy.— In this place we do not profess to give an account of intra- cranial adventitious products as a whole, but shall strictly confine ourselves to such products or growths as have their seat in some part of the encephalon, and we must refer to another article for a description of the morbid growths which take origin from the meninges. Wliilst it is indis- pensable, from a pathological point of view, to refer to these growths under dif- ferent heads, it must not be supposed that we are able clinically to exercise the same precision. And neither, during- the life of the individual, is it possible to" determine whetlier a new formation, imagined to exist, has originated in the midst of the brain substance, or, having sprung up from one or other of the meninges, has merely grown into or pressed upon this secondarily. In both cases the symptoms produced may be almost identical. Simi- lar effects are also, in rare instances, pro- duced by the extension of an external morbid growth inwards through the orbit. 2 In addition to the adventitious products more strictly so called, such as blood-clots, hydatids, &c., many varieties of tumors are met with in the encephalon. As in other parts of the body, these often pre- sent unmistakable characters, though oc- casionally their histological composition is so indefinite as to make it extremely diflScult to classify them. Tliey exist either as distinct growths, with sharply defined outlines, or they may be, as it were, infiltrations passing insensilily, at their circumference, into the surrounding brain tissue. In the former case they are often inclosed in a fibrous envelope, of more or less thickness, which now and then may be found in a calcified condi- tion ; whilst the brain tissue around may be quite firm and healthy, or it may be softened to a variable extent. The soft- ening may be simply white, or, if there have been much antecedent congestion, it may exhibit various shades of red ; whilst in other cases the yellow gelatinous soft- ening is met with, such as Eokitansky^ and Cruveilhier'' have described. This ' See cases reported hy Giacomo Sanfjalli, Gaz. Lom. 1858, quoted in Schmidt's Jahrb. Bd. 102. 1859, p. 22. 2 Ch. Robin, Gaz. M6d. 1855, 6 et 13 Oct. 3 Path. Anat. (Syd. Soc), vol. iii. p. 419. * Anat. Path., 8me Livr. p. 5. seems to occur most frequently around cancerous growths. At other times the bram tissue surrounding adventitious pro- ducts is condensed and indurated. Such adventitious Iwdies as silver and lead are met with only in minute quanti- ties, and are for the most part diffused through the substance of the brain. Not being collected into distinct aggregations we require the aid of the chemist to re- cognize their existence. Saline matters, also, either abnormal in kind or in quan- tity, may be diftlised through the tissue of j the nervous centres, when the nutrition of these fails and the brain matter is undergoing certain modes of degenera- ; tion. This is a subject upon which, at j present, our knowledge is very defective. I The various new formations and foreign bodies which are, from time to time, met with in the substance of the brain, may be thus arraiised, though they will not all be treated of in the present article :— 1. Tubercle. 2. Syphilitic growths. 3. Cancer. 4. Melanotic tumors. 5. Gliomata. 6. Fibro-plastic tumors. 7. Fibrous do. 8. Osseous do. 9. Tumors of the pituitary and pineal bodies. 10. jSTodules of gray matter on ependyma of ventricles. 11. Yascular erectile tumors. 12. Aneurisms. 1.3. Blood-clots. 14. Abscesses. 15. Plastic lymph on the walls of ventri- cles. 16. Cysts. 17. Calcareous and other concretions. 18-Entozoa{-gS-:- 19. Silver and lead. It will be convenient to place also in the last section the remarks that we have to make upon hypertrophy of the brain. 1. Tubercle. — Tubercle in the brain is much more frequently encountered in children than in adults, but, as pointed out by Andral, it is not commonly met with in children under two years of age. The period of maximum frequency is thought to be from the third to the seventh year inclusive. It rarely occurs in the brain in children without at the same time existing in some other organ of the bodj\ In 117 examinations of adults who had died of phthisis, Louis met with tuber- cle in the brain only in one case, whilst MM. Eilliet and Bartbez discovered masses of tubercle in the brains of 37 out of 312 children in whom this morliid de- posit existed in one or other of the remain- ing organs of the body. 890 ADVENTITIOUS PRODUCTS IN THE BRAIN. Sometimes a single mass of tubercle ex- ists in the brain, sometimes two or three, and in others a large number of smaller masses. In size the separate masses vary between that of a millet seed and a large hen's egg — those most commonly met with, however, being about equal to a fil- bert or a small walnut. They are mostly spherical in form, but are occasionally more or less lobulated. All parts of the brain, from the surface to the centre, are occasionally the seat of this deposit. Per- haps, having regard to its size, the cere- bellum is the most favorite seat of tubercle. It is so regarded by Dr. Wilks and by Sir William Jenner ; and Andral was, doubt- less, of the same opinion, since, without regard to size, he placed the cerebellum second, after the cerebral hemisphere, in the order of frequency of site. After these, in order of frequency, Andral names the pons Variolii, the medulla oblongata, the spinal cord, the peduncles of the cerebrum and cerebellum, the optic thalamus, and the corpus striatum. Very frequently, when masses of tubercle are situated in or upon the cerebellum, they impede by their pressure the return of blood through the vense magnse Galeni, or the straight sinus, and so cause effusion of serum into the ventricles, and all the symptoms of chronic hydrocephalus.' Very rarely, almost the whole of the cere- bellum, or one of its lobes, may be, as it were, replaced by tubercular matter.^ The usual condition in which tubercle is met with in the brain is, according to Kokitansky, in the form of masses in the size and shape already mentioned, "of a yellow or yellowish-green color, of the consistence of lard or cheese, and firm, but easily lacerable." It is remarkable that the gray, translucent form of tuber- cle is rarely, if ever, met with in the brain. Lebert says he has seen it rarely, and Eokitansky believes "that there are some rare cases which prove that tubercle in the brain does, in part at least, com- mence in the gray translucent form, for portions of a tubercular mass are some- times found in that state." He believes that it rapidly passes over from this form into that of the yellow cheesy tubercle. So far he is very much in accord with Virchow,' who holds that each mass of cerebral tubercle is in reality made up by the aggregation of a multitude oi" small miliary tubercles. Each mass is formed, not by the growth of one original focus, but "by the continual formation and ad- junction of new foci at its circumference. " ' Wilks' Path. Anat. 1859, p. 158. This fact is strongly insisted upon, also, by Sir W. Jenner in his clinical teacliing. 2 Vide Hooper's Morb. Anat. of the Human Brain, p. 60, pi. xi. 3 Cell. Pathol., transl. by Chance, p, 477. He adds :^" If we examine one of tliCEc perfectly vcllow, or white, dry, cheesy tu- bera, we find immediately surrounding it a soft, vascular layer which marks it off from the adjoining cerebral substance— a closely investing areola of connective tis- sues and vessels." In this layer the young granules' are formed. They are continually produced at the circumfer- ence, "and the large tuber grows by the continual apposition of new granules (tu- bercles), of which every one singly be- comes cheesy."^ But though this is the condition in which growing masses of tu- bercle are met with in the brain, at a later stage the process of increase stops, and, owing to an irritative process, a fibrous envelope gradually forms round the mass, so as completely to isolate it from the surrounding brain tissue. This condition is so general that many patholo- gists have held that all tubercles occur in an encysted condition in the brain." The thickness of the fibrous envelope varies with age — it may be an almost impercep- tible layer of fibrous tissue, or it may at- tain a remarkable thickness and almost cartilaginous consistence. Occasionally, even, it becomes completely calcified'.* Softening is met with, at times, in the centre of the tubercular masses ; and, very rarely, in encysted tubercle the whole contents may undergo this change. Such a change is reported by Dr. Ogle,^ in which a cyst the size of a pigeon's egg, with thin and friable parietes, ^^'as fomul in the pons Varolii, containing a "yellow glairy fluid in which a number of light- colored soft particles of albuminous mat- ter existed." More rarely still, in the brain, the tubercular mass has been found to have undergone a process of cretifica- tion. The brain tissue around masses of tuber- cle is often perfectly natural, at other times it may be congested, more or less softened, or even indurated. 2. Syphilitic Growths. — These are very rarely met with in the substance of the brain. Instances have, however, been ' Gray granulations. 2 Although differing so widely in their views as to the nature of tubercle, Rokitan- sky's description of the circumference of these masses in the brain is almost identical. He says : " An extremely moist and jelly-like cellular structure connects the tubercle with tlie surrounding cerebral tissue This stratum further contains, scattered mostly through its inner part, some small gray or grayish-yellow tubercles, whicli oc- casionally unite with the great central mass." — Loo. cit. vol. iii. p. 429. 3 Vide Andral's Precis d'Anat. Pathol, t. iii. p. 841. * Dr. Ogle, Brit, and For. Rev., Oct. 1864, p. 463. ' Trans, of Path. Soc, vol. v. p. 26. MORBID ANATOMY. 891 recorded. Dr. Aitken saw a "c;umma-| tous tumor" occui^ying the lei't optic thalamus, in a patient of Dr. Goodfel- low's, who had suffered from syphihs, and some of whose children had died from in- herited secondary syphilitic lesions. Dr. Wilks has never seen independent tumors of this kind in the cerebral sub- stance, though he believes, from the symptoms observed in some cases, that " such deposits were very likely to have existed. A firm, tough, yellowish, lymph- like mass, of syphilitic origin, has fre- quently been met witli intervening be- tween and connecting the dura mater with the brain. And although it seems most probable that the primary seat of this is the dura mater, still it is desirable to mention it here on account of the seri- ous way in which the brain matter is often implicated. Dr. Wilks records' a characteristic example of this kind of le- sion, met with in the post-mortem exami- nation of a woman of low character, who was believed to have suffered from sy- philis. He says: " At the anterior fossa the dura mater was united to the bone by a firm, yellow lymph ; here also the bone was slightly roughened, but not carious. The dura mater on the inner side was firmly and inextricably united to the an- terior lobes of the brain, especially on the right side, and corresponding to the ante- rior fossa of the skull. On attempting to separate them, a quantity of hard 3'ellow material was seen uniting them together. This filled up the sulci, and involved the cineritious substance. On the right side it had penetrated to the medullary mat- ter, and here the adventitious substance formed a tumor, tolerably circumscribed on its deep side, the size of a walnut." In the liver were some of the characteris- tic tough masses, corresponding; with a puckered and cicatriform condition of the surface above them. 3. Cancer. — Cancerous growths in the brain are, according to Lebert, decidedly more frequent in the second half of life, though they are met with occasionally in youth, or even in childhood. Dr. Walshe also found that out of .56 persons affected with cerebral cancer, 26 died between the ages of 40 and 60 inclusive, whilst 5 died before the 10th year, and 5 died between the 10th and 20th years. In about one- half of the total number of cases cancer of the brain is primary. All three forms of cancer may occur in the brain, though encephaloid is by far the most common : next to this Lebert speaks of a lardaceous intermediate kind. It may exist either in the form of a dis- tinct tumor, or it may infiltrate parts of the brain. The growths are usually soli- tary, though occasionally two or even ' Guy's Hosp. Rep. 1863, p. 49. more may be met with. The size of the caneenms ma^s varies from that of a pea up to an orange, or even larger. Occa- sionally the greater part of one hemi- sphere may be implicated. The cancer- ous mass is very rarely inclosed in a sort of fibrous cyst, but in the majority of oases it passes, at some part of' its peri- phery, almost insensibly into the adjacent brain tissue. The color is occasionally the same as that of brain tissue, tliough various tints of rose, yellow, and even green may be met with either singly or intermixed: very many cancerous growths in the brain are said to have a yellow color. All parts of the brain are liable to be affected. Cancerous tumors are fre- quently found imbedded in the midst of the hemispheres, and, according to Le- bert, those near the convexity usually at- tain the largest size, whilst those in the pons and medulla are usually the small- est, owing to the more rapid death of the patient when the growth occurs in thi_-se situations. The duration of life varies considerably ; thus in 6 out of 11 cases inquired into by Lebert, the growth seemed to have proved fatal in about 6 months, whilst in 4 the symptoms ex- tended over a period of from 2 to .5 years. The consistence and amount of vascu- larity of the cancerous growth vary much in different cases. Efi'usions of blood may be met with in the midst of soft cancerous masses, and not unfrequently cjsts are developed in their interior, which contain a thick glairy fluid. The surrounding brain tissue may be natural (which is fre- quently the case), or it may be softened, or, still more rarely, in a state of indura- tion. The softening may be white, red, or of the yellow ' variety. Lebert records one instance of a cere- bral cancer which, by its progressive growth, caused a large perforation of the skull, in the situation of the coronal suture. 4. Melanotic Tumor/i.— These are found in the shape of small nodules, generally varying in size from that of a pea to a bean. They may exist in tlie deeper parts of the brain, or at its surface, in the gray matter of the convolutions.'' Some- times these growths may be cancerous in their nature, but others are certainly not so. The black color is due to the infiltra- tion of the cells of the growth with black granular pigment, similar to that met with in the choroid coat of the eye. Dr. Clendinning3 found a mass of melanoid deposit in the upper part of the right cor- pus striatum, as large as a horse-bean, 1 Dr. Ogle, in Journal of Mental Science, 1864, p. 229, cases 1 and 4. 2 Hooper's Morb. Anat. of Human Bram, 1828, pi. xii. flgs. 2 and 3. » Trans, of Path. See, vol. i. p. 42. 892 ADVENTITIOUS PRODUCTS IN THE BRAIN. and, external to this, a hard pea-sized ni.iss. Similar new formations existed in the centrum ovale, and in the right lobe of the cerebellum. In this individual, growths of the same kind existed also, in great numbers, in the subcutaneous tissue, and in most of the internal organs except the lungs. 5. Otiomata. — These growths, to which the above name has been given by Vir- chow, take their origin in the neuroglia or interstitial connective tissue of the brain. They are, in fact, formed by a localized hyperplasia of the neuroglia, and contain no nerve elements in their compo- sition. These tumors are never sharply defined from the surrounding brain tissue, to which they bear a certain superficial resemblance. On section, however, they are often seen to have a somewhat trans- lucent, bluish-white appearance, whilst at the same time they may be firmer and rai.'ier more vascular than the brain tissue itself. Gliomata are usually solitarj-, and of slo^v growth, so that they may exist for a long time without producing any very appreciable symptoms. They often attain to a considerable size — that of an orange, for instance, and occasionally they are even much larger than this. Th(3y are most frequently met with in one or other of the posterior cerebral lobes, and after this, perhaps, they occur on some part of the upper and outer por- tion of the cerebral hemispheres oftener than in other situations. The tumors are composed of an intercellular substance, whicli \'aries in quality and consistence in different parts of the brain, and of an abundant mixture of cells and nuclei. The cells are variable in shape and size — the smaller ones occasionally possessing fine prolongations which are continuous with those of adjoining cells. There are two principal varieties of gliomata : the soft and the hard. The former, contain- ing a soft basis substance, and numerous moderately large cells, are closely allied to medullary sarcomata ; whilst the latter, having a harder and firmer basis sub- stance, and small cells with highly refrac- tive nuclei, have close affinities to fibrous tumors. Dr. Cayley' has recorded an interesting case in which a tumor of this kind, about the size of a large walnut, involved all the deeper parts of the right side of the pons, the right processus ad testes, the corpora quadrigemina to some extent, the right half of the valve of Vieussens, and the fibres of origin of the right fourth and fifth nerves. 0. Fihro-plastic Tumors. — Thesegrowths most commonly arise from the pia mater ; still occasionally they take their origin in the substance of the brain itself. They ' Trans, of Path. Soc, vol. xvi. 1865, p. 23. have been found in the midst of the hemispheres, in the pons, and in the cerebral peduncles. They vary in size from a pea to a hen's egg, are mostly spherical or ovoid in shape, and with a sur- face which is often mannnillated or slightly lobulated. Their color is generally rose- red, mixed with yellowish and even greenish tints. The amount of vascu- larity ditt'ers in different tumors, and in different parts of the same growth. They contract no adhesions, and, in general, do not infiltrate neighboring parts, although they erode by their growth and conse- quent pressure. Dr. Bristowe has recorded' a charac- teristic instance of the occurrence of a tumor of this kind in a man aged 33 years. The growth was irregularly spherical, and about one square inch in bulk. It arose from the right half of the pons and from the corresponding crus cerebelli, whence it extended for a certain distance into the medulla oblongata. The surface was lobulated, and had somewhat the appear- ance of brain substance, owing to its color and the arrangement of vessels on its sur- face. There was no defined limits to the deeper portion of the tumor, which passed insensibly into the surrounding brain tis- sue. On section, the substance of the growth was grayish and slightly translu- cent, interspersed with patches in which the vascularity was more marked than it was elsewhere. Dr. Ogle^ has reported a case of fibro- plastic infiltration, in which the new pro- duct, instead of forming a distinct tumor, had infiltrated itself into the tissue of the left optic thalamus, so as to make this body almost twice its natural size. 7. Fibrous Tumors. — These growths are very rare, and comparatively few cases are on record. They are mostly small and spherical, varying in size between that of a small pea and a walnut. M. Reignier' found a pedunculated growth of this kind of the size of a large filbert, growing from the valve of Vieussens ; and in the Trans, of the Path. Soc, vol. v. p. 18, an account is given of a fibrous tumor about the same size, which was found projecting into the left lateral ventricle, from the side of the corpus striatum. Lebert records two cases : in one a tumor of the size of a pea was found in the pons, composed of a firm, elastic, yellow, and somewhat gelatinous tissue, but presenting the usual micro- scopic characters ; in the other, 17 fibrous tumors were situated upon the ependyma of the lateral ventricles, varying in size between a pea and a small cherry stone, and of a white or slightly yellowish, or even rose color in some places. On sec- ' Ibid., vol. vii. p. 28. 2 Trans, of Path. Soc, vol. vii. p. 12, pi. il. ' Bullet, de la Soc. Anat., t. ix. p. 120. MORBID ANATOMY. 893 tion they were homogeneous, and some- what translucent. Several tumors were situated on the septum, and superficially they were all covered by epithelial cells, similar to those of the ependyma. The substance of the brain, in other respects, was apparently quite healthy, and there was no excess of fluid in the ventricles.' 8. Osseous Timiors. — True bony growths in the substance of the brain are extremely rare, still they have been met with. Dr. Bristowe^ found a growth of this kind occupying the position of the infundibulum and corpora albicantia. It was a hard conical mass about as large as a horse- bean, whose apex rested on the pituitary body, and whose base assisted in forming the floor of the third ventricle. It " was wholly unconnected with the dura mater or osseous parietes of the skull." On microscopic examination, it presented the characters of the true osseous tissue, with perfect lacunae and canaliculi. 9. Tumors of the Pituitary and Pineal Bodies. — Both these bodies are occasion- ally found in a morbid condition, and more or less enlarged. Cysts are then fre- quently met with in their interior. 0. Pituitary Body. — Lebert considers the enlargement of this body to be a kind of hypertrophy. Several cases are on re- cord. In one of them related by Bayer," this body was about 1-J-" in diameter, whilst its tissue was also more dense and resistant than natural. Yieussens' found the "gland" as large as a hen's egg, soft, and containing in its interior a grayish- white glutinous fluid. Heslop* records a remarkable case in which the tumor was soft, deep gray, and of the size of a large walnut, containing a small cavity with fluid in its interior. It occupied the region of the pituitary body, and also extended posteriorly as far back as the pons, and antero-laterally to the fissures of Silvius, so as to occupy the whole interpeduncu- lar space. The corpora quadrigemina were flattened antero-posteriorly, from pressure. Abercrombie" also refers to a case described by Dr. Powell, in which there was found "a tumor of the size of a hen's egg, containing a thick purulent fluid under the anterior part of the brain, and interposed betwixt the optic nerves, which were much separated by it from each other. Below it was attached to tlie pituitary gland, which was very soft, and enlarged to five or six times its natural ' Anat. Path., vol. ii. p. 71. ' Trans, of Path. Soc, vol. vi. p. 25. 3 Archiv. G^n. de M^d., Ire S«r. 1823, t. iii. p. 350. * Nov. Vasor. Corp. humani Syst.; Amstelo- dami, 1705, p. 248. ^ Dublin Quarterly Journal of Medicine, Nov. 1848. ' Diseases of the Brain, &o., 3d ed. 1836, p. 438. size." Davaine' records three cases in which small cysts (supposed to be hyda- tids) were found in the pituitary body. b. Pineal Body. — Hooper^ says, speak- ing of this body: "It is sometimes con- verted into a c^sf, the whole of the natu- ral structure being destroyed. This cyst is firm and membranous, and I have seen it of the size of a tamarind stone. The contents of one which I examined were, a turbid serous fluid, with small parlicles of solid albumen." Dr. Ogle" also relates a case in which " the brain and membranes were natural, excepting that the pineal gland was exceedingly enlarged and very adherent, posteriorly, and contained two cavities, each full of transparent fluid, situated immediately below its investing membrane." 10. Formation of Gray Matter upon the Ependyma of the Ventricles. — Rokitansky and Virchow^ have both described the existence of cerebral gray matter upon the internal surface of the lateral ventricles, in situations where, naturally, grajf mat- ter does not exist. It occurs in the form of numerous small tubercles, from the size of a mustard seed to that of a cherry stone. 11. Vascular erectile Tumors. — These growths are very rare. Nevertheless, Lebert has given the particulars of five cases in which they were found.* In all they were discovered pjost mortem, but had given rise to no notable symptoms during life. In one of these cases the grov.th was lodged in the right lateral ventricle, and was a development from the choroid plexus, but in the other four the tumors were imbedded in the cerebral substance. In the case related by Farre'' the growths were multiple ; two of the same size being met with in the medullary sub- stance oi^'the left hemisphere, and several small growths in the corpora striata and cerebellum. Lebert' himself has min- utely described an erectile tumor, of the size of a hen's egg, found in the posterior lobe of the right cerebral hemisphere, and Luschka,^ met with one of the same size 1 Traite des Entozoaires. Paris, 1860, p. 656. 2 Morb. Anat. of Human Brain, 1828, p. 43, pi. xii. fig. 8. 3 Brit, and For. Rev., July, 1865, p. 2.?,^,. He also adds that the Museums of King's Col- lege and of St. Thomas's Hospitals contain one specimen each of an enlarged pineal gland, hollowed out into a cyst. J Wurtzburger Verhandlungen, t. ii. p. 167. 5 Gu(?rard, Bullet, de la Soc. Anat., t. viii. p. 223. 6 Leubuscher, Die Patholog. und Therap. derGehirnkrankheiten, p. 413, Berlin. Origi- nal reference not ascertained. 7 Anat. Path., t. i. p. 213. s Archiv fiir Path. Anat., t. vi 1854, p. 458. ADVENTITIOUS PRODUCTS IN THE BRAIN. in the left anterior cerebral lobe, which was surrounded by softened brain sub- stance. Lastly, Forster' alludes brietlj' to an erectile tumor of the size of a nut, found in the gray cortical substance of one of the hemispheres, the cavernous spaces of which were found to communi- cate with neighboring dilated veins. The tumors described by Lebert, Farre, and Guerard were made up almost entirel}- of line vascular ramifications. li. Aneurisms. — The intracranial aneu- risms which are best known are those oc- curring on some one or other of the larger arterial trunks at the base of the brain, or on some of the branches of the circle of Willis lying m the midst of the pia mater and therefore whilst they are still on the surface of the proper brain sub- stance. Such aneurisms belong to the meninges, and will not be further referred to in this place. There are, however, aneurisms belong- ing to the encephalon itself, whose exist- ence has only recentlj^ been discovered, and which are remarkable principally for their small size, and on account of their frequent numerical abundance within the same brain. These were first detected and examined by MM. Charcot and Bou- chard," the latter of whom has shown, not only their frequent and close associa- tion with the phenomena of intracranial hemorrhage, but also their apparent de- pendence upon a certain general patho- logical condition of the small encephalic arteries, which may exist alone, or may be associated, in various degrees, with the more familiar atheromatous degeneration. The pathological condition of the arteries favorable to the formation of these minute aneurisms is one of fibroid degeneration • — a process of sclerosis in which there is brought about a great increase in the number of connective tissue nuclei on the perivascular sheaths, and also in the walls of the vessels, whilst the muscular fibre cells of the middle coat are gradually re- placed by fibrous tissue. This change diminishes, or even destroys, the elas- ticity of the arterial coats, so that when, from any increase of the ordinary blood pressure, they have once become unduly dilated, they are unable to regain their normal calibre. In this way, by the inci- dence of increased pressure upon degene- rated parts, are produced the various kinds of aneurismal dilatations, whose characters differ according to the degree and extent of the morbid changes in the parts involved. Thus, we may have uni- form dilatation of an arterial branchlet, 1 Lehrb. der Patholog. Anat., p. 418. 2 Bouchard, De la Pathologle des H6mor- rhagies cergbrales. Paris, 1867. See also joint papers by MM. Charcot and Bouchard, in the Journal de Physiologie, 1868-69. for a certain portion of its length, or this uniform dilatation may be interrupted by constrictions at intervals, owing to the presence of similarly situated sounder por- tions of the arterial walls. The kind of alteration with which we are more par- ticularly concerned at present, however, and which is also the most frequent, is due to an altogether local and circum- scribed change, and results in the forma- tion of the minute and more or less spherical miliarti aneurisms, as MM. Char- cot and Bouchard propose to name them.' These miliary aneurisms are very rarely met with before the middle of life, and Miliary Aueurisms, (Hamilton.)] are most common in the very aged. They are visible to the naked eye, and can be seen readily with the aid of a pocket lens. Their diameter varies between y^j" and j';", and they are attached to vessels which seldom exceed in diameter. Sometimes onl}' two or three can be de- tected in the same brain, though more frequently they exist in much larger num- bers. Bouchard has found even more than one hundred in the same brain. They may be met with in all parts of the encephalon, though with diiferent de- grees of frequency in difterent situations. Hitherto they have been found most fre- quently in the optic thalami, and then, in decreasing order, in the pons Varolii, the cerebral convolutions, the corpora striata, the cerebellum, the medulla oblongata, the middle cerebral peduncles, and, lastly, in the white matter of the cerebral hemis- pheres. When abundant in the convolu- ' Cruveilhier (Anat. Patholog., Liv. xxxiii. pi. ii. fig. 3) figures and gives an accurate description, so far as it goes, of these very miliary aneurisms under the name of " apo- plexie capillaire k foyers miliares." He was therefore ignorant of their real nature, though perfectly familiar with the naked-eye appear- ance. MORBID ANATOMY. 895 tional gray matter, a niimbor of minute and variously colored spots may be seen, after the membranes have been stripped off, lyin^ exposed on the surface of the convolutions ; whilst, when sections are made, others may be recognized in tlic deeper strata of the gray matter. Whether occurring in this situation or in the more central parts of the brain, the color of the minute aneurismal grains varies from a bright red or violet, to a yellowish or even black hue ;' according as they contain in their interior normal fluid blood, or more or less altered blood pigment. Occasion- ally the aneurisms seem to undergo a natural process of cure. Their wall, as well as that of the enveloping and some- times adherent lymphatic sheath, becomes thickened by an increased growth of con- nective tissue elements, whilst at the same time the white corpuscles of the blood have a tendency to adhere to their inner surfiice. The fibroid change creeps on, bringing about, sooner or later, a union between the wall of the aneurism and its sheath, the gradual thickening of these, and an extension of growth inwards, probably owing to a further organization taking place in the substance of the ad- herent and fused white corpuscles. Thus may the cavity of the aneurism be grad- ually diminished, till at last this, and even the miuute vessels on which it is situated, may undergo complete olsliteration. Suchintra-cerebral "miliary" aneurisms may coexist with other and much larger aneurisms of the vessels of the pia mater. Bouchard speaks of a case of this kind where the aneurisms of the arteries of the pia mater were not onlj' exceedingly nmnerous, but varied in size between a pea and a cherry stone. In other cases, minute aneurisms of these meningeal ar- teries may be met with precisely similar to those coexisting on the vessels in the midst of the brain substance. Frequently when miliary aneurisms are met with in the smaller cerebral arteries, the larger arteries at the base of the brain exhibit marked atheromatous changes : such a coincidence, however, is by no means in- variable. Although the majority of intra-encepha- lic aneurisms arc minute, and such as we have described, occasionally others of larger dimensions are met with. The size of the largest, however, could rarely exceed that of a small walnut, seeing that the arteries of the brain are com- paratively small before they leave the pia mater to penetrate into its substance. ' Occasionally this blood pigment, in the form of amorphous yellow grains mixed with lisematoidine crystals, may be principally collected around one of these aneurisms (which has been ruptured), though within its enveloping lymphatic sheath. We have collected the records of five cases of this kind of aneurism, and in each of these the patient's death was oc- casioned by the rupture of the sac. The Cerebellar Aneurism. (Bristowe.) first is related by Dr. Crisp,' and in this a boy aged fourteen died from the rupture of one or two small aneurisms on the an- terior cerebral artery, in the substance of the anterior lobe. The aneurism which burst was as large as a horse bean, whilst the other was about the size of a pea, and was filled with laminated fibrin. The next case was recorded by Dr. Van der Byl,^ and was altogether remarkable from the fact that the aneurism, which was situated on the left posterior cerebral artery in the substance of the brain, was as lai'ge as a hen's eag, and was almost filled with laminated fibrin. In one case recorded by Dr. Gull,' a small pyriform aneurism, ''having much the appearance and size of a withered grain of wheat," burst in the centre of the pons Varolii, and was found in the midst of a coagulum weighing two drachms. Dr. Gull gives the details of another case in which an aneurism about the size of a small filbert, situated on the middle cerebral artery, in the anterior part of the middle cerebral lobe, was found in a girl aged seventeen, surrounded by a large recent coagulum, and by softened brain tissue. The other arteries of the brain are said to have been healthy. Lastly, the writer has himself recorded a case" in which an aneurism, about i" in length and of an elongated pyriform shape, with a distinct rupture in its larger extremity, was taken from the midst of an enormous effusion of blood ' Diseases of Arteries, p. 165. 2 Trans, of Path. Soc, vol. vii. p. 129. 3 Guy's Hosp. Reports, 3d Series, vol. v. (185!)), p. 297. ^„^„ * Trans, of Path. Soc, vol. xviii. 1867. 836 ADVENTITIOUS PRODUCTS IN THE BRAIN. into the outer part of the right corpus striatum and adjacent portions of the hemisphere. In tliis case tlierc was an atlieromatous condition of the arteries at the base of the brain, and, besides the larger aneurism, four or iive of the small miliary aneurisms were fouud in different parts of the organ.' 13. Bloodchts. See Art. "Apoplexy." 14. Abscesses. See Art. "Abscess in Brain." 15. Plastic Lymph on the surface of the Ventricles. — A well-marked instance of this has been related by Dr. Wilks.^ It occurred in a man who had fractured the left orbital plate of his frontal bone bj' a fall. A portion of the broken bone had torn through the dura mater and had injured the anterior lobe of the brain, so as to lead to the subsequent production of an abscess in this situation. The man died after seventeen days: "on incising the roof of the ventricle (left) a membrane was found within it ; and on cutting this through it was found to consist of a layer of lymph, which completely lined the cavity. Some purulent matter escaped from within it. It covered the roof, the floor, and extended from the anterior to the descending comu, and was so tough that it was capable of being re- moved entire ; it formed, indeed, a com- plete cast of the cavity, and resembled a croupous membrane, as seen on the trachea in inflammation of that organ. The sur- face of the ventricle was soft, and in parts tore when the membrane was removed ; but in most places it could be cleanly taken off'. The foramen of Munro was closed, and the right ventricle contained only some turbid serum." It was uncer- tain whether there was a communication between the abscess and the ventricle, but the lymph was undoubtedly produced on the surface of the latter. 16. Cijsis. — It seems extremely doubtful whether simple serous cy.'ts are ever met with in the substance "of the unaltered brain tissue. Those most likely to be of this nature are small cysts from the size of a pin's head to that of a mustard seed, which are sometimes met with beneath or projecting above the surface of the lateral ventricles. They occur either singly or in groups. The corpora striata, on section, some- times present the appearance of small cysts, even as large as a pea. These may, however, be either sections of dilated lymphatic canals, or cavities left after minute softenings. It is true that larger cysts are not un- frequently met with in the brain, but [' See an artideon Intra-cranial Aneurisms, by Dr. J. H. Hutchinson, in Punna. Hospital Reports, vol. ii. 1869.— H.] ' Trans, of Path. Soc, vol. xv. p. 5. these, when not due to one of the two forms of cystic entozoa, to be hereafter described, should rather be termed pseudo- cysts, since they are not primary forma- tions, but have, in all probabilitj', resulted from the modification of pre-existing pa- thological states. Such cavities or pseudo- cysts mostly result from the later changes taking place in the scat of old effusions of blood,' or of circumscribed softenings ; or else they are due to the softening of en- cysted tubercular'' or cancerous nodules. Cysts occasionally form in the substance of cancerous growths in the brain, and, as before stated, they have several times been met with in the interior of enlarged pitui- tarjr and pineal bodies. 17. Calcareous and other Concretions. — These are not unfrequently met with in the brain, and are mostly due to changes which have taken place in masses of tu- bercle or in old abscesses. Such concre- tions consist for the most part of phos- phate and carbonate of lime, and only contain a small quantity of animal mat- ter. More rarely concretions may be met with which, seem to have resulted from previous effusions of blood : thus Las- saigne^ analyzed a mass which was found to be composed almost wholly of fibrino. and contained only four per cent, of phos- phate and carbonate of lime, with traces of cholcsterine. Concretions known as " brain sand" are very common on or in the pineal gland and its peduncles. 18. Entozoa. — Two kinds of parasites only have been met with in the human brain, and these always in an immature or larval condition. They are the Cijsti- cercus, and the Hydatid or JSthinococciis cyst : the first representing the second, or scokx stage, in the development of Tmna Solium, and the other an equivalent stage of T. ikhinococcus, an animal which ex- ists abundantly in its mature condition in the alimentary canal of dogs. Goeze and Zeder" have recorded two cases in which they suppose the Ccermrus cerchralis to have been met with, but they have not been supported by other observers, and Davaine believes these cases, in reaUty, to have been instances of hydatid disease. Certainly, as he says, the descriptions these writers have given are obscure and inexact, and we may well imagine mistakes to have been made, when we consider what was the state of knowledge concerning helminths at the time in which they wrote. a. Cysticerci. — In the brain these vary ' Many cases are recorded by Dr. Ogle (Med.-Chir. Rev., July, 1835, p. 212). ^ Trans, of Path. Soc, vol. v. p. 26. ' Clinique Med., t. v. p. 8. '' Naohtrag zur Naturgescli. der Ehigoweide- wurmer, 1800, pp. 308 and 313, tab. ii. figs. 5-7. MORBID ANATOMY. 897 in size from that of a pea to a small horse- bean, or even larger. The serous cysts, in which they are usually inclosed in other Bituations, are often absent entirely, so that they are bounded only by a smooth layer of unaltered or somewhat compressed brain substance. They often exist in large ' numbers in the same brain, and are very rarely solitary. From ten to twenty are '■ frequently met with. Cruveilhier' records an instance in which more than 100 were found within the cranium of the same individual, and of these about 50 were lodged in the cerebellum. They may be found in almost all parts of the brain, but, speaking generally, they are by far the most abundant at the surface of the brain, in, or in close connection with the gray matter of the convolutions. They are ex- tremely frequent in the pia mater, also where they press upon and partially im- bed themselves in the surface gray matter. Sometimes they are lodged in the midst of the gray matter itself, whilst more fre- quently still they are found intervening between this and the white substance. They have, moreover, been seen in the midst of the white substance, in the cen- tral ganglia, in the pons, in the crura cerebri, and in the cerebellum as before stated ; whilst Cruveilhier says he has seen real cysticerci in the choroid plex- uses of the lateral ventricles. In the lat- ter situation they have to be carefully dis- criminated from the small, non-parasitic cysts which so frequently occur in the same locality. Although usually giving rise to but slight changes in the surrounding brain matter, the cysticerci themselves undergo important modifications with age. It is desirable that this fact should be known, in order that pathologists may recognize them in their different stages, and that individual developmental modifications may not be mistaken for specific distinc- tions. According to Davaine,^ "Les alte- rations portent, d'une part, sur la vesicule qui est devenue plus ou moins globuleuse, plus volumineuse, sans jamais cependant avoir acquis un grand volume, irreguliere, quelquefois divisee en lobules ou meme double ; d'une autre part elles portent sur la tete dont le rostre et les veutouses sont envahis par une matiere noiratre, pigmen- taire. Les crochets sont reconverts a leur base par cette matiere. Dans une periode plus avancee on les trouve en desordre, diminues de nombres ou meme ils ont dis- paru. L'ouverture de la vesicule retrecie ou obhteree ne laisse plus sortir le corps ; la tete invaginee dans celui-ci ne pent non plus en etre extraite par une pression me- ' Anat. Path. Gto., t. ii. p. 88. Paris, 18.')2. * Traits des Entozoaires. Paris, 1860, p. 657. nagee ; sa presence ne peut etre reconnue que par la dilaceration des parties." It should also be added that in those cases where the cysticercus is non-encysted— as when it IS lodged freely in one or other of the ventricles — it tends to grow more easily into the form of a tapeworm, by the elongation and segmentation of the neck of tlie larval aninial.' The cysticerci seem to occur pretty fre- quently in both sexes. They may be met with also at all ages beyond infancy, though, as Cruveilhier has remarked, they seem to be most frequent in the lat- ter half of life, and have often been met with in very old people.' 6. Hydatids.^— In the brain, as in other ' Thus coustituting the third stage of de- velopment, when the animal is termed a strobilus. See Brit. Med. Journ. 1859, p. 272, where a specimen, apparently in this stage oi development, is recorded to have been met with in connection with the fourth ventricle. ' Dr. Cobbold says tliat more than 100 cases of cysticerci in the brain are on record. References to many may be found in his Jin- tozoa, p. 224, and Professor Griesinger (Ar- chiv der Heilkunde, 1862) has analyzed the details of between fifty and sixty of these cases. ' The following remarks do not refer in any way to liydatids having their seat in or between the membranes of the brain. From various sources I have ascertained the details of thirty oases of hydatids contained within the cerebrum and cerebellum. I have seen references to a few other cases also, of which I have not been able to ascertain the details. For many of the references I have been in- debted to Davaine's Traits des Entozoaires, Dr. Cobbold's Entozoa, and Dr. Ogle's paper in the Med.-Chir. Rer. July, 1865, p. 206. The refer- ences to these 30 cases are : 1. Martinet, Lond. Med. Repos. 1824, vol. ii. p. 408.— 2. Baily, Lond. Med. Repos. 1826, vol. ii. p. 144.— 3. Morrah, Med.-Chir. Trans., vol. ii. p. 262. — 4. Hooper, Morb. Anat. of Human Brain, 1826, pi. xiv. p. 65. — 5. Dalgleish, Lancet, 1832, p. 168. — 6. Guerard, Lancet, 1835, p. 45.-7. Bree, Lancet, 1837, p. 53.-8. Sturton, Lancet, 1840, p. 494. — 9. Berncastle, Lancet, 1846, p. 635. — 10. Barker, Trans, of Path. Soc. 1859, vol. x. p. 6. — 11. Baillarger, Brit. Med. Jour. 1861, p. 286. — 12. Risdon Bennett, Med. Times, 1862, p. 80.-13. Ogle, Brit, and For. Rev. July, 1865, p. 207.-14. St. Thomas's Hosp. Mus. No. 101. — 15. St. Barthol. Hosp. Mus. No. 60. — 16. Daraine, Gaz. MM. de Paris, 1862. 17. Abercrombie, Diseases of the Brain, &c., 3d ed. 1836, p. 447.— 18. Zeder, Davaine's Traits des Entoz. 1860, p. 644.-19. Earth, Bull. Soc. Anat. ann. xxvii. 1852, p. 108.— 20. Calmeil, Diet, de Mgd., art. ENcfipHALE, t. xi. p. 588, 1835.-21. Faton, Bull. Soc. Anat. 1848 p. 344.-22. Becquerd, Gaz. Med. de Paris, 1837, p. 406.-23. Rendtorff, Dissert, do Hydat., cap. 10, p. 22, Berlin, 1822; and Lirnis, Rech. sur les Echinoc. p. 100, These, Paris. 1843.— 24. Cazeaux, Bull. Soc. Anat. voii. I. — 57 898 ADVENTITIOUS PRODUCTS IN THE BRAIN. organs, the hydatid or hydatids are mostly inclosed within an outer sac or cyst. In this organ, however, it is generally very thin, and in some cases it has been stated to have been altogether absent, the hy- datid membrane pressing immediately against the compressed brain tissue. When they occur in the lateral ventricles, the enveloping cyst is always absent. In the great majority of cases, only one hy- dated cyst is met with, though this may contain two, three, or more hydatids of ilifferent sizes ; usually, however, a single cyst exists containing a single hydatid. The size of the cyst varies, generally, from that of a marble up to a large orange, though occasionally this limit is much ex- ceeded. Thus, in a case observed by Mr. Headingtou and reported by Dr. Aber- crombie,' an immense hydatid cyst was found within the left lateral ventricle, which nearly extended to the circumfer- ence of the brain on the same side, and "contained about sixteen ounces of limpid fluid ;" and in another case, recorded by Kendtorff, an enormous mass of hydatids weighing two and a half pounds, was found in the same situation, in a girl only eight years of age. The cyst is frequently lodged in the centre of the white matter of one of the hemispheres, and it may in- crease in size till it occupies almost the whole of one of the lobes — anterior, mid- dle, or posterior, as the case may be. Occasionally it occupies the greater part of two contiguous lobes, and may project towards the circumference, as well as into the lateral ventricle. In both these situ- ations the cyst may be covered only by a thin layer of nerve substance ; or it may he uncovered, owing to the brain tissue having disappeared under the influence of the gradually increasing pressure. I have only found one case on record in which an hydatid cyst was lodged in the sub- stance of the cerebellum ; m this instance, however, it was large, measuring three inches by two, projecting into the fourth ventricle, and extending transversely across from the right to the left lobe, so as to be covered by a coating of brain matter at each extremity not thicker than a wafer. Although usually only one hydatid cyst is met with in the brain, still sometimes ann. viii. 1833, p. 106.— 2.5. Carrere, Diet, de Med. de Chir. et d'Hygieue V6t6rin. 1839, t. vi. p. 157, art. Touenis— 26. TonneU, Bull. Soc. Anat. ann. xxvi. 1851, p. 165, case xxxi. — 27. Chomel, Gaz. des Hopit., t. x. 1836, p. 619. — -28. Montansey, Bull. Soo. Anat. ann. ii. 1827, p. 188.— 29. Aran, Aroh. Gen. de Med., 3me. S6r. t. xil. 1841, p. 98.-30. Leroux, Cours sur les G6a§r. de M§d. prat., t. ii. p. 12, Paris, 1825. ' Diseases of the Brain, &c. 3d edit. 1836, p. 447, case xxxiii. two or three, or even many, are encount- ered in different parts of the organ. In these cases their size is generally in the inverse proportion to their number ; so that in some instances, instead of meeting with one large cyst, such as we have be- fore alluded to, we encounter a number of little ones varying in size between a mus- tard seed and a hazel-nut.' As an instance of multiple hydatids I may refer to a case recorded by Leveille, and quoted by Davaine, in which many were found in the meninges and at the surface of the brain, in the corpus callo- sum, in the left middle cerebral lobe, in the right optic thalamus, and in other parts. The increase in size of the hydatid be- ing usually slow and gradual, little or no change is generally observed in the sur- rounding brain substance, which gradu- ally atrophies under the pressure of the growing cyst. But occasionally conges- tion or softening does occur in the sur- rounding brain tissue, and, more rarely still, the presence of an hydatid in some portion of the brain seems to excite changes in the whole organ, and even in the cranium. Thus in the case' of hydatid in the cerebellum, before alluded to, oc- curring in a man 24 years of age, the brain was found to be denser and firmer than usual, the ventricles distended with four ounces of clear fluid, and the skull- cap extremely thin, having a medium thickness of not more than about y^j", and at the squamous portions of the temporal hone being quite wafer-like, and not more than j",," in thickness. In a remarkable case recorded by Dr. Barker (10) : " The calvaria was healthy but exceedingly thin, so as to be transparent in numerous places ; the outer surface was natural, but the inner presented a series of shallow depressions, separated by angular ridges, evidently produced by the long-continued pressure of the subjacent convolutions, of which they presented an accurate mould. The surface also was congested, rough, and softer than natural. The base of the skull and its dura mater were healthy. There was no sub-arachnoid fluid, the convolutions being compressed against each other, and against the paiietes, so as to obliterate the sulci ; the surface was not congested. In the posterior lobe of the right cerebral hemisphere was a hy- dated cyst, occupying nearly the whole ' In cases of multiple hydatids, their small size may be explained by the fatal nature of the malady, and the early death of the pa- tient. The duration of the life of the patient naturally varies according to the situation and number of the hydatids. Davaine re- cords one case (loc. cit. p. 650) in which a large single cyst must have been four years old. MORBID ANATOMY. 899 lobe, which was thus converted into a fluctuating cyst. It had rendered the lobe irregular, and lobulated, and in- creased its dimensions ; but the hydatid was covered everywhere by brain sub- stance, although 'in many situations it was a mere film. The lobulated character seemed to have been produced by the superficial veins acting as ligatures. The cyst was single, about as large as a mid- dling-sized orange, and contained two hydatids, one nearly as large as the cyst itself, the other the size of a walnut. They contained no secondary cysts : the brain in all other respects was healthy." The hydatids met with in the brain are almost always barren, and thus correspond with the acephahcysts of Laennec. Some- times they are perfectly simple, but they may contain smaller secondary cysts in their interior, or bear them as buds on their exterior surface. The hydatids usu- ally contain a clear, limpid fluid, and their walls are made up of the usual thin, struc- tureless, and concentrically arranged la- mellse. In only two (12 and 23) out of the thirty cases of which I have read the de- tails, is any mention made of the hydatids containing echinococci or their remains. In these fertile cysts, in addition to the echinococci, the remains of the fibro- granular germinal membrane may be de- tected on the internal surface of the hy- datid. Many cases of so-called hydatids in the brain are recorded by old writers, which have but a very doubtful right to this title. The word was formerly used with great laxity ; everything in the shape of a cyst receiving this appellation —even the vesicles so common in the cho- roid plexus, which are now known, in the great majority of cases, to be simple serous cysts. Hydatids in the brain seem to occur as often in the one sex as in the other. As regards time of life, they seem to be met with, in the great majority of cases, in individuals between the ages of 10 and 30 years. I have found the age of the pa- tient stated in 24 out of 30 cases : of these, 3 were below 10 years of age (5, 7, and 8 years), and 3 above 30 years (one "middle age," 37, and 38), whilst the remaining 18 were between the ages of 10 and 30 in- clusive.' This is very notable, and in striking contrast with what is known con- cerning the cysticercus and its tendency to occur rather in the latter half of liie, than in younger individuals. We know so little as to the mode in which the hu- man body becomes infected with these cystic entozoa, that it is extremely diffi- cult to explain such peculiarities. We do know, however, that the adult or fully de- ' Several cases of hydatids in the mem- branes of the hrain, of which I have read, have, however, heen over this age. veloped condition of the echinococcus hy- datid exists in the intestines of the do"- though, of course, not in that of all dog" and perhaps we may also say that indi- viduals between the ages ot 10 and 20 years, have generally more to do with these animals than those of an earlier or more advanced age. This is a mere sug- gestion which, unfortunately, we are un- able further to develop. 19. Silver and Lead.— In the 11th vol. of the Transactions of the Pathological Society an account is given by Mr. Sydney Jones of the post-mortem appearances in an old epileptic, who had for several years been in the habit of taking nitrate of silver as a remedy. "The choroid plexuses were remarkably dark : from their surface could be scraped a brownish black soot- like material ; a similar substance was found lying quite free in the cavity of the fourth ventricle, apparently detached from the choroid plexus." A specimen of me- tallic silver was obtained from the plexus. Lead has several times been detected by the aid of chemical analysis in the brain. Hypertrophy. — The accounts given by Dance,' Andral,^ and Eok-itansky,' of the morbid appearance presented in the so- called hypertrophy of the brain, are so harmonious and striking as to point un- doubtedly to some definite structural modification, diflfering altogether from the enlargement due to congestion. A similar condition has also been noticed, and more briefly alluded to, by Bouillaud' and Laennec.^ Dance and Andral give the post-mortem appearances met with in seven adults, one of whom was 39 years of age, whilst the others varied between 26 and 30. In these examinations the following patho- logical conditions were met with : — Tlie skull was of average size and shape ; a great turgescence of the brain was noticed on the removal of the skullcap, which became even more manifest when the dura mater was cut ; the dura mater itself was rather thin, and the arachnoid and pia mater remarkably exsanguine, free from all moisture, and easily torn ; the convolutions were completely flat- tened, and separated only by small lines of demarcation, instead of well-marked sulci ; on section, the substance of the brain was found to be extremely anaemic, with much less than the usual distinction 1 Eepert. d'Anat. Patholog. par Breschet, 1828. 2 Clinique Mgdicale, Trans, by Spillan, 1836, p. 174. 3 Patholog. Anat. (Syd. Soo.), vol. ni. p. 373. * Traite de I'Enc^phalite. Paris, 1825. 6 Journal de M^d. de Chirurg. et de Pharm., t. xi. p. 669. 900 ADVENT. TIOUS PRODUCTS IN THE BRAIN. ■between the gray and the white matter, owing to tlie extreme paleness of the former ; the wliite substance presented an almost completely bloodless section, whilst its density and consistence were so much increased as to make it comparable to " the white of an egg hardened by boil- ing ; " the ventricular cavities were very small, and quite devoid of fluid ; and lastly, these changes, though affecting the whole of the cerebrum, did not extend to the cerebellum, pons, medulla, and cord, all of which had their natural consistence. But there is another form of "hyper- trophy" of the brain, which is of much more frequent occurrence. This is met with in some young children, who present obvious marks of being rickety, and is usually indicated by the existence of more or less enlargement and alteration in the shape of the cranium. The skull becomes especially prominent in the frontal region, and often approximates somewhat to the form met with in hydrocephalus. In this variety of hypertrophy, also, there is more or less compression of the brain, as indi- cated by the existence of anatomical cha- racters similar to, though less strongly marked than thpse already described. Whether any relationship exists be- tween the hypertrophy of the brain as it occurs in adults, and that which occurs in childhood, is not known. Not are we better informed as to the precise nature of the histological change. We neither know whether it is the same in both cases, nor what it is in either. Most patholo- gists seem to agree in the supposition, that the increased bulk is due to an aug- mentation of the interstitial substance or neuroglia of the cerebral hemispheres, rather than to an increase in the number or size of the proper nerve elements. So that, if this be true, the disease cannot be looked upon as a hypertrophy of the brain in any strict sense of the term. It has been held by Rokitansky that there is an actual increase in the amount of neuroglia, whilst Sir William Jenner and others are of opinion that, in childhood at least, and when associated with rickets, the enlarge- ment of the brain is due to an infiltration, more particularly of the anterior lobes, with an albumenoid material similar to that met with in the liver, spleen, and other organs. If this be the case, then the brain substance ought to yield the ordinary reaction with iodine ; and the characteristic changes in the coats of the arteries, peculiar to this albumenoid de- generation, should be recognizable. Accu- rate and careful microscopic observations as to the nature of the morbid changes have yet to be made, and without these no real light can be thrown upon the pathology of these remarkable affections. There are, however, two other cases of hypertrophy of the brain on record, which differ notably in all respects from the forms to which I have just alluded. In both there was great enlargement of the cranium as well as of the brain ; and, owing to this coincident enlargement of the brain and its case, there was not only an absence of the signs of compression of this organ during life, but also an utter absence of the pathological appearances peculiar to the other forms of hypertro- phy. The particulars of one case, that of a child who died at the age of five years, have been narrated by Dr. Scoutctten ;' whilst those of the other, a patient of Dr. Sweetman, who died when a little more than two years of age, have been detailed by Sir Thomas Watson.^ In both these children, the head equalled that of an adult in size, the skull was somewhat thickened, the dura mater was unduly ad- herent to it, the arachnoid was moist, the pia mater fully injected, and the convolu- tions not at all flattened. The ventricles were small : in M. Scoutetten's case they contained a very slight amount of reddish serum, whilst in i)r. Sweetman's they were empty. In this latter case, also, the surfaces "of the medullary matter, exposed by repeated sections, presented very unu- sual vascularity." Nothing is said con- cerning the amount of vascularity in M. Scoutetten's case, and in neither of the reports is any mention made of an undue consistence or alteration in density of the nerve matter. The amount of brain sub- stance above and behind the ventricles seemed to be more especially increased in the elder child, since to reach these, from above, an incision nearly three inches in depth was required. Eegarding the na- ture and cause of this enlargement, we know even less than concerning the other forms. Is there an actual increased growth of brain substance — including a due pro- portion of nerve element proper, and of interstitial substance — or does the in- creased bulk, in these cases, also, result from an augmentation in bulk of the neu- roglia alone ? and even if this be the case, we may still inquire as to the nature of the change which it has undergone. Much doubt also exists with regard to partial hypertrophies of the brain. Whilst admitting their extreme rarity, Kokitan- sky says: — "There can be no question that small portions of the brain really are separately hypertrophied. Many of the observations brought forward as instances of this occurrence are undoubtedly erro- neous ; adventitious formations inflltrated through the cerebral tissue may have oc- casioned at once the enlargement and the error. There are, however, some in- stances which may be relied on, in which 1 Archlv. G6n. de M61. 182.5, t. vii. p. 44. ' Lect. on Princip. and Pract. of Physic, 4tli ed., 1857, p. 427. PROSNOSIS — TREATMENT. 90l the optic thalamus and the pons were hy- perti-pphied ; and I have myself also met with a most remarkable case of hypertro- phy of the medulla oblongata." Andral' also believed in the existence of a limited local hypertrophy of parts of the brain. These so-called hypertrophies were, in all probability, produced by a hyperplasia of the interstitial tissue of the parts, though it seems more than questionable whether we ought to follow Kokitansky, and apply this name to an increase of bulk which has been thus occasioned. Prognosis. — In all cases when the pres- ence of an actual growth within the cra- nium is diagnosticated, the prognosis is very grave, but the degree of gravity de- pends upon the nature of the growth rather than upon the character or inten- sity of the special symptoms which it has occasioned. Thus, if there be reason to believe in the existence of carcinoma, the future prospects are as bad as they can be ; if the conclusion be that syphilis is the cause of symptoms, there may be room for the hope of complete recoverjr. "With- out entering upon a discussion of the gen- eral grounds of prognosis in the several eachexise which have been enumerated (p. 887), as the cause of tumor, it may be well to direct attention to a few points with regard to some of them. If tubercle is believed to exist, the prognosis is highly unfavorable ; but the course of tubercle en masse in the brain, is sometimes exceedingly slow, and this is the case especially in children. The advance towards a fatal issue is to be ap- prehended when there is marked hectic, much elevation of temperature, and when the symptoms indicate the progressive in- vasion of different portions of the brain. On the other hand, when — although there may be distinct paralysis, or amaurosis — the general health is tolerably good, and the symptoms have shown but little ten- dency to increase in either intensity or extent, there may be considerable prolon- gation of life. The hypertrophy of the brain which is met with in children is slowly progressive, but its prognosis, under all rates of ad- vance, is eminently unfavorable. In syphilitic diseases of the brain or its meninges there is much room for hope ; and it seems to be of little moment that the symptoms are varied and severe. Those which are the least amenable to treatment are the losses of sight and hear- ing, which not unfrequently exist ; para- lyses and spasmodic affections are often removed with considerable rapidity. The length of time during which the symp- toms have lasted is a further guide in the prognosis, the hope of restoration being ' Precis d'Anat. Patholog., t. iii. 776. m mverse proportion to the duration of the morbid state. Still, unless the gene- ral condition be one of highly marked ca- chexia, amendment may be confidently expected. The presence of disease in the kidneys is of unfavorable omen, but even it often disappears under an antisyphilitic treatment. There are no cases which ap- pear so bad and which recover so well as some examples of intracranial syphilis. Until the diaonosis of the constitutional state is established, the case may appear absolutely hopeless ; sometimes the only missing link in the history may be unat- tainable because the patient is insen.-ible, or in such a state of mental incapacity that no reUance can be placed on his assertions, but yet from such condition he may com- pletely recover. In the case of lead-poisoning the prog- nosis is favorable, provided that after a few apphcations of either the continuous current, or of faradization, the muscles show some remnant of irritability. When the paralysis has existed for a number of years, and the wasting of muscular tissue is very great, it may be impossible to re- store the limb, but yet, by continuous treatment, the advance of symptoms may be arrested. In those cases where there is reason to suspect the existence of either aneurism, hydatids, or carcinoma, the prognosis is eminently unfavorable ; but the forecast of a fatal termination is to be based upon the state of the general health of the pa- tient, rather than upon the special cere- bral symptoms. Under all conditions of Adventitious Product uncontrollable pain and vomiting are the most unfavorable symptoms ; the former deprives the patient of rest, and the latter renders food useless, and often worse than useless, through the fatigue occasioned by its rejection. Treatment. — There is nothing special which can be said with regard to the treat- ment of adventitious products in the head, for under all circumstances it is simply that of the different dyscrasias upon which they depend. The only remark which it seems to me desirable to make, is one in favor of the administration of large doses of iodide of potassium when there is a belief in the existence of syphilis. I have repeatedly seen the most menacing symp- toms removed by the exhibition of KI in doses of forty grains, three and four times daily. When this has failed, re- course to mercury has proved curative, and with especial frequency when in con- junction with the baths and waters of Aix-la-Chapelle. Small doses varymg from 2V to tV of a grain of the red iodide of mercury have appeared to me to be more generally useful than any other form of mercury ; but when even those doses 902 CBKEBRAL HEMORRHAGE AND APOPLEXY. cannot be borne by the stomach— an event which rarely happens — happy rcjsults may follow the exhibition of mercury by fumi- gation or inunction. The pain of cerebral tumor may be pal- liated, and sometimes removed altogether by Indian hemp, or the application of ice ; and sleep may be obtained by the chloral hydrate. Sickness is sometimes treated most suc- cessfully by absolute rest to the stomach, the patient being fed by nutritive enepiata. Convulsions may be checked by bro- mide of potassium, in doses of ten or twenty grains ; but the powers of the therapeutic art are, with the exceptions above mentioned, inclosed within pain- fully narrow limits, and all that can be done is to palliate evils which cannot be removed. CEEEBEAL HEMOEEHAGE Al^D APOPLEXY. By J. HuGHLiNGS Jackson, M.D., F.R.C.P. The text' of this article is Cerebral Hemorrhage, using the term in the sense of escape of blood within the intracranial nervous centres. Since very little or very much blood may be effused, the symptoms vary extremely in degree ; and since the parts in which rupture of vessels may take place are numerous, the symp- toms vary much in kind. When large and rapid effusion occurs, there is the apoplectic condition. Cerebral Hemor- rhage is one cause, and the most frequent cause of apoplexy. So frequently does hemorrhage cause apoplexy, that the name has got into use for hemorrhages in other organs. Thus we speak of Eetinal Apoplexy and of Pulmonary Apoplexy. Since this use or abuse of the word leads to confusion, the term is often qualified by the word Cerebral. We shall restrict Cerebral Hemorrhage to effusion of blood into the brain, and reserve the word Apo- plexy for the comatose condition which large effusion of blood and other causes ' In my collection of materials towards writing this paper, I have to acknowledge with my warmest thanks the help I have re- ceived from Dr. Anthony Roberts, Mr. F. M. Corner, Mr. Steggal, Dr. James Jackson, Mr. George Mackenzie, Mr. Frederick Mackenzie, Mr. Grubb, Mr. Norton, Mr. Llewellyn, Mr. Gordon Brown, Mr. Stephen Mackenzie, Mr. G. E. Herman, Mr. Louis Mackenzie, and others. I have to acknowledge also most valuable assistance in the investigation of cases of apoplexy from my colleagues Dr. Sutton, Dr. Woodman, Mr. Hutchinson, Mr. Waren Tay, and Mr. MacCarthy. I have to thank my other colleagues for their generosity in placing cases at my disposal for investiga- tion. For valuable help in the revisal of this article, I am indebted to my friends Dr. Woodman, Dr. Gowers, and Mr. Stephen Mackenzie. produce. Cerebral Hemorrhage will be chiefly considered, and other causes of Apoplexy will be spoken of under the head of diagnosis. It will be absolutely necessary to make occasional reference to meningeal hemorrhage, although this has been considered in another part of this volume, since meningeal as well as Cere- bral Hemorrhage may produce Apoplexy. Morbid Anatomy. Position. — The effusion of blood is cir- cumscribed. With rare exceptions it occurs in but one side of the brain, nearly always in a limited part of that side, most frequently in the ganglia at the base. Occasionally, however, it breaks out of the substance of the brain, usually into the lateral ventricle, but sometimes on to the surface. It is of little use to take as a basis for statistics, records of published cases ; from the Pathological Soci^y's Transactions, for instance. No one would think of bringing before the Pathological Society an ordinary specimen of Cerebral Hemorrhage. Cases of special interest are published, such for instance as cases of hemorrhage into the pons Varolii sim- ulating opium poisoning. A goodly num- ber of cases of large hemorrhage into the cerebellum could be collected from medi- cal periodicals, as many such cases are pretty sure to get into print. But large hemorrhage into the cerebellum is in reality exceedingly rare. During the seven years I have been attached to the London Hospital, I have seen but two cases. Again, statistics take count mostly of fatal cases of hemorrhage — of effusions of blood into the brain big enough to kill quickly — and of comparatively few of those cases so frequently seen in hospitals MORBID ANATOMY. 903 of hemiplegic patients who have recovered Irom coma, and who go out of the hospi- tal with more or less permanent palsy. Many of these patients die months or years after in workhouses. If we speak of hospital cases only, we thus exclude many cases of very great clinical impor- tance, and besides those mentioned we exclude cases of rapid death from menin- geal hemorrhage, for most of such cases are seen by those engaged in private practice. For these reasons I do not give nor refer to statistics, but it will, I think, be safe to say that large hemorrhage very often occurs in the corpus striatum and thalamus, often in the pons, rarely in the cerebrum, very rarely indeed in the cere- bellum, and scarcely ever in the spinal cord. We occasionally find blood in the lateral ventricles. In the vast majority of cases, it comes from a rent in the corpus striatum or thalamus opticus. It may extend to the fourth ventricle, and escape sometimes on the surface of the brain. I have, how- ever, twice known blood effused into the ventricle without injury of the ganglia in its floor. These were exceptional cases ; the blood came from bursting of large aneurisms. In one the aneurism was seated in the middle line of the hinder part of the circle of Willis at the diver- gence of tlie posterior cerebral arteries. In the other case an aneurism of a small artery of the posterior lobe had burst into the posterior cornu — blood had escaped also on to the surface of the brain. In the first edition of the article Convul- sion, a case occurring in Mr. Gayton's practice was mentioned, the notes of which were supplied by Dr. Woodman. In this case Dr. Woodman found no an- eurism, and no laceration of the brain.' Multiple Effafiioiis. — Sometimes two or more recent clots, even large clots, are found in different parts of the brain. My friend Mr. Llewellyn showed me a speci- men in which there was a clot in the floor of the lateral ventricle, and another in the pons. Tlie two clots came on at the same time, for the patient had gone to bed as well as usual and died next day of Apoplexy, which began in the night. Dr. John W. Ogle (Pathological Soo. Transactions, vol. xv. p. 8) has recorded a case in which there were three recent ' A man, 24 years of age, died rather sud- denly twelve hours after a fit of convulsion. Although this man had recovered so as to take broth and to answer questions, his cere- bral ventricles were found at the autopsy full of blood. Mr. Prescott Hewett says that a very, very slight laceration of the floor of the lateral ventricle may, if it correspond to the situation of a large vein, give rise to an ex- tensive extravasation of blood into this cavity (Holmes' Surgery, p. 314). Blood in the fourth Ventricle may come from a rent in the pons. clots, one in the right corpus striatum, one in the left thalamus opticus, and one in the pons Varolii. Dr. Baiimler has supplied me with notes of the case of a man, thirty-four years of age, who died three hours after a fit, in whose brain four recent clots were found : a large one in the centre of the right hemisphere, a small one in each of the optic thalami, and a small one in the right cms cerebri. The ventricle was also full of blood. After discovering the main clot, we should care- fully search the rest of the brain, espe- cially the pons and medulla, for small effusions, often only little specks. So far we have spoken of recent clots. It is not at all rare to find effusions of blood of very different dates. Sometimes after discovering a recent clot on one side of the brain we may find much of the oppo- site motor tract damaged by old effusion when there has been no corresponding palsy for some time before death. Size of Clots. — The size of a clot varies from that of a pea or less, to a mass the size of one's fist or more. Its size will depend of course on the size of the vessel ruptured, and its shape depends somewhat upon this also. In small capillary hemor- rhages the blood may lie in streaks in the brain substance, rather pressing the tis- sues apart than destroying them. (We see by the ophthalmoscope in many cases of small hemorrhages into the retinse, in cases of Bright's disease, that the blood is arranged in the direction of the retinal nerve fibres. ) It is doubtful whether ca- pillary hemorrhages in the brain give rise to symptoms. (A patient's sight may be quite good when there is considerable streaking of his retinte with blood. ) When from a large effusion the fibres are torn, the clot is rounder and more distinct, and gives rise to symptoms. The larger the clot, not only the greater the local destruction of nerve tissue, but also the more squeezing there is of the parts not directly damaged. When a large quantity of blood has been effused in one side of the brain, we see post mortem that the affected cerebral hemisphere looks more voluminous, that the convolutions are flattened, and we find on section that the cerebral substance is more anaemic than on the healthy side. If after sawing round the skull we insert the knife in the line of the saw-cut, and remove the skull cap with the part of the brain it contains —a plan Mr. Hutchinson adopts to dis- play the position, and effects of traumatic hemorrhage — we may find that the falx bulges to the sound side, and this is evi- dence that the other hemisphere has been compressed. These facts are of import- ance with regard to the causation of loss of consciousness from Cerebral Hemor- rhage. Changes in Effused Blood.— We find 904 CEREBRAL HEMORRHAGE AND APOTLEXT. post mortem most varied appearances ac- cording to the age of tiie clot, fcjoon after its effusion there is seen a soft black jelly mixed at its edges with small species of brain and lying in a bed of softened brain. In the later stages the appearances are widely different : there is a cyst — " apo- plectic cyst" — filled with ochre-yellow fluid, or there is even a cicatrix. We sometimes find the two extremes, a recent black soft clot, and one or more cysts the relics of old effusions. In the progress from the recent clot to the apoplectic cyst, we have to consider changes in the blood effused and changes in the brain about it. On removing as much as we can of a recent clot we mostly see, especially when the effusion is in the corpus striatum and thalamus, an irregularly-shaped cavity with a shaggy wall of soft brain intermixed for a short distance with specks of blood. The local softening results partly from im- bibition of serum from the clot and partly from inflammatory changes excited by the clot. The inflammation — local encephali- tis — may lead to extensive disintegration of brain ("the apoplectic clot is even trans- formed to an abscess of the brain," Nie- meyer), but usually the process is limited; it is conservative, and leads to the forma- tion of the cyst wall to be presently men- tioned. The progress to the final stage is gradual. The clot diminishes in bulk, be- comes softer and browner ; next the color becomes yellow ; granules of blood pig- ment and heematoidin crystals form. Finally the clot is represented by thin ochre-yellow, or even clear fluid. Simul- taneously, as a result of a slow inflamma- tory change, tlie wall of the cavity under- goes great alteration. An organized mem- brane forms from the neuroglia, and the apoplectic cyst results. This is the most common termination, but the process may go even further. There may be no cyst, but a hard pigmented patch, an " apoplec- tic cicatrix." Traumatic hemorrhage. — In cases of in- jury the clot mostly affects the surface, and most frequently the convolutions of the base ; there is rather a pulp of brain and blood than a distinct clot. An injury is to be suspected whenever l)lood is found effused close to the convolutions, especially if these be bruised, and if there are many small specks of black blood near the prin- cipal clot ; above all, if distant from the principal lesion, there are very many little specks of black blood intermixed with, and round about pulpy patches. At post-mortem examinations, espe- cially of those who have died of chronic Bright 's disease, we occasionally find evi- dence of former hemorrhage into the gray matter of the convolutions. There is often a cup-like depression with hardened walls containing ochre-yellow fluid. But if these be in several parts which we know to be often bruised by injuries to the head, — for instance, on the under surface of the anterior or sphenoidal lobes, — it is prob- able that there has been injury to the head. (See Bristowe, Path. Soc. Trans. 1869-70.) Rupture of Aneurisms of large Cerebral Arteries. — We have to speak of aneurisms of tlie small arteries of the brain (miliary aneurisms, p. 894), but occasionally Cere- bral Hemorrhage results from rupture of aneurism of the large arteries at the base. As a rule, however, their rupture produces meningeal hemorrhage. (See arts. Ad-' ventitious Products, Meningeal Hemor- rhage, and Convulsions. ) Hemorrhage from Cerebral Tumors. — Cerebral Hemorrhage has occasionally, but very rarely, its origin from vascular tumors of the brain. I have recorded three such cases in the Lancet, Oct. 29, 1869. The tumor is the glioma of Vir- chow. As he points out, ordinary Cere- bral Hemorrhage has its seats of election, and these are not precisely the places where glioma is most frequently found. Glioma occurs most frequently in the white mass of the hemisphere, especially in the posterior and anterior lobes, places where ordinary Cerebral Hemorrhage is rare. It is very important to bear in mind a remark he makes to the effect that it often requires a very attentive exami- nation to distinguish hemorrhagic glio- mata from traumatic hemorrhage, from red softening, and from rupture of cere- bral aneurism. (See art. Adventitious Products and art. Softening.) Lungs.- — Of course all organs are to be examined post mortem for, as we shall see, the heart and kidneys are often diseased. There are, however, often striking post- mortem appearances in the lungs, which are owing to the apoplectic condition. These are not peculiar to apoplexy from Cerebral Hemorrhage, and, indeed, some of them at least occur in other modes of dying. They are very varied, and the variation depends on two faetoi's — the ra- pidity of death and the condition of the patient (his age and state of health) when taken ill. I have not been able to make out any difference from posUion of tlie Cerebral Hemorrhage. I have known the lungs pale like "cholera lungs," and weighing only twenty-two ounces, in a patient who died in an hour of large Cere- bral Hemorrhage. But as a rule even in patients who die more quickly — as in some cases of meningeal hemorrhage — the lungs are congested. Tliey are often bulky and cedematous in their dependent parts, which easily break under pressure, and very emphysematous (vicariously) in front. If the patient be a robust, full-blooded man, the lungs may be black, from cram- ming with blood up to thtir anterior mar- ETIOLOGY AND PATHOLOGY. 90o gins, and casil)' breaking into a pulp, as in cases of rapid death from traumatic hemorrhage. In some eases of slower deatli, we find pulmonary apoplexies. I have in two cases (one traumatic and one opium-poisoning ; both patients young) seen lungs which on section looked liks the " damson lungs" of heart disease. In other cases where patients die very slowly, we And on section granite-colored patches of various sizes sliglitly raised and well- margined. These lobular patches are often called lobular pneumonia, and when very numerous and almost contluent, the word pneumonia is sometimes used with- out any qualification. Yet these changes occur with rare exceptions, in both lungs and in the dependent parts of all lobes, and ought not to take the name which be- longs to a well-marked independent dis- ease. They may affect one lung more than the other' — the right usually. Since, when we find these granite-colored patches, we occasionally find recent apo- plexies also, and indeed patches of inter- mediate color, I believe they are, as Brown- Sequard has stated, altered apoplexies. Sometimes one or more of them are broken down into a grumous pulp ; over some nodules near the surface there may be slight pleurisy. Etiology and Pathology. In speaking of Etiology and Pathology we for the present exclude cases vs^here the bleeding is tlie result of injury to the head, where it occurs from rupture of an aneurism of a large cerebral artery, such as the middle cerebral or basilar, or where it starts from a vascular tumor of the brain. We cannot speak at all of cases of intracranial hemorrhage occurring in pur- pura (see art. Purpura, Part I. p. 461 1 , or scorbutus (see art. Scorbutus, Part I. p. 456), or pyaemia (see art. Pysemia, Part I. p. 335), nor of "red softening" (art. Softening). Obviously the above are in their etiology and pathology very differ- ent things ; they only agree in that there is escape of blood in or upon the brain. Moreover they differ much clinically. We consider, in what follows, the common run of cases. Age. — Cerebral Hemorrhage rarely oc- curs in persons under forty. This age is that at which one of the most important ' In one case, that of a woman aged 73, who died in forty-seven hours, of liemorrhage into the substance of the left cerebral lobe ; one lung, which was universally adherent, was solid by this sort of change ; the other, which was not adherent, except by one or two tags, was a good specimen of senile em- physema, and presented scarcely any other morbid appearance. factors in the causation of Cerebral He- morrhage, degeneration of arteries, begins to be common. Changes in the arteries of old men are scarcely to be considered morbid. "To degenerate and die is as normal as to be developed and hve" (Paget). In the progress to healthy old age the body, as a wliole, descends in vi- tality ; the blood wastes, numerous capil- laries obliterate, the lymphafic system undergoes involution, there is senile em- physema. Although the heart becomes somewhat bigger as years increase, there is not excessive cardiac hypertrophy. There is an increase in bulk of the whole organ, not an extreme hypertrophy of the left ventricle only, as there so often is in persons of middle age who die of Cerebral Hemorrhage. The degenerations we are especially concerned with in this article are premature, moreover they are often attended by disease of the kidneys. In a patient under forty the arteries may feel tougher than the arteries of another per- son of eighty. Some of the exceptional cases of large Cerebral Hemorrhage in young people whose arterial system, as a whole, has not undergone degenerative changes, are cases of rupture of aneurisms of the larger cerebral vessels ; for instance, of a branch of the middle cerebral or of the basilar. Indeed, if there be no evidence of the arterial and other degenerations in the body, to be presently mentioned, the pro- bability is that large Cerebral Hemorrhage in young people (excluding cases of in- jury, purpura, and the like) is thus caused. Apart from such quasi-accidental cases, we must observe further that the matter of importance in considering the influence of age in diagnosis is to note the general constitutional state the patient has arrived at rather than the number of years he has lived. For Cerebral Hemorrhage quite like that which occurs so often after forty does sometimes occur at the age of twenty and even under, in people who are sub- jects of chronic Bright's disease, who have degenerated arteries and hypertrophy of the left ventricle of the heart. I have re- corded such a case ( London Hospital Re- ports, vol. iv. p. 337 .. Heredity.— It is asserted that in some families there is a tendency to Cerebral Hemorrhage. Obviously the transmission cannot be of a tendency to certain symp- toms— hemiplegia and Apoplexy— but to certain tissue degenerations most strik- ingly manifested in the arteries. Cerebral Hemorrhage therefore can be inherited only indirectly. Much used to be said of a certain inherited build of body and of the "apoplectic constitution." Little importance is nowadavs attached to this. Austin Flint says, "The larger number of persons attacked are either spare or of an ordinary build." Niemeyer says, 906 CEREBRAL HEMORRHAGE AND APOPLEXY. " There is no such thhig as an apoplectic cou»titution indicated by a short neck and broad shoulders." CONSTITUTIOSTAL STATE PRIOR TO Cerebral Hemorrhage. — It is con- venient to consider an extreme case in order chat we may state the whole of the factors which may be concerned in caus- ing Cerebral Hemorrhage. We are, as was said at page 905, not now consider- ing cases of hemorrhage from rupture of aneurisms of the large cerebral arteries, from injuries, or from the like quasi-acci- dental causes. At autopsies on patients who have died of Cerebral Hemorrhage we frequently, if not mostly, find three things : hypertro- phy of tlie heart, chiefly the left ventricle, chronic renal disease, and degenerated' arteries (Bright, Johnson, Kirkes). A patient so much and so widely diseased has not a liability to Cerebral Hemor- rhage only ; he is liable to inflammation of serous membranes, to bronchial ca- tarrh, to oedema of the lungs, &c. But in this article we have only to do with the triple association as it bears on Cerebral Hemorrhage. We are especially con- cerned with the condition of the vascular system, and can only speak incidentally of the renal disease. We have two tasks. Going the natural round of the circula- tion (heart, large arteries, small arteries, capillaries (and nervous tissue), venous system and lungs), we have first to con- sider the abnormal conditions of different parts of the vascular system, and next how, from the sums of these several con- ditions, it results that rupture of the smaller cerebral arteries is determined. Heart. — The hypertrophy is of the left ventricle : it is of the kind called simple, because, although the wall of the ven- tricle is thickened, there is not dilatation ; the capacity of tlie ventricle is, at all events, but slightly increased. Yet, as in other kinds of cardiac hypertrophy, di- latation may ensue. In patients long bed- ridden from palsy due to Cerebral Hemor- rhage, we may find the heart decreased in size, notwithstanding that there is chronic renal disease. In this form of hypertrophy there is ob- viously increased power acting on the arterial side of the circulation, and con- sequently we infer obstruction somewhere in the arterial system. We limit our- selves to cases where there is no obstruc- tion at the aortic orifice, and no incom- petence of the aortic valves.'' The resist- ' Retinal changes will be alluded to here- after. The careful clinical observer considers minor degenerative changes, — baldness, gray- ness, state of skin, worn teeth. He inquires for history of gout, and of intemperance. ^ For intracranial hemorrhage is not oom- ance to the heart is much further on. It is peripheral. Although this is agreed on, there are great differences of opinion as to the exact nature of the peripheral ob- struction. Dr. Bright suggested that the "altered quality of the blood might so affect the minute and capillary circulation as to render greater action necessary to force the blood through the distant sub- divisions of the vascular system." He suggested also that the blood in Bright's disease might act as an unwonted stimu- lus to the heart. Dr. George Johnson, believing that the blood in renal disease is more or less noxious to the tissues since it contains "urinary excreta," considers that its passage into the capillaries is re- sisted by contraction of the small arteries — the vessels most rich in muscular tissue. The muscular coats of these vessels there- fore are hypertrophied in antagonism to the heart. Since the small arteries are hypertrophied throughout the body, the obstructions, though each is slight, are in their sum total so large, that in order that the circulation may be carried on effi- ciently, hypertrophy of the heart must ensue. But whilst Dr. Johnson believes that the thickening of the walls of the small arteries is genuine hypertrophy, " an in- creased growth of a normal tissue with- out change of texture," Dr. Beale doubts whether there is real hypertrophy of the muscular fibre cells, and supposes that the changes in the small arteries are de- generative. He remarks' that " there is an increased bulk with altered structure, not simply increased bulk without change of structure (hypertrophy)." Traube considers that the cardiac hyper- trophy in Bright's disease is a conse- quence of increased tension of the arterial circulation, partly the result of the dimin- ished calibre of the renal circulation, and partly the result of greater volume of the blood from diminished excretion of fluid. The objection which has been raised to this view is, that the hypertrophy of the heart mostly begins in the earlier stages of Bright's disease. Occasionally, although rarely, we find great hypertrophy of the left ventricle in cases of Cerebral Hemorrhage, when there is neither obstruction at the aortic orifice, mon in oases of valvular disease of the heart, excluding cases of aneurisms of the larger cerebral arteries, and ruptures of these usu- ally produce meningeal hemorrhage. My observations confirm the statement of Dr. Austin Flint, that important nervous symp- toms of any kind — excluding, of course, those produced by the process of embolism — are not common in cases of valvular diseases of the heart (Diseases of the Heart, 2d ed., p. 180). ' Beale on the Urine, 3d ed., p. 72. CONSTITUTIONAL STATE PRIOR TO CEREBRAL HEMO nor renal disease, but simply wide-spread degeneration of the arteries. From these cases it seems clear that degeneration of vessels is a sufficient cause of hypertrophy of the left ventricle. It must be admitted that there are cases of hypertrophy of the heart, which we are unable to explain. We do mostly, however, find hypertrophy of the left ventricle in cases of Cerebral Hemorrhage. Large Arteries.— From a degenerative' change the large arteries lose much of their chief property— elasticity ; they be- come permanently wider, longer, and more tortuous. We see them move in curves on the temples, and we feel that they are tough and sometimes even " bony. " When the large arteries which we can see and feel are thus changed, it is a reasonable inference, that the large arteries of the brain are similarly, although not perhaps equally, altered. Elasticity of the arteries, although it adds no new force, is an important aid to the circula- tion in equalizing the flow of the bjood, gradually reducing it from intermittence m the large arteries to a nearly continuous stream in the small arteries. We readily understand, therefore, that the absence of elasticity of the larger arteries will be an important factor in leading to rupture of the smaller arteries. The circulation is carried on too much in systole. The smaller arteries will receive the impulse from the strong left ventricle intermittent- ly, not remittently. Small Arteries. — Here rupture mostly takes place, always in large hemorrhages. ' I speak of results under the general term " degeneration." Virchow (Cellular Patholo- gy, Dr. Chance's translation) points out that the true atheromatous change in arteries be- gins by a slow inflammatory change of the tunica intima — an endarteritis strictly analo- gous to the intiammatory changes in endocar- ditis. I have in this article, however, to do with changes in the vessels so far only as, by affecting the dynamics of the circulation, they favor cerebral hemorrhage. I have not to do with the processes by which these changes are arrived it ; therefore I use the general term "degenerative," which, with the above qualifications, need not mislead. I conclude the foot-note by a quotation from an able lecture by Moxon, Med. Times and Ga- zette, Nov. 12, 1870: "It is too much the fashion, at least in this country, to assume that all the processes in the arteries which lead to the deformation of their interior by yellow patches, swellings, petrifactions, or erosions, or to aneurisms or rupture of the vessels, are all of a degenerative origin, and that all are sufficiently described and defined in the common notions of atheroma. The truth is, that sub-inflammatory irritation plays a very important part in these changes. ' ' Since this was written, Moxon has considered the whole subject in a valuable article in Ctuy's Hospital Reports, 1870-71. RRIIAGE. 907 We have to consider several pathological conditions of the smaller arteries." (a J^atty degeneration. Arteries of small size have a highly developed muscular coat, and this coat especially is the scat ot tatty degeneration, a change which we may suppose will allow rupture when the vessels are unduly strained. However not so much importance is attached to this pathological condition as was wont to be, for fatty degeneration is found sometimes in the arteries of very yount^ people. Indeed, Billroth and Bouchard consider it to be most frequently a result rather than a cause of cerebral lesions. But even if so, degeneration of arteries, tor instance, in a focus as softening, may favor the occurrence of hemorrhage into the imrt diseased. (6) Charcot, Bouchard, and Charlton Bastian have described what they term "miliary aneurisms:"' aneu- risms mostly visible to the naked eye, of the size of a pin's head more or less. (These have been fully described, art. Ad- ventitious Products.) Capillar ies.—These vessels may be found the seats of fatty degeneration. But rup- tures allowing large hemorrhages do not occur here. If it be degeneration of the smaller arteries which produces obstruc- tion and thus induces hypertrophy of the left ventricle of the heart, the diseased state of the smaller arteries may protect the capillaries from strain. ^ ' Dr. Bristowe has drawn attention (Path. Soc. Trans. 1859) to ruptures of small aneu- risms in the substance of nervous organs as a cause of cerebral hemorrhage, and gives a drawing of an unruptured aneurism, the size of a grain of wheat, which lay in the sub- stance of the cerebellum. Dr. Henri Lion- ville has found miliary aneurisms in the retina (Gaz. des Hopitaux, 1870). See also Dr. Gull (Guy's Hosp. Reports, 3d Series, vol. V. 1859). 2 Here reference may again be made to Dr. George Johnson's view, mentioned p. 906. In one case of large Cerebral Hemorrhage he failed to discover any hypertrophy of the small arteries of the brain, but he found them much hypertrophied in the subcutaneous tis- sue. Inferentially, they were hypertrophied in other organs, although, unfortunately, ex- aminations were made of the arteries for the brain and of the subcutaneous tissue only. In such a case, he suggests that the hemor- rhage results, not from rupture of the arter- ies, but from rupture of the capillaries of the brain. They rupture because they are not protected from the force of the hypertrophied left ventricle by the hypertrophy of the mus- cular coat of the arteries delivering blood to them. It is, however, unlikely that rupture of capillaries would cause a large effusion of blood. "The apoplectic fit does not occur in capillary hemorrhages." (Niemeyer, Test- book of Practical Medicine ; translation of the eighth German edition by Drs. Humphreys and Hackley, vol. ii. p. 198.) 908 CEREBRAL HEMORRHAGE AND APOPLEXY, Nervoiis Tissues. — The influence which changes in the tissues outside the vessels may exert in tlie causation of Cerebral Hemorrhage may be most conveniently considered here. When the brain wastes slowly, there is, in order that the cranium may continue full, compensation. There is, in some cases of wasting of the brain, thickening, genuine hypertrophy, of the skull (Paget). There is, sometimes, increase backward of the capacity of the frontal sinus (Hold- en); but the most important compensation is by increase in the quantity of the cere- bro-spinal fluid. To these sources of com- pensation Leubuscher and Niemeyer add dilatation of the vessels which will, they believe, favor rupture. And Kiemeyer suggests that the frequency of Cerebral Hemorrhage, in advanced life, depends at least partly on the dilatation of the ves- sels induced by atrophy of the brain. Further, he thinks that since Cerebral Hemorrhage leads secondarily to atrophy of the brain, one attack favors the occur- rence of another attack. Softening of the brain, by diminishing the support of vessels, may favor hemor- rhage, but it is almost universally agreed on that the softening we find post mortem near to a clot is nearly always the result of the effusion, not a pathological condi- tion prior to the occurrence of hemor- rhage. Venous System.' — "We shall speak only of obstruction to the return of the blood from the brain by changes in the lungs, excluding cases like phthisis and senile em- physema, in which the volume of the blood is reduced, and in which, therefore, the pulmoiiary impediment is to a great extent compensated. From hypertrophons em- physema there results universal peripheral congestion, consequent on the difficulty the venous blood encounters in passing through the lungs — the vascular area of which is reduced by obliteration of a great number of capillaries.' From theoretical consid- erations therefore we might at first glance attach much importance to emphysema as a factor in the causation of Cerebral Hemorrhage. '"In no other disease does the cyanosis attain such severity excepting in cases of disorder of the orifices of the right heart." (Niemeyer.) However, emphysema probably is not often an im- portant factor in the causation of Cere- bral Hemorrhage. There will, in chronic ' We do not here refer to the acute emphy- sema which we so often find post mortem, and which is especially well-marked in young, robust men who die in the apoplectic condi- tion soon after traumatic intracranial hemor- rhage. In these cases we find great posterior congestion^ccasioually pulmonary apoplex- ies also — and vicarious emphysema of the front parts of the lungs. cases, be much compensation by increased power of the right ventricle. Even if there be not full compensation, the left ventricle will have less blood to send to the brain, and thus the arterial tension will be diminished. It is the venous sys- tem which is overblooded and strained in emphysema ; the arterial, from which rupture in Cerebral Hemorrhage takes place, is underblooded and less strained. In the last stages of emphysema we have, Niemeyer says, the severest symptoms of hypersemia of the brain. Yet Cerebral Hemorrhage is a rare termination of this or of any other form of thoracic disease. It is the tension on the venous side of the circulation which is increased in emphy- sema. ' The veins are of lower functional struc- ture than the arteries — very few of the cerebral veins contain any muscular tissue — and thus probably they are less liable to disease. The degree of hypersemia of the face and lips is no exact measure of the degree of venous congestion of the brain in sudden obstruction at least. The t;erebral veins are protected from sudden backward strain by the large cerebral sinuses. Nevertheless obstruction at the lungs, especially when occurring quickly, will be a factor, if not an important one, in favoring rupture of cerebral arteries. We have now to speak of the dynamics of such a person's circulation, in order to show how abnormal strains lead to rup- ture. To obtain clear ideas upon this point, it is well to run over the peculiari- ties of the cerebral circulation in health. The brain receives a large supply of blood (a large quantity passes through it), but there are provisions by which it is pro- tected from suddenly increased afflux. There are turns of the carotid and verte- bral arteries, the free anastomosis of the circle of Willis, the numerous subdivisions of the arteries beyond that circle, on the convolutions at least, and their small size before they enter the brain substance it- self. Perhaps we may add the possibility of diverticular enlargement of the thyroid body, and of the facial arteries, by which in suddenly increased action of the heart the flow to the brain will not be in pro- portion to the increased quantity of blood sent into the carotid and vertebrals. Further, when there is increased afflux of blood, compensation can occur by dimin- ution of the quantity of the intracranial part of the cerebro-spinal fluid. Some parts of the brain, however, are less pro- ■ Dr. Hyde Salter never saw or heard of Cerebral Hemorrhage during an attack of asthma or as a result of asthma; for, although here there is acute obstruction to the return of venous blood, the arterial tension is very small : in severe attacks the pulse can scarcely be felt. CONSTITUTIONAL STATE PRIOR TO CEREBRAL HEMORRHAGE. 909 tected than others. The arteries which supply the corpus striatum are not capil- lary in size. They, or many of them, come off from the middle cerebral, which artery is almost the continuation of the internal carotid. Thus its branches lie more in the way of strain from the heart. Uut on the other hand we have to observe that here there is special compensation. As Hilton points out, the corpus striatum and thalamus (which parts we may pre- sume to have greater and more frequent functional activity than most divisions of the nervous system) lie in great part in the large water-bed of the brain. By this means rapid compensation by diminution of the tiuid in the lateral ventricle may occur when these highly vascular parts during their functional exercise swell by becoming for a while more vascular. There is even more. Dr. Bastian (on Tubercular Meningitis, Edin. Med. Jour- nal, April, 1367), speaking of perivascular canals, suggests (but only as one hypothe- sis as to their use) that they may consti- tute "an apparatus for the distribution of cerebro-spinal fluid throughout the structure of the brain, in order that the same protective influence may be exer- cised over each individual portion of its structure whicli is exercised over the wliole region by that portion of the fluid situated in the subarachnoid spaces." He says too, speaking of perivascular canals, three times the diameter of the vessels they contain, — '' This large size of the perivascular sheaths occurs more fre- quently in the corpus striatum and optic thalamus." Then on the venous side there is the remarkable arrangement of the sinuses, which is sucli that a back- ward strain, if it be sudden, will not reach the veins of the brain — or will reach them in a diminished degree. The blood will pass, by preference, so to speak, into the outer parts of the head, face, &c. If the backward pressure be slowly ex- erted as in chronic emphysema, there will be cerebral hypersemia, but it will be very slowly developed and very evenly distributed. Let us suppose that all the abnormal conditions enumerated, p. 906 to p. 908, are present. Of course the whole of these factors are not present in all cases. There may be no renal disease, but there are usually degenerated arteries and hyper- trophy of the left ventricle. But as the following is chiefly recapitulatory, we shall in its proper order mention each of the conditions which diffisrent observers have supposed as well as have proved to be factors in the causation of Cerebral Hemorrhage. The small artery is usually the seat of rupture. We take this as the fixed point, and first consider the devel- opment of undue strain upon it. Next we speak of negative circumstances which add to the influence of this strain— of im- pediments to the exit of blood from the arteries into the veins. There is a strong left ventricle. The larger arteries are inelastic, and thus the wave of the blood sent forcibly into them is not equalized : as a consequence t)ie impulse from the heart's jerks will be carried on strongly to the smaller arte- ries of the brain. The small arteries of the brain— normally thinner than ar- teries of other parts — are degenerated. Though this degeneration leads to resist- ance, it is not the resistance of power ; it is a "weak obstinacy." The resisting arteries are fragile and may be actually aneurismal. Moreover if the brain be wasted, the arteries are dilated and less supported. So far for the forward strains. If we hold that changes of nutrition in the penetralia of the body — in capillary regions — contribute largely to the forces of the circulation {vis afronte], there will be from the imperfect nutrition which the disease cf the arteries and capillaries causes (and which in some cases atrophy of the brain signifies), an obstruction (or more precisely a cessation of help) to the flow of blood. The capillaries will not readily empty into the veins. At this point too, as there is often renal disease, we have to recognize, if we follow Bright, Johnson, and Kirkes, a still further ele- ment of obstruction in the unwillingness of the tissues to pass impure arterial IJlood. Further, if there be emphysema or other obstruction at the lungs, the free return of lilood from the brain is hindered. Per- haps a condition of plethora, or at least of transient plethora after large eating and drinking, may add to the tension of the circulation by increasing the volume of the blood. If all the above-named con- ditions be present, there is no wonder that the diseased small arteries, unable to empty readily into the capillaries and veins on the 'one hand, and jerked by a strong ventricle on the other, sometimes give way. Moreover, when we consider the local pecuharities of the circulation of the corpus striatum and thalamus, we can well understand that these bodies are the "seats of election" for large Cerebral Hemorrhage, notwithstanding the special provisions mentioned. The degenerations have been slowly going on, and the diseased vessels are being subjected to increas-ing strain. A time comes when a vessel more diseased than another, perhaps one the seat of a miliary aneurism, or some vessels speci- ally in the way of strain, mostly a branch to the corpus striatum, gives way. It is not at all rare to hear it said that hemor- rhao-e is sometimes the result of obstruc- tion°to the return of venous blood from the head in paroxysms of convulsion. Dr. Todd (Diseases of the Nervous System, 910 CEREBRAL HEMORRHAGE AND APOPLEXY. Lects. vii.'and xii.) held this view. But since tlie hemorrhage is nearly always in the arterial regions of the brain, and since in the most severe paroxysms of chronic epilepsy, Cerebral Hemorrhage is exces- sively rare, it is far more reasonable to suppose that the irruption of blood itself causes the convulsion and the subsequent apoplectic condition. No single instance of actual Cerebral Hemorrhage in an epi- leptic fit has presented itself in Reynolds' experience (On Epilepsy, p. 225). Hemorrhage from Aneurism of the larger cerebral vessels. — in cases of aneurism of the larger cerebral arteries, a very local disease of the vessel may be the sole flaw in the system, except- ing perhaps vegetations on the heart's valves (Dr. John W. Ogle and Dr. Church). If there be no misfitting of the valves, no hypertrophy of the heart will ensue, nor indeed any derangement of the djnamics of the circulation of the brain, possibly not even any change in the nu- trition of the part supplied by the aneu- risraal artery if it remains pervious. In a few cases the fatal attack begins, if not in good health, at least in what appears very like good health. The patients feel well and are about at their work. We can say nothing as to their constitutional condition. I have only to do with rupture of these aneurisms in diagnosis. For rupture of them mostly produces menin- geal, not cerebral hemorrhage. (See art. Adventitious Products.) Localization of Lesions. We have now to speak of lesions of the motor and sensory tract within the cra- nium, and of lesions of the two large masses therewith connected — the cere- brum and cerebellum. In this section we consider almost solely paralytic symptoms — those which localize ; other non-localiz- ing symptoms will be considered under the head of the Apoplectic Condition. The parts of the motor and sensory tract from above downwards are corpus striatum, thalamus opticus, crus cerebri, pons Varolii, and medulla oblongata. All these parts are double, right and left, al- though the halves of the last two, pons and medulla, are welded together. In the vast majority of cases, the lesion is of but one lateral half of the sensori-motor tract, and its results are one-sided palsy — hemiplegia. In the parts we have spoken of as being welded together, the pons and medulla, the lesion occasionally affects both halves, and thus paralyzes both sides of the body. We have to do especi- ally with lesions of one lateral half of the motor and sensory tract at different levels, and consequently with several varieties of hemiplegia. In all these varieties we are concerned with palsies of the limbs, and with palsies of parts suppUed by cranial nerves. The limbs, since their motor fibres have decussated in the lower part of the me- dulla oblongata, are always palsied on the side opposite to the lesion of any level of the lateral half of the sensori-motor tract. In lesions of the medulla, near the decus- sation, however, there is rather a general weakness, and only hemiplegia in the qualified sense that the limbs are more affected on one side. As Brown-Sequard has pointed out in lesions of one lateral half of the medulla, the nerve-fibres from the limbs may be caught in part before and in part after their decussation, and thus from a one-sided lesion there results bilateral paralysis. Above this great decussation, cranial nerves emerge from the sensori-motor tract, and many, if not the whole, of these nerves have special decussations. Hence in hemiplegia, parts supplied by the cra- nial nerves are sometimes palsied on the same side as the limbs, and sometimes on the opposite side, according as the lesion affects the fibres of these nerves after or before their decussations. For instance, both in lesion of the lower half of the right' side of the pons and in lesion of the right corpus striatum, the arm and leg are palsied on the left, but in the former case the face is palsied on the side of the lesion (the right), because the fibres of the facial (portio dura) nerve are caught be- fore its decussation, whilst in the latter the face is palsied on the side opposite the lesion, because fibres of the nerve are caught after its decussation. We must observe further that the decussation'' of cranial nerves, the facial and hypoglossal nerves at all events, is inconiplete, so that, as we shall have to insist on later, we find in lesion of the higher levels of the motor tract, that is to say, in lesions above the pons, and therefore above the decussations of these nerves, that the pal- sies of the face and tongue are not only on the side opposite the lesion, but that they are incomplete in degree — there is paresis rather than paralysis. Cerebral Hemisphere. — Large parts of one cerebral hemisphere may be ' It will he convenient throughout this part of the article to suppose the right to-be the side of the several lesions of which we have to speak. 2 Lockhart Clarke has shown very clearly that there is a considerable decussation of the fibres of the ninth nerve. He finds that the nuclei of the facial are united by many fibres— commissural ; but he has traced very few fibres of the nerve that decussate directly. (See Researches on the Intimate Structure of the Brain : Phil. Trans. 1868, p. 300, plate xiii. figs. 60 and 51.) LOCALIZATION OF LESIONS. 911 destroyed without producing obvious symptoms, either mental or physical. It is not said that diseaae in the hemisphere does not lead to symptoms ; it very often does. {See art. Convulsion, p. 737.) lu the article on Convulsion it vpas pointed out that hemiplegia frequently attends gross disease, syphilitic disease for in- stance, of the surface of the hemisphere, but in these cases the hemiplegia nearly always follows a convulsion, and depends probably on the nervous discharge in the convulsion itself It is, we repeat, certain that a large quantity of any part of either hemisphere may be destroyed while there are no symptoms, with one important exception. If the lesion involves convolutions near the corpus striatum — usually the left — there is, according to the size aud exact position of the lesion, more or less defect or even complete loss of speech (aphasia).' The probability is that when a part of the brain is sknoly destroyed, the undamaged parts take on the function of the part de- stroyed. Something similar is seen in the case of the eye. When the central vision is lost, the peripheral parts of the retina acquire greater acuteness of vision. In large and sudden lesions of the cerebrum there are symptoms, probably from the withdrawal of a part before this kind of accommodation can be effected. We may have no symptoms from small clots in the hemispheres. In very large hemorrhages there are symptoms." These are usually, however, symptoms of Apo- plexy ; but if the Apoplexy be not very severe, we may discover some degree of hemiplegia. The palsy results either, as suggested, because a large part of the cere- brum is suddenly destroyed, or because the effusion by its mere bulk compresses the subjacent motor tract. Lateral Vbittricles. — In cases where blood breaks into the lateral ven- tricle from the corpus striatum or thala- mus opticus, there is usually, not always, a convulsion and rapidly deepening coma. The convulsion, however, I believe, oc- curs not because blood is effused in the ventricle, but because under such circum- stances the clot is usually a large one and has suddenly torn much of the brain : for severe convulsion (with tongue-biting) may usher in the Apoplexy, or may occur later when a large clot, starting in the bodies mentioned, is well walled in. If a patient be first hemiplegic with or without unconsciousness, the subsequent occur- rence of a severe convulsion followed by universal powerlessness and deep coma is strong evidence of rupture into the ven- tricle, and is a very unfavorable sign. We now come to the sensori-motor ' This symptom is considered in art. Soft- ening. tract. In the first two divisions— corpus struitum and thalamus - the lesion is above the decussation, not only of the fibres for the limbs, but of all the cranial motor nerves, so that the paral3sis pro- duced is altogether on the opposite side of the body. Corpus Striatum. — A lesion here produces what may be called "the com- mon form of hemiplegia. " As this is the most valuable symptom in the diagnosis of Cerebral Hemorrhage, it will be con- sidered in some detail, but still only so far as bears on the diagnosis of Cerebral Hemorrhage. It is very important, however, to ob- serve that a very large and sudden efliision in this region leads to such deep coma that, although there must be paralysis of the limbs, we do not often discover any (just as in deep coma with fracture of the base of the skull we may not discover palsy of the face due to injury of the por- tio dura nerve until the patient's coma is passing off). We discover no local palsy, because there is palsy of both sides — uni- versal powerlessness. This may be the result of squeezing of the opposite side of the brain by the sudden intrusion of a bulky mass into one side, the blood per- haps having also escaped into the lateral ventricles. Possibly the universal palsy may be in part owing to the destruction — the sudden lack — of those fibres which pass from the side of the lesion to the same side of the cord, as well as of those which de- cussate. (I have heard Dr. Brown-Se- quard insist that many hemiplegic pa- tients, some time after their seizure, were a little weak on what we usually call their sound side.) However, even in these cases we may learn that the case began in a hemiplegic manner, or we find some kind of one-sided symptoms, as tremor, rigidity, and the like. As we usually see hemiplegia, always in chronic cases and most often in receni, cases, the palsy is incomplete in range. It affects only the face, tongue, leg, and arm of one side. But in complete hemi- plegia we have the following symptoms. We suppose the right to be the side of the lesion : — 1. The head turns to the right. 2. Both eyes turn to the right, and fre- quently both upper lids are fallen. 3. The muscles of the belly and chest are weakened on the left. 4. The muscles passing from the trunk to the left limbs are paralyzed. 5. The face is paralyzed on the left side. 6. The tongue on protrusion turns to the left. 7. The left leg is paralyzed. 8. The left arm is paralyzed. Hemiplegia so complete only occurs 912 CEKEBKAL HEMORRHAGE AND APOPLEXY. from a very grave' lesion, and even then, a.s a rule, the tirbt two symptoms in the list pass oil' in a few hours or days. The sjmptoms in the list are given in what I believe to be the order in which the several parts suft'er. It will be found that those parts suffer most and suffer longest (re- cover latest) ^^•llich have the more volun- tary uses. This is notorious of the arm and leg ; the arm nearly always suffers more and recovers later than the leg. Of course the distinction into complete and incomplete hemiplegia is artificial. There are all degrees of paralysis according to degrees of gravity of the lesion. But there is an order in which paraljsis in- creases in increasing gravity of lesions. "We oljserve that the graver the lesion, not only are the more voluntary parts (arm and leg) tnwe paralyzed, but that tlie further spread in range is the para- lysis, and the method of its spreading is from the more voluntary to the more au- tomatic parts — to parts higher up in the list. Thus, neglecting very small clots, a considerable lesion (I cannot use a more exact term, suddenness of effusion as well as size of clot being a factor) paralyzes only the most voluntary movements of one side of the body, those of the face, arm, and leg, and these parts in degree according to their degree of voluntary- use. A larger lesion not only causes a deeper and more permanent palsy of these three parts, but it leads also to im- plication of more automatic parts ; it causes the additional symptoms 1, 2, and 3 in the list. In still larger lesions the palsy spreads to the most automatic parts of tlie body, even to parts supplied by ganglionic nerves. It produces stertor from palsy of the palate and palsy of the respiratory muscles and of the heart — the palsy of respiration and of the heart showing itself chiefly in slonmess of move- ment. There is also abasement of tem- perature. So we see that degrees of hemiplegia are "compound degrees." Not only are there degrees of more or less amount of loss of power of the face, arm, and leg — there is also, along with increas- ing degrees of loss of power of these most voluntary parts, increasing spreading of palsy to the more automatic parts of the body. There are degrees of hemiplegia, compound degrees as we have seen, from palsy of the most voluntary parts of one side only to almost universal paralysis, when, of course, " hemiplegia" is a mis- nomer. Lateral Deviations of the Eijes and HeiidJ — This is not strabismus, as both eyes are still parallel, although both are ' This word is used to include two equally important factors, size and suddenness of lesion. " In this country attention was first called to this symptom by Gull, Lockhart Clarke, turned to the right side— to the side of the lesion ; to the non-paralyzed side. Indeed there never is, except as an acci- dental complication, strabismus from palsy of the third or of the sixth nerve in hemiplegia from a lesion above the crus cerebri. The patient,' especially when there is deviation of the head also, seems to be looking fixedly to one side. If the patient be sufficiently himself, we can get him to follow movements of our hand, and we may find that he can bring the two eyes to the middle line or even be- yond it, but they soon fall again into the condition of deviation. Along with this deviation there is often more or less turning of the head to the same side. There is, according to Vul- pian and Prevost, " rotation," as there is after experimental lesion of one side of the brain in lower animals. But in man the rotation is only rudimentary ; there is only a slight iwist, not a real turning. The clinical importance of these symp- toms is that they may be, as Prevost sug- gests, valuable evidence of a local lesion — of a clot, for instance — in cases of coma where we can make out no paralysis of the limbs on one side, and when we are in doubt whether the coma is owing to a very large local lesion, such as extensive cerebral hemorrhage, or to a general con- dition, such as urfemia or opium poison- ing. Two things further are to be noted. In cases of convulsion of one side of the body, the two eyes and the head turn to the side convulsed, and they may be per- manently turned to the paralyzed side if it become rigid, and may strain still fur- ther in that direction when a convulsion or a higher wave of rigidity comes on. (Deviation of the head and eyes may occur in meningeal as well as in cerebral hem- orrhage. ) The Muscles of one side of the Chests — Whether the muscles of the chest suffer and Hutchinson. It has been described by Vulpian and PrSvost of Geneva (Gazette Heb- domadaire, Oct. 13, 1865). Cases by Drs. Humphry of Cambridge, Lockhart Clarke, Broadbent, and Russell Reynolds, and some interesting remarks on the symptom by Dr. Elizabeth Garrett (now Mrs. Garrett-Ander- son), will be found in the Lancet for 1866. ' It has been likened to the conjugate de- viation of the heads of two horses when an omnibus driver drops one of his reins, the other rein being "in tone." As, however, his reins do not decussate, that deviation is from the side of the "lesion." 2 Dr. Broadbent has (Medico-Chir. Review, April, 1866) advanced an important and very valuable hypothesis to explain how it is that whilst the muscles which can act quite inde- pendently of their fellows on the other side of the body (those of the arm, for instance), suffer in disease of the corpus striatum, those which must act together (the intercostals, for instance) do not suffer. LOCALIZATION OF LESIONS. 913 or not in this form of hemiplegia, is dis- puted. Niemeyer says : " Patients who, as a result of apoplexy on the left side, cannot move the right arm or leg, move the right side of the thorax just as well as the left during respiration." Todd says that "it must be an extensive lesion which will paralyze the intercostal and abdominal muscles." In some cases of recent hemiplegia, when the patient voluntarily draws a deep breath, the side of the chest paralyzed certainly some- times moves less than the other (see Wilks' Pathology of Nervous Diseases, Guy's Hospital Keports, 1866) ; probably, however, because the muscles passing from the trunk to the chest on the side of the paralysis will not act so stronglj^ At all events palsy of the muscles of one side of the chest is little, and soon passes off. Face. — The muscles paralyzed are those supplied by the facial (portio dura) nerve. The whole of these sufler, but they suffer slightly. Moreover we find that the sev- eral parts of the face do not suffer in the same degree. And it is to be particularly noted that there is only slight weakening of the orbicularis palpebrarum. The pa- tient can close his eyes, although not so strongly on the paralyzed side when urged to close them both tightly ; sometimes, especially in chronic cases, we discover no difference. Hence this cerebral facial palsy differs remarkably from the facial palsy owing^ to affection of the trunk of the nerve (Bell's paralysis). The side of the cheek is the jjart most paralyzed, so that when the patient is asked to "show his upper teeth" the mouth is decidedly drawn to the sound side. The tongue is not paralj'zed ; it is only weakened on one side, and on protrusion it turns but a very little to one side ; it turns to the side of the paralysis. But sometimes, in case of loss of speech with hemiplegia, especially soon after the attack, the tongue seems to be much paralyzed, as the patient does not put it out when asked, even when he knows what is asked of him ; he may try to get it out with his fingers. The fact that he can utter plainly some one or more words —mostly "yes" or "no" — that he masti- cates and swallows well, and that he may now and then put out his tongue to catch a stray crumb, shows that the tongue is not paralyzed in the ordinary sense of the word. There is loss of the most volun- tary movements of it, and we may find that the patient cannot do other simple things that he is told ; e. g., open his mouth, shut his eyes, or frown. Ar7n and Leg.— The arm suffers more and recovers later. We must not infer that the leg is not affected when the pa- tient seems to move it as well as the other when he lies in bed. If we cannot get him up to walk, we can only say that the VOL. I. — 58 leg IS not much paralyzed. Indeed it is an exceedingly rare thing to find paralysis of the arm without some weakness of the leg soon after the attack, although not at all uncommon to find that the leg recovers when the arm remains much paralyzed. Thalamus Opticus.— Disease of the thalamus opticus produces hemiplegia which, in regard of the motor symptoms, is very like that produced by disease of the corpus striatum. lu grave lesions there is lateral deviation of the head and eyes. Probably, however, the palsy is not simi- larly distributed. I think, for instance, that the arm suffers less, and the leg more, the further back the lesion is placed in the two divisions of the motor tract, the cor- pus striatum and optic thalamus. But in disease of the thalamus there is also diminution, or, soon after the attack, loss of sensation, and not of the arm and leg only, but of the whole half of the body, quite up to the middle line. This loss of sensation has been denied ; one reason no doubt is, and it is important to bear this in mind, that sensation returns much more quickly than does power of move- ment.' Crus Cebebei. — Damage to the crus cerebri causes hemiplegia on the opposite side like that above described, there being loss of motion if the under part of the crus only be damaged, and loss of sensa- tion also if the upper strands be damaged as well. From the crus emerges the first cranial nerve, and at this level of the mo- tor tract we may have " cros.s ^jaraZj/sls. " If the under and inner part of the crus be involved, the third nerve is paralyzed on the side of the lesion — on the side opposite the paralysis of the hmbs. The nerve is, so to speak, caught as it goes in,^ and of course before any of its fibres can have decussated, whilst the fibres from the arm and leg are caught long after their much lower decussation in the medulla oblon- gata. But we can only make the diagno- sis of lesion of the crus when the two symptoms— the palsy of the third nerve and the hemiplegia — come on at the same time. If they come on at difterent times, it is just as likely that there are two lesion's,— one of the trunk of the nerve and the other in the thalamus or corpus stria- tum. This is important in the diagnosis of the nature of the lesion, for when the two symptoms— the palsy of the third nerve, and the hemiplegia— come out at different times, or if the palsy of the third nerve be on the same side as the hemi- 1 For important observations on this sub- ject, see Broadbent, Med.-Chir. Review, April, 2 It is convenient to speak of the fibres of both the motor and sensory nerves as passing from their external distribution to the ner- vous centres. 914 CEREBRAL HEMORRHAGE AND APOPLEXY. plegia, we may be practically certain that there is not Cerebral Hemorrhage. In these cases the disease is mostly syphilis. ' So far the sides of the motor tract are distinct. In the next two divisions the two sides are welded together. Pons Varolii. — Hemorrhage may be limited to one lateral half, or it may oc- cupy both sides of the pons. (It may ex- tend to the crua cerebri or crus cerebelli. ) In the former case there is hemiplegia ; in the latter double hemiplegia, or rather a condition of universal powerlessness, in which, as there is usually deep coma, we can make out no local paralysis — a condi- tion, as we shall see, very like that of uraemia and opium poisoning. In other cases the palsy, although on both sides, is more marked on one side. We speak here of hemiplegia from lesion of one lateral half of the pons,'' and we speak of lesions of the right half. Here again we have to do with cross paralysis, because we have to do with cranial nerves which decussate in the pons itself above the great decussation of the fibres for the limbs. The cranial nerves are the fifth, sixth, and facial. First, for general re- marks on the effect of lesions at difterent levels of one lateral half of the pons, taking the facial nerve (portio dura) for illustra- tion. In the right half of the pons, there are fibres of the right and also of the left facial nerves, those of the right before its decussation, and those of the left after its decussation. (1) A lesion in the lower part of the pons will catch the fibres of the right facial nerve before its decussa- tion, and will also involve the fibres from the left limbs, which have crossed lower down in the medulla. There is then palsy of the right side of the face, on the side of the lesion, and of the arm and leg on the left, the side opposite the lesion. (2) A lesion in the upper part of the pons (Brown-Sequard, op. cit. p. 153) may de- stroy fibres of the left facial nerve which have crossed in the pons, and will also in- volve the fibres for the left limbs. Here then the facial paralysis will be on the side opposite the lesion, and therefore on the same side as the palsy of the arm and leg. The hemiplegia will be like the hemi- plegia from disease above the pons. Hemi- ' An important case of hemorrhage into the crus cerebri has been pnblished by Dr. Her- mann Weber in the Med.-Chir. Society's Transactions, vol. xlvi. This report gives a careful account of the condition of sensation and of temperature on the two sides of the body ; there is a reference to cases previously published. 2 In an article on Cerebral Hemorrhage, we can only do so in outline. For a full account of the symptoms resulting from disease of the pons Varolii, see Brown-S^quard's Lectures in the Lancet, 1861, vol. ii. ; and Lockhart Clarke's papers, Phil. Trans., 1868. plegia of this kind is very rarely caused by disease of the pons. (3) Lastly, Brown- Sequard points out, that a lesion in the middle of the pons will catch the fibres of the right facial nerve before its decussa- tion, and those of the left after its decus- sation. Then the face is palsied on both sides from lesion of the right half of the pons and the arm and leg on the left. To repeat, a lesion of the right half of the pons affecting the facial nerve near its implantation causes palsy of the face on the right side and of the arm and leg on the left. A lesion in the upper part of the right half of the pons causes the palsy of the face and of the limbs on the left side. A lesion of the right half of the pons may be so extensive as not only to affect the right facial nerve before its de- cussation, but to extend to the fibres of the left facial nerve after its decussation. Then there is palsy of the face on both sides, more marked on the right, and palsy of the left arm and leg. What has been said applies to the fifth nerve. An extensive lesion may involve both the facial and fifth nerves, and then there is palsy of the region supplied by the fifth nerve and portio dura nerves of the right side and of the leg on the left. Here it is to be observed that in most cases not only does the palsy of the face in cross paralysis from disease of the pons differ from the facial palsy in the common form of hemiplegia, in that it occurs on the side opposite the limbs paralyzed, but it differs in that it is much more decided in degree. The facial palsy may be as extensive as that which results from dis- ease of the trunk of the portio dura nerve. There is, in short. Bell's paralysis of the face. And when the fifth nerve is affected, the face is ansesthetic, the masseter and temporal muscles are much palsied, and after a time they waste as they do in dis- ease of the trunk of the fifth. There are, in actual practice, combina- tions of symptoms which are more difficult to understand, but which can be resolved by a consideration of Lockhart Clarke's researches. (See especiallv Philosophical Transactions, Part I., 1868.) When the portio dura nerve is paralyzed, we often find paralysis of the sixth nerve on the same side too. The opposite sixth may be also paralyzed in a less degree (Brown- Sequard, op. cit.).' The relation of these two symptoms — the facial and ocular palsy ^is easy to understand when we remem- ber that the facial and sixth nerves, al- though they emerge at difierent places, ' We should carefully examine the condi- tion of the opposite sixth ; and if it be not markedly paralyzed, we may see oscillations in the eyeball when the patient tries to avert it, showing that the external rectus on that side also is weakened. LOCALIZATION OF LESIONS. 915 arise, as Stilling and Lockhart Clarke have shown, from a common nucleus. Again, we must observe that in limited disease in one half of the pons, the parts supplied by the motor division of the fifth nerve may be paralyzed on the side of the lesion when there is no diminution of sen- sation on that side. We find diminution of sensation on the opposite side of the face to that on which the limbs are affected. (This has occurred, in the cases I have seen, only when there has been palsy of the sixth and facial also.) Since Lock- hart Clarke has found that the bundle of fibres of the sixtli and the bundle of fibres of the portio dura nerve, after arising from their common nucleus, diverge so as to inclose the motor nucleus of the fifth — the fibres of the portio dura separating it from the sensory nucleus of the fifth — it is easy to understand why we have, from a single lesion, palsy of the portio dura sixth, and the nwtor division of the fifth all on one side. But the occurrence of tlie diminution of sensation on the oppo- site side of the face is not easy to under- stand unless we assume a crossing of the sensory and motor fibres of the fifth in the pons, on separate levels, analogous to the crossing of sensory and motor fibres of tlie Umbs on separate levels, which Brown- Seqnard has discovered. As to the limbs in hemiplegia from dis- ease of the pons, there is usually affection both of sensation and motion. We find, of course, differences in the amount of loss of power, and of degree of anaesthesia. Moreover, we find differences in distribu- tion of the two. I have seen the leg very much palsied and anaesthetic when tlie arm was scarcelj' weakened but nearly altogether anaesthetic. These points do not specially concern us in an article on Cerebral Hemorrhage, although they are of very great physiological interest, as showing relations of strands of motor and sensory nerve-fibres for the limbs in the pons. Whilst the diagnosis of hemiplegia from hemorrhage on one side of the pons is usually very easy, the diagnosis of hemor- rhage into both sides of the pons is some- times very difficult. A large effusion in this part usually produces death rapidly —in a few hours. In large effusions there is usually marked contraction of tlie pupil on both sides, and there is universal powerlessness — a condition so like that of opium poisoning, that treatment for opium poisoning has been adopted in cases of hemorrhage into the pons. (See Special Diagnosis. ) MedullaOblongata.— Of the effects of effusion of blood limited to the medulla oblongata little is known. A large effu- sion would no doubt be very rapidly fatal, but I have never seen a large effusion here. I have made but one autopsy on a patient who had had a small effusion limited to the medulla. 1 saw this patient with Dr. Lockhart Clarke and Dr. Morell Mackenzie. The patient had recovered from an attack of hemiplegia due, as we afterwards found, to a clot in his right thalamus opticus, when all at once he lost power to articulate from paralysis of his tongue— remaining able to write well. A few years later the patient died, and Dr. Lockhart Clarke,' to whom I gave the medulla oblongata, found in it remains of past effusions of blood. The symptoms which would lead us to infer disease of the medulla oblongata are paralysis of the lips, tongue, palate, and vocal cords. These symptoms, however, mostly come on very slowly, and usually both sides are equally affected. This is so in the "Paralysie labio-glosso-laryngee" of Duchenne. There can be no clot nor any kind of sudden lesion in such cases. If any of these palsies are on but one side, they must be attributed to tumor or to syphilis, if they come on slowly ; but whether on one or on both sides, if they or any of them come on suddenly, they must be attributed either to clot or to softening from thrombosis.^ Cerebellum. — Nothing definite can be said as to the special symptoms pro- duced by hemorrhage into the cerebellum. Sometimes there is loss of consciousness, and sometimes there is not. Sometimes there is hemiplegia, and at other times none. And when there is hemiplegia, it is sometimes on tlie side of the lesion and sometimes on the opposite side. Of course these diflferences depend on differences in the exact part of the cerebellum injured, on the size of the clot, and on the rapidity of the effusion, but these differences have not yet been put in order. When there are no paralytic symptoms, we can make no diagnosis. Sometimes there is a con- jugate deviation of the eyes — not lateral deViation; one eye is turned upwards and outwards, and the other downwards and inwards. When this symptom is present, we may diagnose sudden lesion of the crus cerebelli. When there is hemiplegia, the pais}' is not diagnostic as to the seat of the lesion unless perhaps we can ascertain the absence of facial and lingual palsy. For Brown-Sequard {Lancet, Nov. 2, 1861) says that in hemiplegia from hemorrhage in the cerebellum there is neither lingual nor facial palsy, although there is a loss of facial expression. In cases of deep ' See Phil. Trans., part i. 1868, where the case is published. 2 Here I would refer the reader to very im- portant remarks by Lockhart Clarke (Phil. Trans., part i. 1868, pp. 316-17, &c.), and to a case illustrating his views which I have published (London Hospital Reports, vol. i. 1864, p. 361). 916 CEREBRAL HEMORRHAGE AND APOPLEXY. coma, however, we might he unable to tell whether there was "facial or lingual palsy. But if there be hemiplegia of any kind in a case of apoplexy, we can at all events sa}' there is a local lesion, and this with other symptoms would be good evi- dence of the existence of large Cerebral Hemorrhage — and this is the most im- portant matter — in some part of the cnce- phalon. Vomiting occurs in Cerebral Hemorrhage, but very urgent vomiting would point to Cerebellar Hemorrhage : severe pain at the back of the head would supply still further evidence, but this symptom would only be presented when the patient was not unconscious. Fortu- nately, hemorrhage in the cerebellum is very rare, so that we have not often the chance of being wrong. [Since this article was written, an im- portant advance has been made in the direction of inquiry above pointed out. Localization of brain-lesions (not only hemorrhagic, but also traumatic, inflam- matory, and degenerative) has been during the last deca'cle (1870-80) extensively studied, by combining the results of ex- perimental physiology with those of clini- cal observation and morbid anatomy. Since 1861, Dax, Bouillaud, and Broca have obtained the general recognition in pathology of the causative association of lesion' of a certain portion of the left cere- bral hemisphere with aphasia.' Besides the now neglected but ingenious hypothe- sis of Gall (popularly known as phrenol- ogy), other suggestions had been often previously thrown out, of a similar kind. One of the most noticeable of these was that of Serres,^ based upon two actual cases ; to the effect that "if the right arm be affected, the lesion will be in that por- tion of the brain which corresponds to the upper left parietal bone, and r('ce versa." The study and discussion by Bravais in 1827 of "hemiplegic epilepsy," and some- what later, by Todd, of " epileptic hemi- plegia," followed by Hughlings Jackson's able analysis of unilateral convulsions, and of epilepsy connected with cortical brain lesion, prepared the way for the new era in localization. In 1870 were published the investigations of Fritsch and Hitzig upon the effects of electriza- tion of the surface of the cerebral hemi- spheres in animals. These were fol- lowed by similar experimental inquiries by Ferrier, Schiff, Braun, Jfothnagel, Eckhard, Carville, Duret, Burdon San- derson, Lussana, Vulpian, and Dupuy. In the connected clinical and pathological observations and studies, contributions have especially been made by Charcot, [' See Aphasia, in the article in this vol- ume on Softening of the Brain.] [' Anatomie Compar^e du Cerveau, 1824- 26.] Bouchard, Pitres, Brun, Lepine, Meyiiert, Hugueniu, Proust, Broca, and Hughlings Jackson. Upon the physiological portion of the subject, Ferrier may be considered as the representative authority. From the care- fully studied effects upon animals of the stimulation by electricity of different por- tions of the cerebral hemispheres, he con- cludes that, in the graj' matter of the convolutions, there aro: psycho-^notor zones, which have a functional relation to the voluntary movements of certain groups of muscles. These are not exactly the same in all animals ; being, for example, differ- ently located in monkeys, dogs, and oats. From experiments upon monkeys (con- firmed by a considerable amount of evi- dence from morbid anatomy), it is inferred that the psycho-motor zone is, upon each side, in the immediate neighborhood of the fissure of Rolando ; comprising the ascending frontal and ascending parietal convolutions, the paracentral lobule, and probably the base of the frontal and su- perior and inferior parietal convolutions.' "Broca's convolution," the now accepted seat of the faculty of speech, is the third frontal convolution of the anterior lobe of the left hemisphere. The other " centres" in this zone are, by the advocates of localization, regarded as governing the volitional movements of the head, eyes, eyelids, pupils, angles of the mouth, arm, hand, leg, and foot. Fer- rier draws an important distinction be- tween the central determination of volun- tary, and that of automatic, instinctive, or reflex movements. The latter he refers to the lower centres, at the base of the brain ; ascribing to the gray matter of the limited region above named those actions only which involve conscious discrimina- tion. He also asserts (with less amount of plausible evidence, however) the exist- ence of sensory centres, in the parieto- temporal region, between the motor-zone and the occipital lobes. To these, the occipital lobes, he ascribes, hypothetically, a governing relation to the viscera, and the functions of organic life. The most anterior frontal and orbital regions of the cerebral hemispheres he believes may be the seats of true psychical centres. Somewhat confirmatory of these views, as to a regional subdivision of the func- tions of the hemispheres, are the observa- tions of Duret, Cohnheim, and Charcot, upon the distribution of the arterial cir- culation of the brain. Duret asserts that the areas or territories of vascular supply are to a considerable extent independent of each other. This has great conse- quence in connection with cerebral em- [' See Ferrier on the Functions of the Brain, 1876 ; on Localization of Cerebral Dis- ease, 1878.] LOCALIZATION OF LESIONS. 917 bolism. The "motor zone" is supplied by the superficial branches of the Sylvian artery. If thrombosis or embolism of this vessel occur after it has given off the branches going to the corpus striatum, on either side, softening may occur in the psycho-motor region alone; producino- hemiplegia of the opposite side as one of Its results. Notwithstanding the amount of evi- dence accumulated in favor of this theory ol localization, it cannot bo considered Lateral view of brain, showing fissures and convolations. Fig. 55. Inner surface of hemisphere, showing convolutions and fissures, and Ferrier's ceutres of touch, smell, and taste. Fiasarea (Figs. 54 and 55) : — a, superior frontal ; b, inferior frontal ; c, fissure of Rolando ; d. fissure of Sil- vlus ; c, inter-parietal ; /, fronto-parietal ; ff, parieto-occipital ; ?i, first temporo-sphenoidal ; i, second ditto ; j' inferior ditto ; ft, occipito-temporal ; I, calcarine ; m, hippocampal. Convolutions (Figs. 64 and 50) : — A, superior, or first frontal ; B, second ditto ; C, third ditto ; D, ascending frontal ; E, ascending parietal ; F, superior parietal ; F^, prfficureus ; G, supra-marginal ; Gi, gyrus annularis, It pU courbe ; H, first temporo-spbenoidal ; I, second ditto; J, tliird ditto; K, fusiform lobule; L, linpual lobule ; M, gyrus fornicatus ; M^, gyrus hippocampi ; My^, uncus gyri fornicati, or subiculam cornu Ammonis ; If, cuneas. yet as a finally established doctrine in Physiology. Brown-Sequard has brought the weight of his immense experience in cerebro-nervous experimentation and mor- bid anatomy to bear against it. Vulpian, Lussana, and Lemoine prefer to ascribe to the fibres of white substance, connected with the cortical gray matter of the brain, the motor control in question. Goltz, Schiff,' Munk, Luciani, and Tamburini" have obtained considerably different ex- perimental results from Ferrier's. Brown-Sequard's position on the sub- ject affords a remarkable exemplification [' See also Lauterbach, Amer. Journal of Med. Sciences, October, 1877, p. 371.] [2 Brain, July, 1879, p. 189.] 918 CEREBRAL HEMORRHAGE AND APOPLEXY. of the liability of vivisectory experimenta- tion to complicate the problems it pro- ceeds to solve. After having arrived at quite different results in his previous in- vestigations, they, and those of other physiologists, have been, by his last de- monstrations, swept away ; with the de- duction of conclusions such as the follow- ing : a lesion of one side of the brain can produce symptoms either on the same or on the other side of the body ; a lesion on both sides of the brain may cause symp- Lateral view of brain, showing Ferrier'B psyclio-motor centres. Fig. 57. Upper aspect of brain, showing on left side Ferrier's centres ; on the right, the arterial arese. The Roman numbers in Fig 66, 57, and 55, refer to Ferrier's centres. I, lateral movements of head and eyes, with elevation of eyelids and dilatation of pupils ; II, extension of arm and hand ; III, complex movements of arm and leg, as in climbing, swinging, &c. , IV, movements of leg and foot, as in locomotion ; V, movements of lips and tongue, as in articulation , VI, depression of angle of mouth ; VII, elevation of angle of mouth ; VIH, supination of hand and flexure of forearm ; IX, centre of plaiysina^ retraction of angle of mouth ; X, movements of hand and wrist ; XI, centre of vision ; XII, centre of heai-ing ; Xlll, centre of touch ; XIV, centre of smell and taste. (From Bristowe.) toms limited to one side of the body ; and most extensive lesions may occur in any or all parts of the brain without corre- sponding symptoms. Instead of a few restricted cerebral centres governing spe- cial functions, he believes that very nume- rous brain-cells related to each of such functions must be located throughout the hemispheres ; acting in solidarite by means of intercommunication amongst them. LOCALIZATION OF LESIONS. 919 Each hemisphere, especially, he asserts to be ill itself complete for all brain func- tions, for both sides of the body ; although both are not nearly always alike devel- oped and actively used. Minute anatomy has not yet furnished a complete explana- tion of the intercommunication of all parts of the brain ; the exact nature and func- tions even of the neuroglia cannot be said to be fully understood. Analogj' fur- nishes an important suggestion, in the discovery by Gerlach, confirmed by Boll,' of a network of extreme fineness in the spinal cord, composed of the union of the ramifying nerve-filaments of the spongy substance of the cord. Dupuy, by his experiments, has placed a great difficulty in the way of the adop- tion of the hypothesis of cortical motor ceutraHzation. Having exposed the "mo- tor zone" of the left hemisphere of a dog, he produced the usual movements by elec- trical stimulation, and then cauterized the cortex of that region. Electricity applied to the cauterized part still caused the same movements. Leaving the ani- mal for four weeks, it presented no symp- toms affecting the motor functions. Then, reopening the wound, he found a dry eschar, with meningeal adhesion. Elec- tricity applied to the eschar produced no movement ; but application of the current to the parts around the eschar brought on muscular action. This certainly shows great insufficiency in the proof of the de- pendence of the motor function upon the condition of the cortical substance. This, indeed, is not exactly what Eerrier has asserted, ■ as he refers a large class of movements to the corpora striata and other lower brain centres, and dwells on the fact that actions which at first are volitional, may become subsequently automatic ; the superintendence of the higher centres being sometimes, when in- complete, supplemented, or even substi- tuted by the lower centres. This happens with especial facility in the loiver animals. On the whole, all that has been pre- viously known and rendered probable of the functions of the cerebral hemispheres makes it reasonable to emphasize what Terrier recognizes as the psijchical element in the history of these phenomena. Other reasons exist, which have been very gen- erally overlooked, for concluding that the anterior portion of the cerebrum is emo- tional in function ; the intellectual powers having their seat in the posterior, or pos- tero-median, portion.^ Per emotional [' See Erb, in Ziemssen's Cyclop, vol. xiii.] [^ Since 1860, I have taught this in lec- tures to students of physiology ; having been led to it by facts in embryology and compara- tive anatomy, to whicli this would not be the place to allude in detail. See my Manual of Physiology for Students, 2d edit., Philada., 1874.] expression there must be a relation to the muKcles, through their immediately con- trolling centres ; and this relation appears to be well established in regard to certain parts, at least, of the anterior region of the brain. As a question in Physioloo-v this is all that should be claimed as s^et- tled ; the nature and extent of the relation being yet open for farther investigation. In experimentation upon the brain and nervous system, one of the most impor- tant facts is, the frequent diffusion, not only of electrical stimulation, but of all impressions. Action at a distance, through nervous conduction, directly stimulant, reflex, or inhibitory, is, rather than exceptional, almost the rule. This Introduces a great difficulty into the in- terpretation of results, both of vivisection and of accidental injury or disease.' Coming to our immediate subject of the pathology and diagnosis of brain afiec- tions, this must be considered upon the merits of its own evidence, while awaiting the explanations of Physiology, to be hereafter completed. It has been known since the time of Andral, that extensive lesions of the cerebral cortex may occur without motor symptoms. Andral, Vaut- tier, Marot, Herpin, Sabourin and others" have reported cases of this kind. Men- tion has been made already of the names of those who have especially studied of late the coincidence of marked muscular symptoms (paralysis, convulsions, &c.) with lesions of a limited portion of the surface of the hemispheres. It is necessarily admitted' that, as yet, it is not always possible to make during life a certain diagnosis between paralysis from lesion of the cerebral cortex and that from lesion of the corpus striatum, alone, or involving a portion of the inter- nal capsule. In both, those movements are most affected which are the most voli- tional. Sensation is not affected in either, if the lesion be confined, in the one case, to the cortex, in the other, to the anterior two-thirds of the capsule. In neither is the nutrition or electric contractility of the paralj'zed muscles impaired. In both, a tendency exists to the development, sooner or later, of descending S(;lerosis of the motor tracts of the crus, pons, me- dulla oblongata, and spinal cord, with late rigidity or contraction of the para- lyzed limbs. Characteristic, however, of paralysis of [' To make the most of this argument, one might ask what more of demonstration is there of purely motor centres in the cortex of the brain, tlian there is of epilepto-genetic centres in the skin of the guinea-pig, under Browu- Sequard's experiments ?] [2 Charcot and Pitres, Revue Mensuelle de MMecine et de Chirurgie, Jan. 1S77.] [3 Farrier, Localization of Cerebral Disease.] 920 CEREBRAL HEMORRHAGE AND APOPLEXY. cortical origin seems to be the occurrence of dissociated paralyses, or nionoplegiee. An arm and hand alone, or the face, or one leg, may be atfected with paralysis, which may successively extend to other parts. A comprehensive summary from Ferrier' may conclude our account of this subject : — " Wliile we cannot be quite certain of the position or extent of a cortical lesion causing a sudden and complete hemiple- gia, we may take a monoplegia of the leg or of the arm and leg as an indication of lesion of tlie upper extremity of the ascend- ing convolutions close to the longitudinal fissure ; bracliial monoplegia as a sign of lesion of the upper part of the ascending frontal convolution, or, if the paralysis affect the hand more particularly, of the ascending parietal convolution ; brachio- facial monoplegia as indicating lesion of tlie mid-fronto-parietal region ; while fa- cial and lingual monoplegia, or tliis com- bined with aphasia, indicates lesion of the lower part of the ascending frontal con- volution, where the third frontal unites withit."— H.] The Apoplectic Condition. Apoplexy, as was remarljed in the In- troduction, p. 902, is not peculiar to Cere- bral Hemorrhage. It will be seen when we come to Special Diagnosis tliat it is sometimes difiicult and occasionally im- possible to tell whether Apoplexy is owing to a fatal lesion of the brain, or to the comparatively minor cause, deep drunken- ness. Again, from clot there are all de- grees, from slight and transient mental obscuration to profound and rapidly fatal coma. It is not a xiriori likeh', when we consider that the clots vary in size, in the suddenness of their irruption, and in their seats of effusion, that tliere would be any uniformity in the conditions produced by Cerebral Hemorrhage, and, as a matter of fact, the conditions vary very much in- deed. "We can here only speak of severe cases, admitting that they are not typical. Under the head of Diagnosis we shall notice cases of Cerebral Hemorrhage in which there is no loss of consciousness ; and under the head of Special Diagnosis, various degrees of impairment, or "loss of consciousness"— if the phrase degrees of loss of consciousness be permissible — will be spoken of. The striking symptoms of the apoplectic condition are, (o) loss of consciousness, (6) states of pupil, (c) stertor, [d) altera- tion of pulse, respiration, and tempera- ture. Loss of Consciousness. — "We are consid- ering a severe case — apoplexy, the result [' Op. citat.] of a large and sudden hemorrhage— and as we admit that such a case is not typi- cal, we shall only discuss how it happens that from a cirnimscribed lesion in but one side of the brain there results total aboli- tion of consciousness. We know that loss of consciousness can- not result from mere lack of the compara- tively small part which tlie hemon-hage has destroyed, for, as autopsies sliow, much of the brain may remain lacking for years in patients wlio have been uncon- scious only a few hours or days at the time when the destroying lesion occurred. But Cerebral Hemorrhage is a bulky le- sion — it squeezes ; it is also a brusque lesion — it not only destroys, but it de- stroj's suddenly — there is shock. Niemeyer attributes the loss of con- sciousness to squeezing. He does not suppose it to depend on squeezing of the nerve-iibres and cells, but on squeezing of the capillaries ; in other words, he attri- butes it to rapid anaemia of the brain, produced mechanically. It is true that there is no loss of consciousness in cases of very large cerebral tumor when there is evidently increased intracranial pres- sure ; but clot and tumor are manifestly not comparable lesions. Tumors increase slowly, and probably, as Niemeyer sug- gests, the fibres of tlie part of the brain directly compressed become atrophous, and thus more room is made. Again, there is compensation by diminution in the quantity of cerebro-spinal fluid. But blood is rapidly effused, and the clot will squeeze before either of these modes of accommodation can take place, and thus the accommodation is, according to Nie- meyer, obtained at the expense of the capillaries. They are emptied. In esti- mating the gravity of a lesion, rapidity is to be considered almost as important a factor as size, as will be best seen when we come to speak of sudden death from intracranial hemorrhage. Mr. Hutchinson (Lectures on Compres- sion of the Brain, London Hospital Re- ports, vol. iv., 1867) also believes that the apoplectic condition is the result of ex- tensive and rapid squeezing of a large quantity of the brain, and that the direct cause of the loss of consciousness is sud- den anaemia quoad arterial blood. He points out that an enormous effusion, if it occurs very slowly, need not be attended by any insensibility whatever. The above theory of the occurrence of loss of consciousness firom aneemia, me- chanically caused, may serve in the ex- planation of many cases of large Cerebral Hemorrhage, but will not serve in all cases. It does not explain, as Jaccoud insists, the transitory loss of conscious- ness which sometimes occurs from small clots, the squeezing from which can be very trifling. Moreover, there are many THE APOPLECTIC CONDITION. 921 cases of loss of consciousness from other causes in whicli there can be no squeezing, for instance in some cases of embolism' of the middle cerebral artery, and in the fit of epilepsy. In cases of laceration of the brain from injury — cases without any con- siderable effusion of blood being now con- sidered — the apoplectic condition comes on although there is no squeezing. Thus _ Mr. Hutchinson says: "It is bometimes quite impossible to make any diagnosis by the symptoms alone [eases where there is no history of the mode of onset, for in- stance] between cases of sudden compres- sion of the brain and those of laceration of the brain." We must consider the shock -producing element — that of sud- denness of lesions. We may here avail ourselves of what Jaccoud has written in his important work, "Pathologie Interne," vol. i. p. 164. The normal function of the brain, he says, depends on the joint and simul- taneous activity of its two halves. When one is injured, the other can in a certain measure compensate, provided the lesion occurs slowly, as in tumor. But the dis- turbance of a sudden, although local, lesion reacts on the whole brain, its two halves being united hy '•'■ powerfuV co nunissurcs. The torn brain receives a shock on the side injured directly, and this is trans- mitted and reflected on the other side, and then there is produced the "n^vro- lysie"^ which is apoplexy. In unconsciousness produced by urcemia there may be no arterial antemia in the ordinary sense of the expression, but still in effect the action will be the same. The blood is not good arterial blood. But, if we accept Traube's view that Bright's disease leads to ojdema of the brain, there will be veritable ansemia in ursemia from the squeezing which the exuded fluid will cause. ' He says, op. cit. p. 139, of the apoplexy which occasionally occurs from embolism, that it may be attributed "soit &, une n^vro- lysie prodiiite par la perturbation subite de rSqnilibre circulatoire (Jaccoud), soit ^ iin (Bdime aigu ggnSralise par suite de I'augmen- tatiou de pression dans les artferes permeables (Niemeyer). Cette derniSre interpretation me parait difficilement admissible pour les cas oil I'apoplexie dure a peine quelque min- utes." 2 Niemeyer, op. cit. vol. ii. p. 184, admits that "the entire loss of consciousness, the apoplectic attack, which usually accompanies the commencement of hemiplegia when the arteria fossse Sylvii is stopped by an embolus," is diifloult to explain. He thinks it is "most probably due to the diseased hemisphere be- ing decidedly swollen by collateral oedema, and that, as occurs in large extravasations of blood, the opposite hemisphere is not suffi- ciently protected from the pressure by the falx, which only offers a limited amount of resistance." _ Pupils.— Thuxe seems to bo a wide-spread impression that when a patient is coma- tose, his pupils must be either "con- tracted" or "dilated."' It is quite cer- tain that there may be a very hirije clot on one side of the brain when tlie'pupils cannot be declared to be normal. Ex- treme contraction or extreme dilatation of the pupils are rare symptoms in Cerebral Hemorrhage. It is to be observed that in the many cases of coma, although the pupils are very small when the patient is left still, as small as in healthy sleep, they may become much larger when attempts are made to rouse him. Prom not con- sidering this, different accounts are given as to the condition of the pupils in the same case by different observers, or there are supposed to be remarkable variations in the signs of the pupils. On the Avhole, the conditions of the pupils are of little value. ^ We shall speak of contraction of both pupils under the head of Diagnosis of Apoplexy, owing to hemorrhage into the pons, from opium poisoning. Tlie follow- ing further remarks on the pupils belong strictly to diagnosis, but they are most conveniently considered here. Importance must be attached to differ- ence in the size of the two pupils, but only when the difference is great ; for the pupils are often of slightly different size in healthy people. Difference in the size of the pupils points to a local lesion. Thus, were one pupil very minutely contracted and the other presumably unaltered, the contraction would be some evidence of dis- ease of the pons Varolii on the side of the contraction. But I have not yet seen minute contraction of the pupil on one side from clot in the pons when there has been coma. I have seen it in cases of hemiplegia from disease of one side of the pons : in one of these cases there was a clot. Were one pupil very loidely dilated, it would lead me to search most carefuUy for signs of injury to the head, as Mr.- Hutchinson has found very wide dilata- tion of one pupil in cases of blood effused ' In case-taking, I prefer the terms small and large, as they have not the misleading implications the more technical terms have. 2 Dr. Wilks says (Guy's Hospital Reports, 1866, p. 177) that "we cannot connect the conditions of the pupils with any definite le- sions, for their state is very variable and lia- ble to be influenced by very slight causes." Speaking of the contraction of the pupils ob- served in disease of the pons, he adds, "just as we see this produced by effusion of blood at the base or into the ventricle." Callender (St. Bartholomew's Hospital Reports, vol. iii. p. 430), speaking of the pupils in oases of injury to the head, says, "their condition varies remarkably in these cases, and no sort of reliance can be placed upon the appearance they may seem to present." 922 CEREBRAL HEMORRHAGE AND APOPLEXY. under the dura mater in the sphenoidal fossa from fractured base ; the dilatation is on the side of the effusion. During convulsive seizures the pupils may dilate very widely; this is not always the ease. Stertor is the sign of a grave lesion, or more generally of serious implication of the brain, and, like the other symptoms of the apoplectic condition, is not of diag- nostic value. There may be uraemia, alcoholic poisoning, or large Cerebral Hemorrhage. It will occur in any one of these conditions. It may be absent in any of them, and is often absent in apo- plexy from Cerebral Hemorrhage. The noise made will depend on the condition of the respiration, and varies with it in the same case. It shows that the lesion is large enough or widely enough spread in the brain to affect muscles supplied by or through the ganglionic nervous system. It is of value in prognosis. It shows grave lesion. Pulse, respiration, and temperature. — This is the most important and at the same time the most difficult part of the subject. It is really impossible to give a proper account of the condition of pulse, respiration, and temperature without cit- ing numerous cases, and these would show extreme differences, differences so great that it is most difficult to make generalizations. The great point to ob- serve is that the condition of the pulse, respiration, and temperature varies very much according to the time elapsed from the seizure. So that so far as the pulse, respiration, and temperature are con- cerned, the patient may be in opposite conditions according as he is seen early or late. And since the lesions differ greatly in gravity — in size and suddenness — we can say nothing definitely as to time. "What is early in one case is late in an- other. This is obvious when we consider that a clot may destroy life in an hour, or may not kill for days, or that the pa- tient may recover from it. Moreover, alterations of pulse, respiration, and tem- perature, depression of them at all events, are not peculiar to Cerebral Hemorrhage; they are found in cases of meningeal hem- orrhage, alcoholic poisoning, and even in some cases of tumor of the brain. We are obliged then to speak most generally. For convenience we make two stages of the apoplectic condition : one we call col- lapse and the other reaction. There is no absolute demarcation betwixt the two. Loss of consciousness continues through both. Of course, if the clot be small there are no stages— neither collapse nor reaction. Again the patient may recover from his collapse, if it be faintly marked, without any obvious reaction ; he may die rapidly, and then there is practically no question of stages. First stage :— Soon after the effusion, even of a large clot, the pulse, respiration, and temperature may be absolutely nor- mal, the patient seeming as if gently asleep. But we shall speak of cases in which they are abnormal ; the symptoms are those of depression. The face is pale, the pulse is slow and labored, the respira- tion is shallow, and the temperature is lowered. The pulse may be 60 or under, the temperature may be in the axilla 96 or lower. In the second stage, the stage of reaction, the pulse quickens, respiration quickens, and the temperature usually rises, for instance, to 101, or 103. Shortly before death, it may rise to 107 or more. These points concern us most in prognosis : the quicker the pulse and respiration, and the higher the temperature, the less likely is the patient to recover. We frequently observe also tliat the pulse becomes irreg- ular or intermittent. The respiratory ac- tion undergoes great variation in fre- quency. Thus the patient for a while lies breathing quickly, but pretty evenly in rate, and then for a short time there is a series of more rapid respirations, with loud stertor, after which comes a period of comparative calm. Again, not only is the rate of respira- tion to be considered, but the character of the respiratory movements are to be noted. As they quicken in rate, so do they become more extensive in range, though each respiration is still short. Thus, in the first stage there may be only quiet action of the diaphragm, but at length the sides of the chest evert strongly in inspiration, the abdominal movement being less obvious, and at length the up- per thorax takes part in the process. In severe cases the epigastrium sinks in dur- ing inspiration. This is probabl}' partly owing to elevation of the attachments of the diaphragm from increased action of the sides of the thorax, and partly to pushing down of the diaphragm by the increasing bulk of the lungs from conges- tion or oedema. Diagnosis. An account has been given of the gen- eral bodily state of the patient who is especially liable to Cerebral Hemorrhage. We have described the symptoms which we know that hemorrhage produces — both the local, such as varieties of hemiplegia, and the general, the apoplexy which oc- curs from large and sudden hemorrhages; but other lesions produce exactly similar local symptoms, and many conditions cause Apoplexy. We now come to the most difficult part of our subject— Diag- nosis. Under this head we speak first of Premonitory Symptoms ; next of Modes BIAaNOSIS. 923 of Onset, under which will be considered the comparatively simple cases of patients who have hemiplegic symptoms ; and lastly, under Special Diagnosis, of the condition of those apoplectic patients in whom we can discover no hemiplegia. The separate consideration of those cases of Cerebral Hemorrhage in which there is, and of those in which there is not hemi- plegia, is justified by convenience ; for practically they are different things. When called to a patient who is hemi- plegic, whatever other difficulties we have, we are certain, since there is clearly a local lesion of some kind, that there is not only drunkenness, uraemia, poisoning, &c. ; but if we make out no hemiplegia, we maybe in doubt whether the apoplexy be owing to a very large clot in the brain, to a very central one as in the pons, or to some one of the more general conditions mentioned. Premonitory Symptoms. — The gene- ral bodily condition already described (p. 906 et seq.) furnishes the best basis for premonition, and in no nervous affection in people of, at least, middle life, however trivial the symptoms may be, do we neg- lect to examine the heart, arteries, and urine ; but that condition leads to, or is associated with, disease of many parts of the body. We here speak of slight ner- vous symptoms which point more expressly to the future occurrence of Cerebral Hem- orrhage, and which, when occurring in a patient who has degenerated arteries, hy- pertrophy of the left ventricle of the heart, and chronic renal disease, show it to be very likely that this unsound state in his particular case is about to lead to decided hemiplegia, or fatal apoplexy, from the rupture of vessels in the nervous centres. Some of these patients, however, die after having had slight warning symptoms — some evidently due to hemorrhage, for we may have seen clots in retinae and have heard of epistaxis — in other modes, as by pericarditis, uraemia, &c. Before we speak of special premonitory symptoms, we must remark that some pa- tients who die of Cerebral Hemorrhage have had none, at least we hear of none ; and this is sometimes the case when ex- amination both during life and after death reveals signs of most extreme degenera- tion. The degeneration of arteries of which we have spoken (p. 907) leads to two pa- thological states of nervous centres ; to softening by thrombosis, and to hemor- rhage by rupture. The slight symptoms of which we are about to speak as pre- monitory of Cerebral Hemorrhage may depend on either ; practically it matters little, since the symptoms to be mentioned may be taken as warnings of the possible supervention of large Cerebral Hemor- rhage, ivhether they signify small hemor- rhages or very limited softening. It may however, be denied that there is any local lesion when such slight symptoms as those I have to mention pass away altogether in a few hours or days. Besides the reply that local symptoms of necessity imply local lesion, it may be added that it is quite certain that even decided hemiple- gia, whether from clot or from softening, will pass away even when, as subsequent post-mortem examination shows, tht^re remains a permanent, although a small, void in the motor tract. One general remark may be made : the premonitory symptoms of Cerebral Hem- orrhage are owing to affections of nervous centres, and not of nerve-trunks. In cases of Apoplexy from rupture of aneu- risms of the larger cerebral arteries, there may have been palsy of a nerve-trunk — third especially — from compression of that nerve-trunk by the aneurism ; but rup- ture of such aneurisms, with very rare ex- ceptions, leads to meningeal, not to cere- bral hemorrhage. There are, however, some seeming exceptions to the rule laid down. We may have palsy of the tongue from hemorrhage into the medulla oblon- gata, and palsy of parts supplied bj' the facial nerve from thrombosis or small clot in the pons ;' but these are, as stated, only seemingly exceptional. The}' are not owing to affections of nerve-trunks ; and practically, when we are consulted for palsy of any cranial nerve, we do not attach much importance to it as a warn- ing of Cerebral Hemorrhage, we think of syphilis, and, if the nerve palsied be one of those to the muscles of the eyeball, of locomotor ataxy also. So far negatively. The symptoms which are premonitory of Cerebral Hemorrhage are innumerable. We may divide them into two classes, local and general. The local ones to be mentioned are : Defect of Sighf occurs now and then before Cerebral Hemorrhage. In these cases we find mostly the degeneration of the retinae which occurs with Bright's disease, and usually Unear clots are to be seen in the retinae too ; indeed it is an affection of a nerve centre,^ and of one ' Dr. Moxon has recorded (Path. Soc. Transactions, 1869-70) a case of paralysis of the portio dura nerve from hemorrhage into the aqueductus Fallopii. 2 I do not know that deafness is of value as a warning of Cerebral Hemorrhage ; it is a rare symptom in cases of serious brain disease of any kind. s In many of these cases of retinal hemor- rhages there has been nasal hemorrhage also. Epistaxis, however unimportant in itself, is a serious warning if there he chronic Bright's disease. It is of very great importance to use the ophthalmoscope in all cases of bram disease. There are often changes significant of Bright's disease, so well marked that the 924 CEREBRAL HEMORRHAGE AND APOPLEXY. supplied by the same arterial system of the brain, and is not owing to aftection of a nerve-trunk. The existence of these changes makes us take a very gloomy view of the case of a patient who has even the slightest nervous symptoms. ' If we find either optic neuritis or any kind of optic atrophy, we cannot infer liability to Cere- bral Hemorrhage unless we know that the atrophy has followed the neuro-reti- nitis of Bright's disease. Indeed optic neuritis (there being no albuminuria) is rarely associated in any way with Cere- bral Hemorrhage. It rarely precedes, and it very rarely follows it. As, how- ever, optic neuritis is frequently associ- ated, especially in young persons, with tumor of the brain, there is to be consid- ered the liability to hemorrhage from tumor ; but this is of very rare occurrence. Limited Facial Palsy. ^ — This is really a part of an attack of hemiplegia. It is the kind of facial palsy which occurs in hemi- plegia which is so common in disease of the higher motor track. (See p. 913.) "We must observe, however, that a facial palsy of exactly the same kind occurs after cer- tain epileptiform seizures ; but in these cases there is occasional spasm of the paralyzed part. The patient is usually young, and we have often a history of syphilis. The facial palsy which is a warning of Cerebral Hemorrhage comes on suddenly without spasm, or is found on waking, and usually passes off in a few days. It is a very unfavorable sign, be- cause it shows central disease. Speech. — There may be loss of speech with the above-mentioned kind of facial palsy, but more often there is defect of speech only ; a difficulty of articulation for which the degree of palsy of the face and tongue does not account; and we find that the patient writes, that is expresses himself in writing, about as badly as he talks. Again, there is central disease. Speech defects are not of special value as warnings of Cerebral Hemorrhage unless they come on suddenly. We must also bear in mind that temporary loss of speech occurs from embolism; at all events it occurs in young patients who have valvu- lar disease of the heart. Occasional mis- takes in words occur in many presumably oplithalmic surgeon is the first to discover that the patient has Bright's disease. There m/iij be no impairment of sight when the oph- thalmoscopical appearances are extremely well marked. This is to be strongly insisted on. ' I may here refer to a record of several cases in a lecture on Cerebral Hemorrhage (London Hosp. Reports, vol. iii. 1866). In some cases of coma the detection of these changes may enable us to make the diagnosis of Cerebral Hemorrhage. 2 See Trousseau (Bazire's Trans.), vol. i. lect. 1. healthy people, and their significance as evidence of coming cerebral disease of any kind is, I think, overrated. Suddenly oc- curring difficulty of articulation is the condition of most evil import. Slight weakness or numbness of o»je arm and leg points to a local and central lesion, although to a minute one ; but many peo- ple are subject for years to a slight numb- ness and to queer feelings on one side, who seem to be otherwise in good health, or the symptom obtrudes itself when they are slightly out of health— dyspeptic, for instance. It is not uncommon in young and apparently healthy people. A slight weakness of one side is only of value as a warning of Cerebral Hemorrhage when it occurs suddenly without spasm, and even then we do not attach great importance to it unless the patient be past middle age and show signs of degeneration. Successions of slight local symptoms are of more value than any single symptoms. From syphilis also there are successions of nervous symptoms : they are such as palsies of cranial nerves, optic neuritis, partial convulsion. But preceding fatal Cerebral Hemorrhages we may find epis- taxis ; defect of sight from degeneration of, often with clots in, the retinse ; sudden numbness or weakness on one side (with- out spasm) ; occasional difficulty of articu- lation, and drawing of the face. These are due to affections of nerve-centres ; or the patient may have many epileptiform paroxysms of very different kinds, some- times slight without loss of consciousness, sometimes severe with tongue -biting, sometimes local, sometimes general. Here we suspect small meningeal hem- orrhages. General Premonitory Symptoms. — A page might be filled by the enumeration of symptoms of this class which authors give as warnings of Cerebral Hemorrhage. They are such as drowsiness, loss of mem- ory, especially for recent events, irrita- bility of temper. Such symptoms point only to general deterioration of brain, to slow wasting, for instance — and do not point especially to a liability to Cerebral Hemorrhage. More valuable symptoms of this class are giddiness, pain in the head, and vomiting. But these again may be found in the onset of many kinds of brain disease ; for instance, in young people the subjects of cerebral tumor : in- deed, if the headache be intense and con- tinued for weeks, and if the vomiting be urgent, it is, provided there be no albu- minuria, likely that there is tumor. If, however, the symptoms come on suddenly in a person of middle age, especially if there be slight confusion of mind at the time, and above all if there be any para- lytic symptom, however faintlj- marked, such as thick speech or unilateral weak- ness, they may be taken as warnings of DIAGNOSIS. 925 Cerebral Hemorrhage. Doubtless they are owinjj to small clots or to limited thrombosis. If there be albuminuria, they are often ascribed to uremia. Pa- tients with chronic Bright's disease are prone to attacks of headache and vomit- ing, especially on getting up in the morn- nig. Even if these symptoms are de- pendent on ursemia, they may still be considered as warnings — indirect, it is true — of the possible future advent of Cerebral Hemorrhage, when they occur in a person past middle age who has tough arteries, hypertrophy of the left ventricle of the heart, and no notable dropsy with his albuminuria. The Mode of Onset of Ceeebral Hemorrhage. — This is often the only diagnostic evidence of value, and in many cases when it is not forthcoming we can- not make a diagnosis at all — as when a patient is found by the police in the streets "drunk and incapable." When we consider that the clot differs in seat, in size, and rapidity of effusion, we cannot a priori expect any great uni- formity of manner of onset ; as a matter of fact it varies greatly indeed. A pa- tient may not be unconscious from a hem- orrhage large enough to produce perma- nent hemiplegia, or he may, minutes or houi's after being hemiplegic, become apo- plectic, or he may become apoplectic almost without prior symptoms. I say almost, because however quickly Apo- plexy from Cerebral Hemorrhage comes on, there are nearly always some prior symptoms. As Trousseau says, Apo- plexy, in the classical sense of the word — a sudden falling — is rare in Cerebral Hemorrhage. There is nearly always something wrong before the patient be- comes unconscious, and often the interval is considerable — minutes, or even hours. Trousseau excepts cases beginning by con- vulsion, and also cases of hemorrhage into the pons Varolii ; but even in cases of hemorrhage into the pons, there are, I believe, mostly some symptoms before the loss of consciousness. Thus, I have notes of a case of a man who came off a scaffold because he was giddy before he became insensible, and of another patient who, when taking a drink, cried out that he was poisoned. Dr. Hare relates the case of a patient who was able to knock at a door and say she was going to die before she became insensible. In each of these cases there was large hemorrhage into the pons. In considering special modes of onset we shall give further illus- trations. The first statement as to mode of onset is that Cerebral Hemorrhage, even when large enough to produce Apo- plexy, does not as a rule cause Apoplexy instantly. To consider mode of onset more par- ticularly we must make a grouping of cases. The following, although in actual practice we sec all degrees of interme- diateness, is convenient. linpid Death.— This practically includes onset and termination. It is a rare thing for Cerebral Hemorrhage to cause rapid death ; within half an hour, for instance. 'From theoretical considerations we might suppose that when the clot is effused near to the medulla oblongata — in the pons — death would occur very rapidly ; but as a matter of fact it rarely does. Yet cases of sudden death are frequently put down to "Apoplexy," Cerebral Hemorrhage being meant. Since this term is often made to include meningeal hemorrhage, the statement is not altogether wrong, for meningeal hemorrhage may cause death in a few minutes — Ave, for instance, and probably in less time. Yet, since menin- geal hemorrhage may lead to death very slowly, we have to infer that it is rapidity of effusion which is rapidly fatal, and not the position of the hemorrhage. If the patient dies rapidly, within half an hour let us say, cerebral hemorrhage is most unlikely. If he be young and healthy- looking, the probability is that there is meningeal hemorrhage from rupture of an aneurism of a large cerebral vessel. Usu- ally there is a convulsion in these cases, and if death occurs "in a fit," or very quickly after, we still incline in a young person to the diagnosis of ruptured aneu- rism ; but it is quite certain that in some cases of death in a first convulsion we discover nothing abnormal post-mortem. If death occurs instantly — the patient dying in a minute — we infer failure of the heart, rupture of aneurism of the aorta into the pericardium, or rupture of the heart itself. Death by intracranial hem- orrhage is never so exceedingly rapid as it often is from these causes. Co^imdsion.— This mode of onset has been considered in the article Convulsion, (p. 7.37). What further is to be said will find its place best when the cases of pa- tients who are apoplectic without discov- erable paralysis are spoken of. However, convulsion from clot is frequently followed by apoplexy with hemiplegia ; such cases will be considered under the head of " Hemiplegia with loss of consciousness. " Hemiplegia without loss of Consciousness. —If we are called to a patient of, or past, middle age who is hemiplegic without loss of consciousness, we have to consider two possible kinds of lesions : softening from thrombosis ;' clot from rupture of a ves- sel. In the great majority of cases hemi- plegia without loss oi^ consciousness is the result of local softening. I believe we can say very little more than this, for a ' For further points in diagnosis, and espe- cially for the diagnosis of softening from em- bolism, see art. Softening. 926 CEREBRAL HEMORRHAGE AND APOPLEXY. clot occasionally causes permanent hemi- plegia without producing loss of con- sciousness at its irruption. However, a very deliberate mode of onset strongly favors the diagnosis of softening. If, for instance, a patient, when he gets up in the morning, finds his arm weak, next his leg numb, and half an hour later is para- lyzed on one side, little or much, we diag- nose softening. What has been said before as to constitutional state — or as to premonitory symptoms— helps us but lit- tle in this difficulty, for degeneration of arteries leads either to softening or to clot, and any local premonitory symptoms the patient may have had may have been the result either of thrombosis or of rup- ture of small arteries. Still, the exist- ence of chronic Bright 's disease is much in favor of clot ; and if we see clots in the retinae and hear that the patient has epistaxis, we are warranted in inferring from these visible hemorrhages that the encephalic lesion is also hemorrhagic. When the hemiplegia is on the right side, and now and then, but very rarely, when on the left, there is loss or defect of speech. This furnishes no further diag- nostic evidence. I think, however, that frequent mistakes in words during recov- ery in young' people favors the diagnosis of plugging of vessels. Hemiplegia with loss of Consciousness. — Hemiplegia with deep loss of conscious- ness (Apoplexy) is nearly always owing to Cerebral Hemorrhage. These cases are therefore more important than any other, and we must consider the mode of onset in some detail. The attack may begin either by special nervous symp- toms, such as one-sided numbness, loss of speech, defect of speech, or by such symp- toms as pain in the head, vomiting, and confusion of mind, and, of course, it may begin by both sorts of symptoms at once. It may begin by convulsion. We here consider the special symptoms only ; the general symptoms are of additional diag- nostic value, but we could only repeat what has been said (p. 924) when speak- ing of them as premonitory symptoms. When a patient has suddenly decided, although very slight, local palsy (for in- stance a little thickness of speech, a tri- fling drawing of the face, or loss of use of one arm, one-sided weakness, or even numbness), it is clear enough that he has ■ Plugging of cerebral arteries in older people is not the same thing as plugging of cerebral arteries in young patients, as the vascular condition of the brain is different at different ages. There is in older people less free anastomosis from obliteration of capil- laries, and also from the atheromatous condi- tion of small arteries. The vessels of the optic disk become fewer in number as age ad- vances. some kind of local lesion of his nervous system. We should believe hemorrhage was that lesion if anj' one of these symp- toms were followed quickly by deep loss of consciousness, or if after some delibera- tion, or even if after partial recovery, a convulsion occurred. If the patient be above middle age, if he have tough arte- ries, if there be albuminuria, we are almost certain that hemorrhage has oc- curred ; and if, after such a mode of onset, hemiplegia is found with deep coma, we are practically quite certain. If the mode of onset has been by convulsion, we still think it most likely that there is hemor- rhage, if there be decided, and especially if there be complete hemiplegia — complete in range, that is. (See list p. 911.') We now consider the case of a hemi- plegic patient when he is fully apoplectic. As before said, the degree of the coma in cases of Cerebral Hemorrhage varies ; the deeper it is, the more is the diagnosis of hemorrhage warranted : but loss of con- sciousness, accompanied by stertor, slow pulse, lower temperature, is not diagnos- tic of Cerebral Hemorrhage. If we have no history of the mode of onset, or only that the patient was taken with a fit of convulsions, the first thing we do is to in- quire for hemiplegic symptoms. While hemiplegia is certain evidence of the ex- istence of local lesion, and with other cir- cumstances of the existence of clot, we must not suppose that its absence nega- tives clot. (See p. 911.) Hence we have often difficulty in saying whether there is cerebral hemorrhage, or poisoning, or uraemia. We usually discover some kind of one-sided symptoms if we do not find definite hemiplegia ; we find some differ- ence in the two sides when we raise the arms and let them fall, and when we pinch the legs. There may be spasm, or there occur occasional waves of tremor down one side ; or we may find both eyes or the head turned strongly to one side. These symptoms point decisively to a one-sided lesion at all events ; and when there is no history of injury, no evidence of embolism,^ they mostly, In persons past middle age, signify clot. Yet there may be meningeal hemorrhage, and if the limbs of one side be continuously rigid, with or without occasional higher waves of rigidity, the probability is that there is meningeal hemorrhage, although per- haps cerebral as well. However, and this really is the important matter, very deep coma occurring suddenly or quickly with one-sided symptoms of any kind, point at least to intracranial, if not to cerebral hemorrhage, in the vast majority of cases of patients past middle age. ' See, however, art. Convulsion, p. 753, "Epileptic Hemiplegia." ' See art. Softening. SPECIAL DIAGNOSIS. 927 Special Diagnosis. Apoplexy without Local Parali/sis. — When there are no local symptoms in the apoplectic condition, no hemiplegia for instance, it is most difficult to make a diagnosis. "We shall here discuss only the difficulties we most frequently en- counter. We shall suppose that we are called to a case of coma, and try to show by what means we may arrive at the diagnosis of Cerebral Hemorrhage. We often cannot ; but even then we may be able, at all events, to decide whether there is a fatal lesion, or the compara- tively minor condition, drunkenness, and to exclude violence and poisoning. Speak- ing generally, the difficulty is to deter- mine whether a patient is suffering from local lesion so large and sudden, or placed so centrally (as in the pons), as to pro- duce coma with universal powerlessness, or whether he is suffering from some con- dition such as uraemia, poisoning by opium, drunkenness, &c., which, as it were, imitate the effects of the grave local lesions mentioned. It is important to bear in mind that we may have combinations of states. I have known an " epileptic" fracture his skull by a fall in a fit, and die from hemorrhage the result of rupture of the middle men- ingeal artery. A drunken man may have been struck on the head. A drunken man falls like a log, and a seemingly slight blow on the curbstone, for instance, will lead to hemorrhage into the arachnoid cavity. I have seen two cases of this kind in drunken people. Prescott Hewett says that extravasation of blood in the arachnoid cavity is much commoner than is usually supposed ; that the injury causing such extravasation is often a trifling one ; that it may occur without any apparent lesion of the brain or mem- branes. Mr. Stephen Mackenzie has known a patient who died of garroting to be treated for alcoholic poisoning ; the patient was drunk when attacked. If the patient be often drunk, a fit of drunken- ness may not improbably coincide with, and perhaps be the direct cause of, rup- ture of cerebral arteries. But the difficulty is not nearly so great practically as it is logically ; for when we know the constitutional history of an apo- plectic patient (see p. 906), and if we are told, as we mostly are, the mode of onset (see p. 925), we are very rarely in doubt as to the cause of Apoplexy. We may know that the patient has had an attack of hemiplegia or some other paralytic symptom (see p. 923) before ; and this will favor very strongly the diagnosis of liemorrhage. Then cases of Apoplexy without hemiplegia or without some hemiplegic symptom are comparatively rare. In most cases the patient becomes ill at home among his friends, or at his work, or he is found comatose in bed, and in the great majority of instances the circumstances negative drunkenness, poi- sonmg, violence, and the like, when the symptoms do not. Indeed, in most cases the diagnosis is really easy ; or, to speak strictly, the prediction is usually verified. Suppose, however, there is no history. Suppose the patient, as is pretty often the case in hospital practice, is found in the streets universally powerless and deeply comatose, we very often cannot tellfrom what he is sufferiiuj. Or let us suppose we are called to a guest at an inn, who is found comatose in bed or in the water-closet— the discovery of an empty laudanum bottle may be the (mly clue to the nature of the case. In such cases we can only say there is apoplexy ; we cannot declare the cause of it, and simply because there is not evidence. I would most earnestly beg young practi- tioners not to trust blindly to the fact that the patient is found at the bottom of a scaffold in the diagnosis of injury, nor to the smell of drink, nor to an " uproari- ous condition," for the diagnosis of in- toxication ; and, above all, not to con- clude, from bitten tongue, that the pa- tient has "• only had an epileptic fit." It is true enough that if he be led entirely by these circumstances, he will mostly be right, but he must run no risk of being wrong. Most painful mistakes are occa- sionally made because a practitioner con- cludes from insufficient evidence. Having first examined the apoplectic patient for hemiplegia (the existence of which we are now supposing that we can- not determine), we next inquire for con- vulsions. If we obtain no history of a convulsion, we search for evidence of tongue-biting. However, we cannot often get a look at the tongue, but we may judge by the presence of blood on the gums or by bloody foam. If the foam be very frothy in large bubbles, it no doubt comes from the bronchial tubes, and is no evi- dence of tongue-biting. The tongue may have been bitten but not lacerated. And when we do find evidence of convulsion, we must remember that to use the words of Gull,' '^general convulsion with insen- sibility is in itself of little value in the diag- nosis of any brain disease." (The itahcs are mine.) If we feel sure that there has been a convulsion either before or after the onset of the symptoms, we can only exclude drunkenness and poisoning. If there be no convulsion, we have still these two causes to consider. We next ex- amine the urine for albumen. We speak first of the comatose patient who is not ' Abscess of Brain, Guy's Hosp. Reports, vol. iii. 3d Scries. 928 CEREBRAL HEMORRHAGE AND APOPLEXY. hemiplegic and who has had no convul- sion, so far as we can tell, and whose urine is not albuminous. The first ques- tion is — DrunTcenness.^— The smell of drink must only lead us to a very careful examination for evidence of drunkenness, as patients who suffer Cerebral Hemorrhage may have been drinking, or may have taken spirits for premonitory symptoms. Oddly enough, patients soundly drunk, their real condUion not being recognized, are now and then treated by doses of brandy-and- water. This shows in another way the difficulties of diagnosis. A drunken man may be in one of two conditions. (1) He maybe insensible without excitement; he may, indeed, be as deeply comatose as if he had extensive and fatal Cerebral He- morrhap;e. This is so when the patient has been "sucking the monkey, " i. e. suck- ing raw spirits out of a cask by aid of a gas piping, or when he has drunk off a large quantity of spirits for a wager or out of bravado. In these cases, from the con- dition of the patient alone we cannot make a diagnosis, although, fortunately, it is usually made for us by the history. If we hear that the insensibility came on very slowly while the patient was drinking, especially if it were preceded by excite- ment of talk or manner, we should sup- pose we had to do with drunkenness. If, however, the insensibility began suddenly, or if there were a sudden increase of stu- piditj', or if the patient all at once stag- gered and fell insensible, cerebral or meningeal hemorrhage is almost as likely. Let us now suppose there is no history of the mode of onset, the patient being found in the streets by the police. We try to rouse him, and we may get him to give his name or his address. This is, per- haps, some evidence that the case is not one of Cerebral Hemorrhage, but it had better be disregarded, as patients coma- tose from fatal cerebral lesions of several kinds can be roused so far. That he re- sists our endeavors to examine him, or ' Here I wonld refer to papers on Alcohol Poisoning by my collpague, Dr. Bathurst Woodman, in the Medical Mirror, July, 1865, and February, 1866. Dr. Woodman has had an unusually large experience of cases of apoplexy from numerous causes, and to him I have to acknowledge myself greatly in- debted for facts serving in the diagnosis of causes of coma. I have recorded (Lond. Hosp. Eep., vol. i. p. 35, from notes by Dr. Woodman) a case of death by hemorrhage in the pons, in which, when the patient was first seen, the symptoms were like those in some cases of deep drunkenness. He could move all his limbs, put out his tongue when asked, and, although insensible, was roused by shouting to answer, "What's that to you?" when asked his name. He had been found in tlie street by a policeman. swears when roused, is of no value at all as excluding fatal lesion of the brain. The patient may vomit (as he may in Cerebral Hemorrhage), and the vomit may reveal the nature of the case. If he does not we are justified, in doubtful cases, in using the stomach-pump. Then, the drunken patient oftener passes his urine and feces than do other apoplectic patients. Again, we may find alcohol in the urine. The mere presence of alcohol in the urine is not to be relied on to show that the apoplectic patient is suffering from a 2Misonous dose of alcohol only. As before said, a drunken man may owe his coma, in part at least, to hemorrhage into the arachnoid cavity. However, Dr. Anstie tells me that it would be possible to re- cognize the presence of a poisonous dose of alcohol in the system if one drop of the urine itself, added to 15 minims of the chromic acid solution,' turned the latter immediately to a bright emerald green. (2) The other condition is one of excite- ment, of which there are all degrees ; as we have seen, the patient, who when left to himself is insensible, may be roused to resist and to swear, but the main features of a case to which we are called may be one of " uproariousness. " If the patient he violent, and struggle, he is probably drunk. A cautious man will still continue his examination for other causes, because it is certain that after severe and fatal'' injuries to the head the patient may struggle and swear, and even, as I saw in one of Mr. Hutchinson's cases, make re- plies as definite as "What's that to you about my tongue ?" when asked to put his tongue out. I have recorded a case supplied to me by Mr. Stephen Mackenzie," in which violence and swearing were the striking symptoms in a case of death from meningeal hemorrhage. As in this case, we have often a history of a mode of onset under circumstances which exclude the diagnosis of drunkenness. But to make a diagnosis from the condition of the patient only is quite a different thing. We can only make a diagnosis by exclusion, and the most important thing is to exclude injury to the head. The J'oung practi- ' The chromic acid solution is made by dis- solving one part of bichromate of potash in three hundred parts by weight of strong sul- phuric acid. Of course Dr. Anstie does not represent this test as a certain one for alcohol, but there is not likely, he tells me — and his experience on this point is very great indeed — to be any practical objection to the conclu- sion when the reaction is so sudden and de- cided on the addition of but a drop of urine to the test solution. ^ See Callender, St. Bartholomew's Hosp. Rep., vol. iii. p. 415, and especially Case 5 of his series of cases. 3 Medical Times and Gazette, April 1, 1870. SPECIAL DIAGNOSIS. 929 tioner must not hastily conclude that a patient is "only drunk," even if he be oaly confused, or if he swears or is violent, or if he lies on his back insensible, growl- ing or swearing if disturbed. If he does, I am quite certain that he will have now and tlien bitterly to regret trusting to such circumstances. To have said that a pa- tient was " only drunk" when a post- mortem examination shows a fatal lesion of the brain is very painful to all con- cerned. Besides, deep intoxication is itself a serious matter. Injury. — "We need not speak of cases where there is a clear history of very severe injury, because then the diagnosis is made for us. However, when the diagnosis has blindly rested on the fact that the patient has been in the way of injury, it is sometimes wrong. Prescott Hewett says (op. cit.), "There is no doubt that many a case reported as one of traumatic effusion of blood in the brain was simply a case of apoplexy."' In all cases of coma we search for bruises on the head and face. We examine the ears for discharge of blood, watery fluid, or even brain matter ; the face for evidence of palsy of muscles supplied by the portio dura nerve — two things the frequent re- sult of fracture of the base. We must be especially careful to note the condition of the conjunctivfe and eyelids, as effusion of blood here coming on after the injury, or after the patient was comatose, is evidence of fracture of the orbital plates. (By it- self this is not, my colleague Mr. Hutchin- son teaches, a serious symptom.) The absence of external signs of injury unfor- tunately does not negative serious and fatal injury to the brain. As before said, a slight fall may cause hemorrhage into the arachnoid "cavity;" the heavy fall of a drunken man, or a fall in an epileptic fit. Even in cases of bruising and lacera- tion of the cerebellum, the accident is not, Prescott Hewett says, always severe. In several cases the cerelDellum was thus in- jured by the patient falling in the street when drunk. 2 Even if we hear only that the patient has been in the way of injury some time before the symptoms set in, we must still consider the possibility of injury, as symp- toms due to traumatic effusion of blood on the surface of the brain, especially if it be betwixt the dura mater and the bone, may come on, or at least develop largely, es- pecially by a convulsion, sometimes hours or days after an apparently trifling in- jury. If there be hemiplegia immediately after a fall, especially if the palsy does not fol- low a convulsion, non-traumatic hemor- rhage is most likely. Yet it is not quite ' Holmes' Surgery, vol. li. p. 265. 2 Op. cit. p. 312. VOL. I.— 59 certain, for there may be laceration of the hemisphere. Opium Poisoning.~ln both poisoning by opium and large hemorrhage, especially into the pons Varolii, there may be minute contraction of the pupils, universal power- lessness, and deep coma. "Contraction of the pupils is the most constant of all the effects of opium."' Hence there are on record cases of hemorrhage into this part of the nervous system, mistaken for and treated as cases of opium poisoning. Unfortunately, there is not always minute contraction of the pupils in effusion into the pons, nor are they always contracted in opium poisoning. And in either con- dition, contracted pupils may dilate shortly before deatli^— " full active dilatation, which is uniformly observable when death (from opium) is imminent."" When we learn that the symptoms set in when the patient was with his friends, we must bear in mind that he may have taken the poison half an hour or even an hour before. We may detect the odor of opium in his breath. If there be a con- vulsion at the outset or soon after — cases of children are not here spoken of— we may almost certainly decide that there is not poisoning. My friend Dr. William Proctor, of York, however, has supplied me with notes of a case of rapid death of a woman in convulsion, after taking six grains of morphia. Caspar^ says, "There are fits of spasms extending even to general convulsions." Scoresby Jackson^ says that occasionally convulsions precede death. But these accounts of the symp- toms refer to cases of children as well as of adults. I think we may say that in an adult, a convulsion— a severe convulsion at least, and certainly if it markedly affects but one side of the body — especially at the beginning, or soon after the be- ginning of the attack, nearly always nega- tives opium poisoning.* If we hear that 1 John Harley, The Old Vegetable Narcot- ics, p. 137. 2 See Anstie, Stimulants and Narcotics. ' John Harley, op. cit. p. 138. • Forensic Medicine, Syd. Soc. Translation,, by Dr. Balfour, vol. li. p. 63. 6 Materia Medica, p. 330. s It is right, however, to state that Tardieu describes one rare form of opium-poisoning which is not, so far as I can judge, to be dis- tinguished from a case of large and rapid in- tracranial hemorrhage. "Dans la forme foudroyante I'ingestion du poison est presque immfidiatement suivie d'un sommeil comateux que rien ne peut vaincre ; la respiration est stertreuse et de cet etat de narcotisme pro- fond individus empoisonn^s passent sana transition k la mort dans I'espace de trois quarts d'heure a une ou deux heures. Rare- ment celle-ci est prec^dee de quelques mouve- ments con vulsifs. Une remarque est pourtant a faire dans cette forme, c'est que les pupilles sont constamment dilatees." 930 CEREBRAL HEMORRHAGE AND APOPLEXY. the onset of the sj'iiiptoms was very gradual — there being uo albuiuinuria — we think that tlie patient was poisoned. Coma from efl'usion of blood into the pons Varolii will, it is true (see p. 925J, come on deliberately, but not so deliberately as opium poisoning. In hemorrhage the symptoms usually develop in a few min- utes, or there is a sudden development of coma after slight symptoms. Soon after the poison has been taken the patient may be roused to give his name, but later he is in a state of as profound insensibility as clot ever produces. Moreover, the test is of little, if any, diagnostic value in cases of coma of any kind. If, however, we have no history, suppose the patient is found comatose in bed (we are supposing there are no local symptoms — such as palsy of the sixth nerve, turning of the two eyes or of the head to one side — that there is no convulsion), we cannot mcikea diag- nosis. If the patient be a young adult, poisoning is probable ; if past forty, apo- plexy is more likely ; and I know of nothing in the pulse, in the respiration, or in the condition of the skin, wliich is of certain diagnostic value. An extreme slowness of the pulse, thirty or forty in a minute for a long time — say an hour or more — is said to iavor the diagnosis of poisoning. Eut the pulse is sometimes rapid in opium-poisoning. If the patient -were dead when we were consulted, we should think he had not died of opium-poisoning if death occurred in less than six hours.' Poisoning by opium proves fatal in from six to twelve hours (Taylor). Effusions of blood into the pons, extensive enough to cause deep coma, will kill at varying times, from a quarter of an hour, which is rare, to twelve hours or more. However, we often have exceptional cases. Dr. Wil- liam Proctor, of Yorlt, has recorded a case in which an ounce of laudanum killed a woman fifty years of age in less than two hours. We have next to exclude epilepsy (see arts. Epilepsy and Convulsion). VrfPinia. — We now suppose that we find albumen in the urine. We have many times insisted on the fact that patients who are prone to Cerebral Hemorrhage have frequently chronic renal disease. We caimot therefore logically attach much diagnostic importance to the mere presence of albumen in the urine. Prac- tically it is not of value when the patient is past middle age, for his coma may be due either to urpemia or to Cerebral Hem- orrhage ; and this is so whether the ill- ness begins by convulsion or not. How- ever it begins, we are sure there is not uremia only, if there be hemiplegia, for ' See, however, Tardleu, quoted in pre- ceding footnote. then, if the patient be past middle age, we are prAetically certain that there is clot. But we are now supposing there is no discoverable paralysis. There are two chief wajs in which ursemic coma comes on, without convulsion and then usually slowly, or rapidly and with convulsion. If the patient, known to be the subject of chronic Bright's disease, gradually be- comes languid, and stupid, aud as it were sleeps into coma, we may fairly diagnose uraemia. If the coma comes on suddenly, the diagnosis of clot is more likely ; and if the coma be very deeji, and the patient never moves nor can be roused to move any of his limbs, the clot is probably in the pons, especially if the pupils be mi- nutely contracted. If, however, there is no history, we cannot tell when the coma is deep. I have known a patient found comatose in the street, from whose symp- toms it would have been impossible to make a diagnosis betwixt clot in the pons (this was found postviortern), uraemia, aud jjoisoning by opium. Further, uriemia may begin suddenly, in the midst of seeming good health, by convulsion ; but so may Cerebral Hemor- rhage (hemisphere or pons) ; and, to make the matter more difficult, these are the cases of Cerebral Hemorrhage in which we often cannot make out any hemiplegia. If the convulsion were strictly limited to one side — most convulsions affect one side a little sooner and a little more than the other — I should for my part feel certain that there was not uraemia only, although of course we could not under these cir- cumstances say there was Cerebral Hem- orrhage. (See art. Convulsion, p. 7.59.) Serous Apoplexij. — This term is rarely used nowadays. Most cases so called were doubtless cases of uraemia. Yet we occasionally hear of cases of death by Apoplexy ascribed to "effusion of serum on the brain." If there be Bright's dis- ease and, inferentially, uraemia, this may not be an altogether inaccurate descrip- tion ; for Traube considers that uraemia symptoms are directly dependent on 03dema of the brain. These are doubt- less, when there is no renal disease, cases of what are here called " Simple Apo- plexy. " By this term is to be understood cases of Apoplexy in which no lesion is discovered ; that is to say, no lesion which we can suppose to have been the cause of so dramatic a mode of dying. One reason why these cases are called serous is prob- ably that there is not unfrequently found at the autopsy a large quantity of serum in the meshes of the pia mater. But this is rarely a chronic state of things, and so far from the fluid exercising pressure, it has simply been " effused" very gradually to take up the room vacated by wasting of the brain. This is seen strikingly in cases in which there is wasting of but one PROGNOSIS. 931 cerebral hemisphere ; here the serum is "efi'used" on one side only. Simple Apoplexy. — Now, supposing we have excluded drunkenness, injury, epi- lepsy, and ureemia, we have still to deter- mine whether the case be not one which for want of better knowledge we can only name from its negative post-mortem ap- pearances, Simple Apoplexy. We have already (art. Convulsion, p. 761), when speakirig of patients dying after attacks of convulsion, stated that in some we find marked changes post mortem, and in others we discover nothing abnormal in any part of the body. But patients pass into deep coma when no convulsions have been observed, or after apparent recovery from a convulsive seizure. A patient, sometimes even a young man, quickly be- comes apoplectic and dies in a few hours, and in the whole body we find nothing abnormal which can reasonably be sup- posed to have been the cause of the symp- toms. This class of cases is well recog- nized. Dr. Todd' says, speaking both of delirium and coma, that "both these for- midable states may take place in a brain which shall reveal on the minutest scru- tiny no appreciable aberration from the natural standard." Dr. Wilks says in his Lectures on Pathology: "Occasion- ally you may be called to a case where the patient is insensible or suffering from apo- plexy, and on examining the brain you find nothing. During the last two years I have seen two cases where the post- mortem revealed nothing." It seems certain that these patients die from the brain. At all events they die in the same way as patients do who die in coma from Cerebral Hemorrhage, and in such cases during life Cerebral Hemorrhage is fre- quently diagnosed. The post-mortem ap- pearances of the heart and lungs are such as those we find in patients who have died with large cerebral hemorrhage. I freely confess that I know of no rules by which to distinguish simple from san- guineous Apoplexy, or other forms of coma. We cannot rely on the kind of pulse, nor on the temperature, nor on the state of the pupils, nor on stertor. I have, in short, nothing to say of diagnosis here. I have observed that some medical men seem, if I may use such an expression, to be disappointed in not finding in the head of a patient who has died in an apoplectic manner, anything which can be supposed to have given rise to his symptoms. In these cases the suspicion of poisoning will occur. Indeed, this possibility ought to be carefully considered. Yet this part of the question is legal rather than medical, and at an inquest we can assure the coro- ner—who, if he be a medical coroner, requires no strong assurance on that mat- ' Nervous Diseases, chap. viii. ter— that the profession recognizes such cases as cases of natural death. Some of those cases are put down to congestion of the brain. But this conclu- sion is often drawn from the distension of the cerebral veins, which is a very com- mon appearance- in patients who have died rapidly from any cause ; and in all cases, even in cases of death from hemor- rhage, we find fulness of the veins in the occipital region. For the diagnosis of Apoplexy from Congestion of the Brain and from ISun- stroice see those articles. Aneurism of the larger cerebral vessels. (See arts. Adventitious Products and Convulsion, p. 759.)— Cerebral aneurism has been incidentally considered in seve- ral parts of this article. Hemorrhage from Tumors. — Occasion- ally fatal hemorrhage occurs from cerebral tumors. We can only make the diagno- sis from the evidence supplied by a his- tory of tumor of the brain (see art. Adventitious Products), and if there be no history we cannot make a diagnosis. If, however, in a young patient we dis- cover double optic neuritis, we should suspect tumor. Occasionally apoplectic sj'mptoms come on suddenly from Ahscess of the Brain (see art. Abscess of the Brain). We can only make the diagnosis from such facts as the history of a blow, presence of "puffy" tumor, disease of the ear, &c., and when these facts are not forthcoming we cannot make a diagnosis. Prognosis. — Here we speak of Cere- bral Hemorrhage only. It is again to be insisted on that Cerebral Hemorrhage is not a constant quantity ; the dot varies in size, in suddenness of effusion, in posi- tion, and there are differences in the ages of the patients attacked, and in their con- stitutional condition. Obviously then we can only speak very generally on prog- nosis, and what would probably come under this head has been already in chief part considered. Thus, under Etiology, we pointed out that in many cases the constitutional condition of the patients who suffer Cerebral Hemorrhage is one of widespread degeneration. If therefore the symptoms which we attribute to Cerebral Hemorrhage be in themselves trifling and transitory (see Premonitory Symptoms, pp. 923-4), they are of very evil omen if the patient be past middle age, and if there be hypertrophy of the heart, degenerated arteries, and chronic renal disease. But here the evil omen is as to the future. We speak next of cases of larger hemorrhage, and of prognosis as to recovery from hemiplegia, or apoplexy, or, as is usually the case, from both. Of course the graver the lesion, the worse the prognosis. We estimate its gravity 932 CEREBRAL HEMORRHAGE AND APOPLEXY. by the degree of the paralysis and by the degree of the apoplectic condition. Under Localization, p. 537, it was pointed out that the more complete the paralysis the graver the lesion. Thus if the patient has, besides palsy of the face, arm, and leg, lateral deviation of both eyes and of the head, the worse the prognosis ; if he escape vrlth his life, palsy of the face, arm, and leg will almost certainly remain. If the palsy be incomplete, the prognosis is less grave, both as to life and recovery from paralysis. But we cannot judge by the paralytic symptoms alone. The de- gree of the apoplectic condition is to be considered also, although it is usually greater in degree the more complete the palsy. The less, and the more transient, the loss of consciousness, the better the prognosis ; the deeper the loss of con- sciousness, the worse the prognosis. The prognosis is very grave indeed if the pa- tient, after being simply hemiplegic, be- comes suddenly profoundly unconscious and universally powerless, and it is graver still if the change sets in by convulsion, for this mode of ingravescence points to rupture into the lateral ventricle. The other symptoms of the apoplectic condi- tion are to be considered. The more the pulse, respiration, and temperature are implicated — either depressed in the first stage or raised in the second — the graver the prognosis. In other words, the more the automatic processes are involved, the worse the prognosis. AYc have seen (p. 911), that along with degrees of loss of consciousness there are in different cases all degrees of range of palsy, palsy of the most voluntary parts (face, arm, and leg), palsy of these and of more automatic parts (deviation of the eyeballs and head, &c.), and even palsy of the most automatic parts as evidenced by stertor and depres- sion of pulse, respiration, and tempera- ture. When the patient has come round from the apoplectic condition, his condition varies. Since there are all degrees of gravity of the lesion, there are all degrees of the conditions left when the apoplectic symptoms have passed off. The deeper and the more continued the apoplexy has been, the worse the after condition of the patient is likely to be. He may be, espe- cially when speechless, in a state of com- plete imbecility, lying in bed, taking no intelligent notice of what goes on, and passing urine and feces in bed. Although frequently he eats voraciously, he gets gradually thinner and often dies in a few weeks or months. In other and less se- vere cases, there is great defect of memory, especially for recent events, and great emotional instability ; the patient is easily made to laugh or to shed tears, though he does not laugh with any healthy ring, and his crying is a blubbering, very painful to witness. There is also great irritability of temper and often a heedless selfishness ; the patient's disposition, his friends tell us, is quite changed, liis mental field is narrowed : he seems to care much for his own immediate wants, and cares little about his family or business concerns. In other cases there is little more than paral- ysis, although the patient's mental condi- tion is not so good as before. The palsy often diminishes, and im- provement follows a certain order. The more automatic parts recover first. Thus the lateral deviation of the two eyes and the head usually passes away in a few hours or days. The leg is the next part to recover, although it rarely recovers completely after severe apoplexy, and the lingual and facial palsy diminish or pass away altogether. When rigidity of the limbs comes on, we fear no further im- provement will follow. We may find the patient speechless' (aphasic), on recovery from the apoplectic condition, and he usually remains so if the apoplexy has been deep and continued. If there has been no loss of conscious- ness, or only transient loss of memory, the patient has a good chance of recover- ing altogether from the paralj'sis and the affection of speech. But as we have seen (p. 925), it is not easy to be sure that hemiplegia without loss of consciousness is owing to clot. Most cases of this kind are owing to softening from embolism or thrombosis. Kecovery from hemiplegia will occur from any kind of lesion if it be a small one. We can only judge by the early beginning of the recovery. If the patient begins to move the arm next day, he is likely to get well altogether. We cannot infer so much from early recovery of the leg, as this is very often not com- pletely paralyzed at the outset, and we know that it frequently recovers when the arm remains much paralyzed. Treatment. — The recovery of the pa- tient, it is most probable, depends alto- gether on the quantity and seat of the hemorrhage. If the ventricles be opened, if there be a large clot in the pons, the patient will die. But, as in many cases we cannot be absolutely sure that there is any hemorrhage, we must treat the apo- plexy (see arts. Softening and Eenal Dis- eases). We must particularly bear in mind that if the cause of the apoplexy be alcoholic poisoning, recovery usually fol- lows, even in very severe cases. When in doubt we should use the stomach pump. There is unfortunately little to be done, in cases of large Cerebral Hemorrhage, and the chief thing is simply to keep the ' See art. Softening for aa account of Apha- TREATMENT. 933 patient quiet, especially when we see him soon after the attack. Bousing him may lead to such increase in the size of a clot in the brain that it breaks into the ven- tricle. Bleeding used to be almost a routine practice. In this country it has fallen into disuse. Although I have observed very many cases of Cerebral Hemorrhage, not only in my own practice but in that of others, I have seen but one patient bled for it. I quote, however, part of what Niemeyer says on this point. It will be observed how carefully he tries to distinguish the cases in which bleeding is admissible from those in which it is hurt- ful : " If the impulse of the heart be strong, and its sound loud ; if the pulse be regular, and no signs of commencing (edema of the lungs exist, we should bleed without delay. Local bleeding by leeches, behind the ears, or to the tem- ples, or by cups to the back of the neck, cannot replace general bleeding, but may be used as adjuvants. If, on the con- trary, the heart's impulse is weak, the pulse irregular, and rattling in the trachea has already begun, we may be almost certain that bleeding would only do harm, since the action of the heart, which is al- ready weakened, would be still more im- paired, and the amount of arterial blood going to the brain would thus be still more decreased. When the latter state occurs, the symptomatic indications re- quire just the contrary treatment, in spite of the original disease being the same, and being due to the same causes. We must strive with all our skill, by the use of stimulants, to prevent paralysis of the heart. If we cannot give wine, ether, musk, &c., internally, we should apply large sinapisms to the chest and calves of the legs, rub the skin vigorously, sprinkle the breast with cold water, or drop melted sealing-wax on it." It must be difficult to select the right time as well as the right case, as the pulse, respiration, and temperature are in very different conditions at different stages in the same patient (see p. 922). In the first stage the pulse may be very slow, and the temperature greatly re- duced. We should rather give stimulants than bleed in this condition, but I think it is better not to do this, unless the pulse be very feeble, and the temperature much reduced ; we may also apply mustard plasters to the calves. When the pulse and respiration become very quick, when there is evidence of engorgement of the lungs— as shown by the loud rattles we hear from oedema of the lungs — we might, from theoretical consideration, suppose that bleeding would be of service by relieving the venous system, which is evidently overcharged. But at this time the pulse is really feeble, and occasionally it is irregular. It is, I think, good practice to give croton oil in either stage, unless the al- teration of pulse, respiration, and tem- perature be extreme. lu the second stage — the stage of reaction, and when the clot is producing a local encephalitis— it is well to apply cold to the head. Blisters relieve the severe headache in the cases of cerebral tumor (no doubt often one of the symptoms of a local encephalitis), and it is possible that blisters to the back of the neck, and behind the ears, are of service when the patient is recovering from the apoplexy, and has pains in the head. Let us now suppose that the apoplexy is past, or that there has been no uncon- sciousness, or a verjf temporary confusion when a hemiplegia, indicating effusion of blood, came on. The more vividly we realize the fact, that a mass of blood is lying abroad in softened and torn nervous tissue, the less confident do we feel in our power to interfere for the patient's good. The feeling of helplessness is greatest, when we are looking at a clot lying in nerv- ous tissue, e. g. in the retina. There is, to my knowledge, no treatment for effu- sion of blood in nervous tissue. There are no drugs which assist in the absorp- tion of the clot. However, it is quite certain that some patients recover satis- factorily from hemiplegia, the result of Cerebral Hemorrhage. But recovery from hemiplegia will follow when damage to the motortract remains. From not recognizing this fact, erroneous conclu- sions may be drawn as to the effects of remedies. We must particularly bear in mind that ansesthesia disappears or di- minishes quickly when no drugs are given, and also that there is a natural order of recovery, as stated under Prog- nosis (p. 932), which probably is not in- terfered with by treatment. We have still, as in many other dis- eases, to improve the general health. This is, however, not unfrequently, rather general disease, and the local lesion— let us say epistaxis, paralysis for a few days, or a day's thickness of speech— is some- times a small matter in comparison with the state of the system of the patient who comes to us for such slight symptoms. The proper care of a patient who has a clot of blood in his brain, and who is lia- ble to have further effusions, consists in attending to his diet, excretions, sleeping and exercise. Care in diet is especially important. In this connection we may quote what Niemeyer says (op. cit. vol. i. p. 314), under the head "hypertrophy of the heart." We have seen that in most cases of Cerebral Hemorrhage, there is cardiac hypertrophy, and in many cases the nervous symptoms, when theclot is smiill, may be almost unimportant in com- parison with the unsound state of the sys- 934 ABSCESS OF THE BRAIN. tern: " Such patients must beware of im- i moderate eating and drinking, in order to avoid the plethora wliich, althougii but transient, always follows upon a free use of food or drink. How often does the long-threatening apoplexy set in in the midst of the plethora which has developed after a long and hearty meal ! . . . In this connection I may mention an act of folly which I have often seen practised by tavern-keepers and itinerant wine dealers. The latter often suppose that, by a free use of water, they can counteract the per- nicious influences to which they expose themselves, although it is evident that the plethora arising after a full meal would only be increased by an immoderate addi- tion of fluid. Besides this, however, the patient must avoid all the causes which, independently of plethora, stimulate the action of the heart, and further distend the already overcharged arteries. Under this head come the use of stimulating drinks, mental excitement, and immode- rate bodily exertion. Hot water must be included in this class, and there is no wonder that the use of the Karlsbad Sprudel should make victims every year who die of apoplexy." ABSCESS OF THE BEAIN. By William W. Gull, M.D., F.R.S., and Henry G. Sutton, M.B. Abscess of the Brain is comparatively a rare disease, and it falls to the lot of no man to see a great many cases. "\Ve have collected seventy-six cases in all from various sources, and the details in this paper are based upon these records. Many of the cases have not before been published. We have arranged the diffe- rent parts of this subject in the following order: A description of the various condi- tions that are known to give rise to cerebral abscess, the morbid anatomy, the symp- toms, pathology, diagnosis, and treatment. Suppurative inflammation of the brain may be caused bj' injury to the head, espe- cially where the skull is fractured and the brain contused. Mr. Prescott Hewitt sajs ; "All traumatic inflammation of the brain substance may end in suppuration and abscess." Cerebral abscess may follow a penetrat- ing wound of the brain substance, by a knife, by a splinter of wood, or by some sharp instrument being forced through the skull. Abscess of the brain may follow a frac- ture of the skull where there is no dis- placement of the bone ; acute suppurative inflammation of the membranes and brain substance being set up by the injur3^ In many cases, caused by fracture of the skull, the abscess in the brain is seated immediately under the injured bone, and close to the surface of the hemisphere. In others the abscess is not seated near the surface ; for instance, a person may receive a fracture of the skull, symptoms of compression may set in, and'the skull may be, in consequence, trephined ; the portions of depressed bone may be re- moved, and the patient go out of the hos- pital apparently well. But after a few weeks or months, cerebral symptoms may again appear, and the patient may die ; and the autopsy reveal an encysted ab- scess embedded in the substance of the brain, and seated at some distance from the surface. Cerebral abscess may follow an injury to the skull, where there is no fracture of the latter, and with or even without a scalp wound. In such cases the injury excites inflammation and suppuration of the deploe of the bone, and the suppura- tion extends and involves the brain. Cerebral abscess may follow contusion, or, as it is sometimes expressed, concus- sion of the brain, without there being any fracture or other discoverable injury to the skull. Mr. Prescott Hewett says that he has seen two cases of this kind, and the abscesses were large.' This is a very important class of cases, for it probably embraces not a few of the so-called idiopathic abscesses of the brain. In two of our cases, abscess was found in the brain, though in neither was there any evidence to show that the skull had been fractured or otherwise injured. With both patients the symptoms fol- lowed directly after the injury ; one had a fit on the same day as the accident, and the other suffered from almost constant pain in the head for a fortnight after the accident, and was otherwise generally in- disposed. The abscesses were encysted ' Holmes' Stirgery, vol. ii. p. 185. ABSCESS OP THE BRAIN. 935 in both instances, and, during tlie time they were forming, there were symptoms indicative of cerebral disea^e, although, in the second case, the symptoms were, for a while, obscure. One patient died seven weeks, and the other three mouths after the accident. Cases might be given to show that ab- scess may follow injury to the head, with- out any fracture "or other discoverable injury to the skull ; and the abscess may remain latent for months or even loncer. One of the commonest causes of cere- bral abscess is disease of the internal ear. The clinical history of this class of cases is usually as follows : the patient has a discharge from the ear for some time — for months — and, in many cases, for years ; the discharge being continuous or inter- mittent. It is common to hear it said that the discharge began in childhood, after an attack of measles, scarlatina, or smallpox ; and since has returned, more or less. With the discharge there is often deafness and pain in the ear, but more often the patient makes no complaint of either. In some cases, the discharge is very offensive, and has been so for some time past. The extension of the disease to the brain is often very insidious. There may be no indications that the brain has become seriously involved until acute symptoms set in a few days before death. "\'ery often the first sign is a great increase of the pain in the ear. The pain is often very severe, and comes on in paroxj-sms, so violent in some cases, that the sufferer screams with it. Occasionally the acute mischief in the braiu is ushered in with rigors ; at other times with nausea and vomiting. Sometimes an epileptiform convulsion ushers in the acute symptoms, aud a few days after this the convulsion is repeated, and followed by hemiplegia. The accession of acute symptoms ap- pears, in many cases, to correspond with the commencement of acute inflamma- tory softening, either primarily in healthy brain, or secondarily around an old ab- scess. Then the skin becomes hot, the pulse quick, tongue dry and parched ; great prostration, dr(jwsiuess, and stupor set in — such symptoms as resemble con- tinued fever, and have been mistaken for it in some cases. The discharge from the ear varies very much during the acute symptoms. It is common for it to sub- side, or even entirely to disappear. Chronic changes, dependent upon dis- eases of the internal ear, may be insidi- ously going on in the brain substance, without there being any symptoms of cerebral disease. Mr. Toynbee was of opinion that the inflammation extends to the brain, from the pus not escaping from the cavity of the tympanum externally. He says : So long as there is a free exit for the discharge, I believe the disease rarely ex- tends to the brain. '" He also remarked : In all fatal cases the discharge has been deprived of a free egress." Mr. Toyubce further stated, in cases where the disease attacks the mastoid cells in early life, the cerebrum is the part of the brain which IS most likely to suffer, while in later periods of life the cerebellum is the part most generally affected. Long experience has clearly shown that, when disease of the internal ear has gone on for a long time, the temporal bone is very lialjle to become diseased. When the patient dies with cerebral symptoms, it is common to find caries of the petrous, or mastoid, por- tion of the temporal bone. It is also common to find suppurative inflammation of the dura mater covering the diseased bone, with or without sloughing of that membrane. There is, in some cases, no direct extension of the disease from the bone to the contiguous parts. In such cases the bone, membranes, and surface of the brain are healthy. A portion of healthy brain may lie between the alvscess and the bone. The diseased action is considered to extend by a vein. It is rare to find abscess of the brain following acute disease of the ear ; but one case is alluded to by Mr. Toynbee. In cases of chronic disease of the ear, the causes of the acute brain mischief are various. A blow on the head, violent exercise, or otlier depressing influence ; also cold air, or some irritating applica- tion, is sufficient to engraft acute changes upon the chronic disease. Cerebral abscess may be associated with, and apparently dependent upon, chronic disease in the lunirs , but in two of our cases the morbid appearances were such as to indicate acute changes in the lungs, extending, however, over several weeks. In a case that occurred in St. Bartholo- mew's Hospital, the lung presented the appearance of acute pneumonia in the third stage ; but the symptoms indicated that the disease had been going on about two months and ten days. In all the other cases which have come under our notice, the morbid changes in the chest had evidently been going on several months and even years. In one, there was a large suppurating chronic empyema. In another, there was a large cavity at the apex of the right lung, which was firmly adherent to the chest walls by a thick layer of indurated tissue. Another patient had had flattening and general contraction of the left chest for years, signs of dilated bronchial tubes, and of disease in the left lung. Suppuration in any part of the body ■ Vide Diseases of the Ear, by Mr. Toynbee, p. 303. 936 ABSCESS OF THE BRAIN. may give rise to secondary abscess in the brain. In one of our cases there was an abscess in tlie sheath of the left rectus abdominus muscle, and several abscesses without cyst in the brain. In this case it is instructive to notice that the lungs, the common seat of pyeemic abscesses, did not contain any abscesses, nor were there any in the liver or spleen. In another case there were pysemic abscesses in the brain, apparently the result of chronic suppura- tion of a mesenteric gland and coexisting recent abscesses in the spleen and kidney. In a case of acute necrosis of the tibia, which occurred in St. Thomas's Hospital, there were numerous abscesses in the brain, and pysemic abscess in the lungs, liver, and spleen. In a case given by Dr. Bright, a whitlow was the source of gen- eral pysemia and abscess of the brain. In another case, referred to by Lebert, the drawing of a tooth was followed by inflam- mation of the upper part of the face and cerebral abscess. Dysentery was the cause in one instance ; abscess near the uterus ; suppuration in the Fallopian tube ; carcinoma of the face ; abscess in the liver, and the phagedenic ulceration, following amputation of the breast, were the causes in other cases. Dr. Ogle re- lates a case of secondary purulent deposit in the brain, apparently the result of ulceration of the csecal appendage. There is also another recorded case following amputation of the forearm. ' In chronic disease of the bones of the nose, and in cases of syphihtic disease of the bones of the skull, there is a liability to cerebral abscess. Morbid Anatomy. — An abscess may form in any part of the brain. Usually it forms in the white substance, and when in the gray it is formed by extension from the white. The middle cerebral lobes are the most frequent seats of abscess. One hemisphere is as frequently attacked as the other. Of 80 cases, abscess was situ- ated in the left hemisphere in 23, and in the right in 29. Practically, therefore, one hemisphere would appear to be as liable to be attacked as the other. In 12 cases abscess was situated in the middle lobe, but it is not stated in which hemi- sphere. The middle lobes were the seat of abscess in 2.3 out of 74 instances. Ab- scess was found in the cerebellum in 13 cases, in the pons Varolii twice, in the corpus striatum twice, in the optic thala- mus twice. Abercrombie mentions an ' From analogy we sliould expect that an hydatid tumor, or a so-called strumous de- posit in the brain, would cause ahsoess. We have, however, no record of such a case. Ab- scess is also said to have occurred when the carotid artery was tied. Probably it was Bofteuing of the brain, and not abscess. instance of abscess in the medulla oblon- gata. In several of the 74 cases the ab- scesses were multiple, and found in more than one part of the brain. The appear- ance of the abscess varies according to its duration. If it have been recently formed, the pus is not inclosed in a cyst, but di- rectly surrounded by ragged suppurating brain tissue, and there is not a trace of lining membrane to the cavity. If the abscess have been formed some time, the pus is inclosed in a cyst of variable thick- ness. In very old abscesses the cyst wall has been found a quarter of an inch, or more, in thickness. When the abscess is a few weeks old, the cyst wall is usually a line or two in thickness. The wall of the cyst is formed of flbro-cellular ele- ments, and, in some cases, well-formed spindle-shaped fibres are seen ; in others the fibro-cellular tissue has undergone granular degeneration, and the fibre cells are very indistinct. The cyst, when of old date, may be divided into three parts — an outer layer, which is made up of loose, fine, fibrous tissue ; a middle layer, which is firmer and more coarsely fibrous than the outer ; and the inner surface of the cyst is formed by a smooth, pyogenic membrane, in which some small irregular dilated veins may be seen running in dif- ferent directions. In abscesses of recent formation, the pus is generally of a greenish hue, and may, or may not, have a disagreeable smell. In old abscesses, the pus is green, fetid, mucoid, and is decidedly alkaline. The pus removed from old "abscesses, when placed under the microscope, shows few or no well-developed pus corpuscles; there is a large quantity of granular fat and granular matter without any nuclei. There may be several encysted ab- scesses in the brain. In one of our cases there were no less than four ; in another a large encysted abscess in each hemi- sphere. The condition of the brain substance immediately around the abscess may vary very much ; it has commonly undergone a process of softening. Eokitansky, speaking of recent abscess, says, round the abscess the brain substance is in a state of inflammation, producing red soft- ening, yellow softening, and in more dis- tant parts oedema of the brain tissue. When a large abscess is situated in one of the hemispheres, the brain is often altered in shape ; the convolutions being packed together and flattened : the hemi- spheres bulged at the side, and if the ab- scess be very large, the hemisphere con- taining it may feel more like a bag of pulpy thick fluid than solid brain sub- stance. Collections of pus, in the hemi- spheres, tend to make their way towards, and discharge themselves into, the lateral ventricles, or on tlie surface of the brain. SYMPTOMS. 937 Pus, like blood, may fill one lateral ventri- cle only, or escape into the ventricle on the opposite side. In abscesses, as in very vascular, soft, gliomatous tumors of the brain, hemorrhagic efiusions are occasion- ally met with, and a coagulum of blood may be seen surrounded by pus. ' We have already stated that several abscesses may exist together in the brain; this is common when a patient has died of pysemic cerebral abscess. In such cases every part of the brain may be studded with minute collections of pus ; they may be found in the cerebrum, in the cerebel- lum, in the optic thalamus, in the corpus striatum, and pons Varolii. The size of these abscesses may vary from a pin's head to a hazel-nut, or even larger. They are usually situated near the surface of the brain. The cerebral substance around these pyaemic abscesses may be softened, at other times it is firm and comparatively healthy. When abscess of the brain is de- pendent upon disease of the internal ear, the morbid appearances are much as fol- lows : the dura mater, situated over the diseased petrous or mastoid portion of the temporal bone, is often found highly con- gested, softened, and ulcerated ; or of a dirty green color, and evidently slough- ing, and the bone laid bare. In other cases the dura mater is simply thickened and covered with purulent lymph, and betwixt the dura mater and the bone there is often a collection of pus. The lateral sinuses are frequently involved and plug- ged, especially when there is disease of the mastoid cells ; the sinus is often seen enveloped in pus and purulent lymph. The suppurative inflammation may ex- tend along the internal jugular vein, and set up suppurative pleuritis and abscess in the lung. In abscess of the brain due to disease of the ear, there is, in tlie majority of cases, caries of the temporal bone ; the latter is seen of a dark color, with an irregular roughened surface. The abscess in the brain may have direct communication with the diseased bone, and the contents of the abscess make their way through the ulcerated openings in the dura and bone into the tympanum, and then escape through the perforated membrana tym- pani into the external meatus, thus con- stituting what has been termed "otor- rhoea cerebralis." A similar communi- cation and escape of the pus is said to have occurred in cases of abscess in the brain caused by diseased ethmoid bone. At other times there is no such direct communication, for there is a layer of brain substance separating the abscess from the membrane of the brain. This layer is often softened, of an ash-gray ' See Guy's Hospital Reports, vol. iii. 3d Series, Case No. 6, p. 291. or yellowish appearance, and looking as if the pus wore about to burst and dischari^e itself on the surface of the brain. In some cases of abscess dependent on disease of the internal ear, there is no caries of the bone, as we have already mentioned, the membranes may be healthy, and the abscess may be l^ituated at a distance greater or less from the sur- face of the brain. Symptoms.— In 73 cases of abscess of the brain, the symptoms were as follows : —Pain in the head in 39 cases ; epilepti- form seizures in 38 ; coma in 30 ; heavi- ness, stupor, and drowsiness in 30 ; paral- ysis in 24 ; rigors in 17 ; pyrexia in 13 ; delirium in 13 ; vomiting in 12 ; inconti- nence of urine, or of feces, or both, in 15 ; vertigo in 8; disordered sensibility, not including pain in the head, in 6 ; defective articulation in 4 ; defective sight in 3 ; an apoplectic attack in 1. That some of the symptoms may have existed in greater proportion, we should be prepared to expect, especially such symptoms as vertigo, pyrexia, emacia- tion, and probably in a greater number of cases, defect of sight would have been dis- covered had the eye been tested. The symptoms, therefore, that are most fre- quently observed in cases of abscess in the brain are pain in the head, epileptiform attacks, paralysis, coma, heaviness, drow- siness, stupor, rigors, pyrexia, delirium, vomiting, and incontinence of urine and feces. In a few cases defective articula- tion was met with. The records show that the intellect was very little affected. Paralysis was observed in 24, that is in about one-third, whereas in Lebert's cases it was observed in about one-half. He included, however, not only local paraly- sis, but also general loss of muscular power, whereas we have confined the term to local paralysis only, such as loss of power on one side of the body, of one arm or leg, one side of the face, or some other part. The first symptom, in many cases, is pain in the head ; it may be the only indi- cation of cerebral disease present for months. The pain is often very agoniz- ing^^ ' One patient lay in bed continuously hold- ing his head with both his hands : another walked about with his hands pressed against one side of his head, crying out constantly, "Oh, my head I oh, my head !" The pain is often so severe that the patients shriek from the agony they suffer. A patient, who was perfectly sensible, said he could not help screairiing ; and, although he tore and bit any- body or anything near him, he at the same time expressed contrition for what he was doing, and said the pain in his head was un- bearable ; it felt as if some one was knocking it with a hammer. ABSCESS OF THE BRAIN. An intense neuralfjic pain situated over one spot is occasionally tlie first symptom; sometimes the pain is seated almost im- mediately over the region of the abscess. A boy, having an abscess in the anterior lobe of the right hemisphere, complained of almost constant burning pain over the front and right side of the head, but this localization of pain over the seat of the abscess is by no means constant. In some cases the pain is very remote. In one patient there was an abscess in the cerebellum, and the pain was felt in the forehead ; in another there was an abscess in the right middle cerebral lobe, and the pain was referred to the left side of the head. The pain often comes on in paroxysms ; in other cases it is continuous, remittent, or intermittent. It is not present in all cases of cerebral abscess, as the statistics of our 76 cases show. It is very commonly associated with pain in the ear, when the abscess is due to disease of the auditory apparatus. Instead of pain preceding, it may follow the convulsive attacks. Cases of this kind are by no means few. Occasionally the first indication of cere- bral mischief is a svidden and unexpected epileptiform seizure. The epileptiform seizures are occasionally the most promi- nent symptoms from the time of seizure to the patient's death. The epileptic at- tacks do not necessarily come on every day ; occasionally some days elapse be- tween the seizures. After each convulsion the side affected is often left weak, and this increases until there is complete hemiplegia. The con- vulsive movements are sometimes unat- tended with nisensibility, and are confined to one extremity, especially the arm. This has been long noticed. Abercrombie alludes to a case of Lalle- mand's, in which there was pain in the right side of the head and tremor of the left arm. This was followed by continued convulsions, flexion, and extension of the left arm, which after some days ended in palsy. Instead of convulsive movements, the first indications of brain disease may be numbness and tingling in one extremity. The symptoms in other cases of cere- bral abscess are like those that are said to indicate cerebral softening. There is sudden loss of power on one side of the body without any loss of consciousness ; the leg being less affected than the arm. In several instances rigors were very prominent symptoms throughout the at- tack. A patient, suffering from suppura- tion, was noticed to be getting thinner and weaker ; then he was seized with rigors, diarrhoea, a dry brown parched tongue, and a hot skin; he becanie coma- tnsM find died. Pyremic abscesses were discovered in the brain. In some cases of pysemic abscesses, there are no special symptoms to show that organic disease is going on in the brain ; but only the general indications of pyemia. In others the accession of con- vulsive seizures, paralysis, or coma indi- cates disease in the cerebral organ. Ei- gors were noticed in a few instances so severe, and returning with such regularity every day, that they closely resembled those of ague. One patient had head- ache, rigors, and vomiting, returning every da}' for five days, and then became unconscious. Rigors do not occur, in some instances, until after convulsive seizures have indicated cerebral mischief. Imperfect articulation, to a marked de- gree, was noticed in some cases, and in one there was loss of language. With respect to the eye. Dr. Hughlings Jackson has mentioned to us that he has seen changes in the retina (optic neuritisV) in a case of cerebral abscess. Dr. Jackson thinks such changes are common to seve- ral kinds of cerebral disease. Mental disturbances were observed in some cases. Now and then, the only symptoms noticed were a heavy expres- sion, a disinclination to speak, and indif- ference to surrounding objects. In some cases with disease of the ear, it was stated that the patients had attempted to com- mit suicide. One patient appeared to become hypochondriacal. Emaciation setting in rapidly was a marked symptom in several cases. Similar emaciation is seen in some cases of tumor of the brain ; but is not so frequent as in abscess. Patients suffering from cerebral abscess may have symptoms so closely resembling continued fever, that it is exceedingly difficult, if not impossible with any degree of certainty, to say whether it be a case of fever or of organic disease of the brain. Pathology. — Cerebral abscess may be produced by direct injury, or by contre- coup, contusing or lacerating the nervous tissue, and setting up inflammation and suppuration. It may be produced by sup- purative inflammation in some tissue in the neighborhood of the brain which spreads to a contiguous part ; namely, in the ear or nose, which extends, and in- vades the dura mater, pia mater, and brain substance. Or the diseased action may spread bj' continuity of structure, as along a vein, and thus to the brain. Dis- ease of the ear or nose, or of other cranial bones, may give rise to cerebral abscess in this manner. Again, abscess may be produced where there is disease of the cranial bones, or some growth involving them, by the veins communicating with the diseased bone becoming plugged. The process of coagulation extends and invades the veins communicating with the sinuses of the dura mater. These become plugged, PATHOLOGY. 939 as also the veins of the pia mater and pro- 1 bably some branches entering the brain tissue also, and intlanimation, terminating in suppuration, is thence set up in the brain. In other cases, minute coagula, or thromboses, are supposed to be detached and carried along by the circulation until they are arrested in the capillaries of the brain, and often of the lungs, kidneys, and other organs. Pycemic abscesses are occasionally found in the brain, and not in any other organ of the body. Besides the coagula, some of the elements of pus may be "carried by the circulation to aid in, or be the means of, setting up suppuration in the parts where the thrombosis is arrested. In this way abscesses in the brain are probably caused by abscess or suppuration in the liver, lungs, bowels, or in other parts. We next inquire if every form of cere- bral inflammation, or encephalitis, no matter what its origin, be liable to end in suppuration and an abscess. It has been many times stated that such is the case ; but it would appear that the inflammation must be set up by a special cause, and un- less it be so, it does not end in suppuration and abscess. Suppuration may appa- rently be excited by local injury, or by the elements of pus or thrombosis ; bvit experience shows that other forms of in- flammation do not terminate in abscess. For instance, encephalitis and softening, the result of plugging of a cerebral artery, or encephalitis around a hemorrhagic effiision, or around a gliomatous tumor or old cyst, shows no disposition to the for- mation of pus or abscess. The brain may soften, disintegrate, and a cyst may be formed, but there is no pus formed. It is necessary, now, to ask if there be not good evidence to show that the brain may be the seat of suppurative inflamma- tion and abscess without there being any cause to account for it ? Is there not, in such cases, idiopathic inflammation which gives rise to idiopathic aliscess ? By id- iopathic cerebral abscess, we suppose, is meant abscess which is not preceded or occasioned by injury or disease; its origin being unaccounted for. Lebert and others admit the occurrence of idiopathic cere- bral abscess. Such- cases are, however, in comparison with others, rare. It is beyond all doubt that a certain number of cases of cerebral abscess do occur in which no disease is discovered in any other part of the body, and there is no history of any recognized cause to account for the cerebral abscess. Before, however, it be concluded that abscess has been formed idiopathically, it is necessary to remember that in the ma- jority of cases there is a cause to account for the formation of such abscess, and that only in a very small minority have ob- servers failed to find some admitted cause. In the face of such evidence, is there not good reason to think tluit, in this small minority of cases, the primary cause has been overlooked ¥ And, when it is still further remembered that hours ha-\e been passed in searching for the primary dis- ease or cause, and at last it has been found limited to a mesenteric gland, a gum-boil, or a whitlow — in fact the pri- mary disease was so small, that it might have been very easily overlooked — it ap- pears to us not diflicult to understand ho-s^', even after very great care, the primary cause maj' have remained undiscovered. Bearing all this in mind, we recognize that in a few cases of cerebral abscess, the cause cannot be discovered ; but even when the cause is undiscovered, we should not as- sume that the suppurative inflammation has commenced idiopathically in the brain. Cerebral abscess proves fatal in many cases, not by a collection of pus in one or other part of the brain, but by extensive inflammatory softening around the ab- scess, involving vital parts of the brain ; and it is from such softening that the ab- scess is enabled to make its way towards the ventricles or the surface of the brain. The softening around very old cncjsted abscess would appear not to bo set up by pyogenic changes going on in its lining membrane, for there is not a large quan- tity of well-formed pus corpuscles in old encysted abscesses to show that such ac- tive changes have been going on in this membrane. The softening would rather appear to be due to some circumstance interfering with the nutrition of the parts outside of the abscess, but in its neighborhood. The nutrition of such parts, owing to the pres- ence of a foreign body, being very feeble, it is easy to understand how a blow on the head or a debilitated or cachectic state of the system may be sufficient to excite such feebly nourished parts to take on acute inflammatory softening. Has abscess in the brain any tendency to spontaneous cure? Lebert thinks not ; and when we remember that there is no well-established case on record, showing that an abscess has been spontaneously cured, we readily admit that the evidence very strongly favors the belief that cere- bral abscesses do not tend to a spontane- ous cure. It is, however, necessary to remember that the brain is a very vital oro-an, severely taxed in our every-day labors, and, if not sound, its functions, which are essential to life, may be brought to a stop. When there is an abscess in the brain, the organ being unsound, its functions are very liable to be perverted, and death follows ; whereas, if the ab- scess were seated in an organ less essen- tial to life, any perversion of its func- tional activity would not be attended with fatal results, and thus time would be 910 ABSCESS OF THE BKAIN. gained for the abscess to pass through the different stages e^seutial for its cure. We may tlierefore ask ourselves whetlier it is that an abscess of the brain has no disposition to spontaneous cure, or whether it is that the patient does not live long enough for such a process to be accom- plished ? The development of a firm cyst wall would show that there is a possibility of spontaneous cure. The cyst wall ex- erts a protective influence, by localizing the mischief and protecting the sound from the diseased part. And experience has shown that time is only required for such protection to be very great, and for the harrier guarding the pus to become stronger and stronger. "\Vc are next led to ask, is there any- thing in the condition of the pus discov- ered in old abscesses to show that these were in a process of cure? To our minds, there is. It is usual to find such pus in a very degenerate condition, viz. granu- lar and fatty, which is favorable to ab- sorption and concretion : such changes as occur in abscesses that have undergone spontaneous cure. This is no idle ques- tion. It is simply — Is cerebral abscess necessarily a fatal and incurable disease? Practically it is, but there is nothing in its morbid anatomy to lead us to conclude that it is necessarily incurable. Diagnosis. • — Cerebral abscess is in- ferred when there are symptoms of brain disturbance indicative of organic disease, and there are present those morbid con- ditions that are known to give rise to cere- bral abscess, such as a discharge from the ear, nose, or chronic suppuration else- where, or when there is a history of a blow, or of some other acknowledged cause of the disease. No doubt that in some cases the inference proves correct, where there is evidence showing that the cerebral substance is undoubtedly dis- eased, and further evidence of suppura- tion goiug on in some part of the body ; for here there are indications of acute brain disease, and we are led to suspect that this is due to abscess, since such causes are present as are known to pro- duce it. With the brain, however, as with other organs, we are more often able to say that it is diseased than to say what is the precise nature of the pathological changes going on in its substance. There may be evidence to show that a patient has chronic disease of the nose or ear, and cerebral symptoms may super- vene suddenly ; epileptiform seizures and other symptoms may be present, such as are seen in cases of cerebral abscess ; the patient may die, and yet there may be no disease of the brain or of its membranes. In some cases, the membranes alone are diseased ; in others, the brain substance is softened, without abscess. Disease of the bones of the skull — no matter whether it be fracture, syphilitic disease, or a growth— is liable to set up inflammation of the membranes of the brain, and the inflammation may spread, and give rise to suppurative inflammation of the brain substance. If the patient survive six or seven weeks, an abscess may be formed ; if he die in two or three weeks after acute symptoms have set in, the brain may be found softened, but without abscess. Kot unfrequently death takes place before there is time for the suppurative inflam- mation to form an abscess. There may be a history of injury to the head, cerebral disease may appear to have followed as a consequence, and the post- mortem examination reveal disease in the brain, but not abscess. Injury may be followed by the forma- tion, not of an abscess, but of a tumor, malignant disease, or by softening in the brain ; or further, the disease may not be in the brain at all, but on the surface. Experience has shown that an injury to the head may produce a large cyst in the cavity of the arachnoid, and the symptoms of the case may be similar to what are seen in cases of encysted abscess. Cerebral symptoms associated with of- fensive discharge from the ear and nose, would lead one to suspect abscess in the brain, but in one of our cases there was tumor, and not abscess. The coexistence of tumor in the brain with the conditions that are known to produce abscess, makes the differential diagnosis extremely diffi- cult. There are no pathognomonic symp- toms of abscess or of tumor. It is only the different manner in which the symp- toms are grouped, and the existence of those conditions that are known to pro- duce one and not the other disease, which leads the practitioner to suspect that there may be tumor rather than abscess, or vice versa. The symptoms of abscess may differ from those of tumor in the following re- spects. In abscess there is often marked cachexia and great emaciation. In tumor, the patients have often no marked ca- chexia, even look healthy, and the body is fairly nourished, certainly not ema- ciated. In abscess the duration of the cerebral symptoms is generally much shorter than in tumor. The symptoms in abscess are usually either latent or acute; in tumor they are often chronic. In the lat- ter there may be local paralysis extending over several months, which is very rare in abscess. The intracranial nerves are much more frequently affected in tumor than in abscess. Occasionally, however, a person with tumor is seen to be much emaciated. These differences may enable the practitioner, in some cases, to diagnose TREATMENT. 941 one condition from the otlier, but in neither case are these dift'erenues so constant that a certain diagnosis can be made. An abscess may lie latent in the brain for many months, and then acute symp- toms may suddenly set in, and the patient die in a few days. The same thing may take place with respect to cerebral tumor. Experience has shown that cancerous de- posits also may exist in the brain witliout there being any decided cerebral symptoms. Chronic encysted abscesses and tumors of the brain have many symptoms in common. A hydatid tumor, gliomatous tumor, a cyst, cancerous deposits in the brain, or any other substance acting as a foreign body, may produce pain in the head, epileptiform seizures, with or with- out paralysis, optic neuritis, vomiting, or gradual loss of muscular power. We are often able to say, when there is acute persistent but variable paralysis, with pyrexia, that there is acute intlam- matory softening of the brain; but whether that softening is going on around an ab- scess, a tumor, or a cyst, or whether ex- cited by disease situated on the surface of the brain, we may be unable to give any exact opinion. With respect to rigors in cases of cere- bral abscess, we have already stated that they are very well marked in some in- stances, and may be not unlike those of ague. This symptom is not, however, peculiar to cerebral abscess. It occasion- ally occurs in other forms of brain disease, for instance, as gliomatous tumors or tu- bercle. Treatment of abscess of the brain should be, by anticipation,— obviating the causes which lead to it; in chronic disease of the ear or nose, by maintaining a free exit for the discharge, no matter what the exciting cause. Kest is the most impor- tant part of the treatment, avoiding thereby both mental and mechanical ex- citement. By a simple diet and quiet life, abscess may be dormant in the brain for an in- definite time.' In cases where abscess follows injury to the head, surgical interference must be thought of. The principle in such cases is a mechanical one, namely, to reach the abscess and evacuate its contents, if that be thought advisable, — experience shows but little to commend it.^ ' This is, however, to be observed, that encysted abscess of the brain is fatal from changes outside the cyst of an acute kind, such as might be presumed to be preventible to a great extent. In support of this opinion vie may say that, in our experience, we have known abscess lie quiet for months after a blow on the head, and the patient and the medical attendant become confident that all was well ; the symptoms of lesion having slowly gone off, and j'et a fatal issue be pro- duced after a few hours' suffering by neglect- ing the precaution of rest and regimen. Probably such rest and care should be con- tinued, not for months only but for years. This we say from' clinical observations of the changes in the cyst of old cerebral abscess. [» A series of statistical tables, giving the particulars of 76 cases of Abscess of the Brain, are omitted from this edition ; for the reason that, valuable as they are in themselves, yet in proportion to the space they occupy, they are likely to be referred to in detail by very few readers. Their general history, and the lessons to be derived therefrom, are well stated in the preceding article. — H.] B.-PARTIAL DISEASES OF THE NERVOUS SYSTEM.- CONTJNUED. 2. Diseases of the Spinal Column. Meningitis. Myelitis. Congestion. Tetanus. Locomotor Ataxy. Irritation. General Spinal Paral- ysis. Hysterical Paraple- gia. Reflex Paraplegia. Infantile Paralysis. Hemorrhage. Non-inflammatory Softening. Induration. Atrophy and Hyper- trophy. Tumor, etc. Concussion. Compression. Caries of Vertebrae. Spina Bifida. DISEASES OF THE SPIISTAL COED. By C. B. Radcliffe, M.D., F.R.C.P. A. Preliminary Remarks. Before proceeding to cope with the intricate and difficult pathological topics which form the subject of the present article, it appears to be expedient to glance at some points in the physiology of the spinal cord, and also to try and ascertain the true significance of pain, spasm, and certain symptoms analogous to pain and spasm, which figure conspicu- ously in the histories of spinal maladies ; for if these matters be not disposed of as preliminaries now, they will prove to be the cause of frequent and distracting di- gression afterwards. I. A Glance at some Points in the Physiology of the Spinal Cord. 1. Roots of spinal nerves. — The result of recent researches has been to establish in the fullest manner the truth of Sir Charles Bell's great discovery, that the posterior roots of the spinal nerves are devoted to sensation only, and the anterior roots to motion only. In one article, at least, the creed of to-day is the same as that of yes- terday : and it is some comfort to have it so, for in many other articles the creed of yesterdav is not that of to-day. (942) 2. Posterior columns. — If these columns be cut across, the result is, not numbness, as it would be if these columns were, as was once supposed, simply the continua- tion of the posterior roots of the spinal nerves, but hypertesthesia and loss of co- ordinating power in the parts below the section, with a certain degree of local pain ; and on inquiring further, it is found that this pain is due, not to any sensitiveness in the columns themselves, but to the irritation of the cut having travelled through the posterior roots of the spinal nerves, which posterior roots, as the researches of Lockhart Clarke show, pass through the posterior columns, more or less directly, to the central gray matter of the cord. 3. Restiform bodies and small posterior pyramids. — What has just been said of the posterior columns of the cord appears to apply equally to the restiform bodies, and to the small posterior pyramids of the medulla oblongata, which pyramids lie between the restiform bodies posteriorly. Hypereesthesia and incoordination in the parts below the section, with some local pain, are still the result of cutting these parts across : and as the connections of these parts are above with the cerebellum, and below with the posterior columns of the cord, the natural inference is, that PHYSIOLOGY OF TUB SPINAL COPD. 943 the channel through which the cerebellum acts upon the body is formed of the resti- form bodies and small posterior pyramids in the upper part of its course, and of the posterior columns of the cord in the lower part. 4. Anterior columns. — If one of these columns be cut across, it ceases to act on that side of the body in the parts below the section, and the paralyzed parts arc benumbed to a certain degree, unless the cut be made in the part which lies imme- diately below the anterior pyramids of the medulla oblongata. In this part the an- terior pyramid may be cut across without causing any very obvious paralysis or loss of sensation : in this part the results of dividing the anterior column at a lower level are only obtained when the cut is extended transversely, so as to divide the lateral column. It is plain, in fact, that in the uppermost part of their course, the anterior columns have not that intimate connection with the anterior roots of the spinal nerves, and that all-important part to play in voluntary movement, which they evidently have everywhere else : and it is also plain that the anterior columns, where they have to do with voluntary movement, have also something to do with sensation, for it is a fact that a cer- tain degree of numbness is produced by the injuries which give rise to paralysis. 5. Anterior pyramids. ^ A transverse section of one of the anterior pyramids of the medulla oblongata in any part of its course- annihilates all power of voluntary movement in the muscles below the sec- tion on the opposite side of the body, with- out affecting the sensation in any appre- ciable manner ; and thus it is plain, not only that each pyramid contains very many, if not all, the conductors concerned in carrying the orders of the will to the muscles of the opposite side of the body, but also that the conductors which are collected in one pyramid decussate with those collected in the other pyramid at the lower and not at the upper boundaries of the pyramids. In a word, all the evidence, old and new, goes to show that these bodies are composed of conductors con- cerned in voluntary motion without any admixture of sensory conductors. 6. Later cd columns. — In the cervical region, for a short distance below the point at which the anterior pyramids of the medulla oblongata intercross, the lateral columns of the spinal cord have certainly very much to do in transmitting the orders of the will to the muscles ; for, as has just been seen incidentally, the muscles below the section on the same side of the body are paralyzed by cutting one of them across in this part. In the lower part of the cervical region, and in the dorsal and lumbar regions, it is very different, and the difference is not very j clearly determined. Hero some trifling paralysis may )je produced by dividing these colunms transversely, but never more than this. Here, indeed, it would seem that this operation is followed by a certain degree of auKsthcsia, and by the same result, as regards movement, as that which follows transverse division of the posterior columns— that is, not by paraly- sis, but by incoordination. A certain degree of ansesthesia appears to be a con- stant consequence of cutting across the lateral colmnns in any part of their course ; and herein would seem to be an impor- tant distinction between the lateral and the posterior columns, for, as has been stated already, the result of cutting across the posterior columns is to produce hyper- esthesia, not anwsthesia. 7. Olivary bodies. — A section of the olivary bodies is followed, not by any marked degree of paralysis, or antesthesia, but by a state of persistent spasm in many muscles on the same side of the body, in the neck especially, — a state which may sometimes continue for daj-s, weeks, or even months. It is found, also, that this strange result is produced by irritating several parts of the base of the encephalon, the lateral and posterior parts of the me- dulla oblongata and pons Varolii especi- ally, as well as by irritating the olivary bodies. These parts are not very clearly defined. "They seem," says Dr. Brown- Sequard, " to be quite different from those employed in the transmission of sensitive impressions, or of the orders of the will to the muscles, at least in the medulla oblon- gata and pons Varolii. They constitute a very large portion of these two organs, and, perhaps, as much as three-fourths of the one first named. They are placed chiefly in the lateral and posterior columns of these organs ; and Ijecause many of their fibres do not decussate, the sjaasm produced by irritating them is on the same side of the body." 8. Oixiy substance of the cmxl. — Instead of being merely a nerve-centre — the spe- cial centre of Marshall Hall's excito-motor system of nerves — there is now reason to believe, with Dr. Brown-Sequard, that the gray substance of the spinal cord is an important conductor of sensory and motor impressions. Paralysis without loss of sensation on the same side of the body, loss of sensation without paralysis on the other side of the body, are the strange re- sults of cutting across one lateral half of the gray substance of the spinal cord : anesthesia on both sides of the body, paralysis on either side, are the equally strange results of making a longitudinal section midway between the two lateral halves : these are the two great facts which, when properly interpreted, furnish the reasons for believing, not only that there are sensorial and voUtional conduc- 944 DISEASES OF THE SPINAL CORD. tors in the gray substance of the cord, but also that these two forms of conduc- tors follow a diflerent and definite course. Nor is it difficult to see how this may be. Let the course of the conductors in con- nection with the anterior and posterior roots of a pair of spinal nerves be what is represented in the following diagram, — a h being the motor conductor descending to the right, and «' 6' the corresponding conductor descending to the left ; c d being the sensory conductor ascending from the left, and c' d' the corresponding conductor ascending from the right, — and very little reflection will serve to supply the demon- stration wanting. With the sensory and motor conductors arranged in this manner, it is plain that a cut across the lateral half of the gray substance — a lesion indicated in the diagram by the line A e — must de- .r^ stroy the continuity of the motor conduc- tor a h, and of the sensory conductor c d, and leave untouched the motor conductor «' 6', and the sensory conductor c' d' — must bring about, that is to say, what has been seen to happen in the first of the two experiments under consideration ; namely, preservation of sensation with loss of motion on the side of the lesion, and preservation of motion with loss of sensation on the opposite side. Again, with the sensory and motor conductors arranged in this manner, it is plain that a section of the gray substance of the cord midway between the two lateral halves — a lesion indicated in the diagram by the line C A D— must leave the motor conduc- tors a 5 and a' b' untouched, and cut across the sensory conductors c d and c' d' at their point of decussation— must bring about what happens in the second of these two experiments, viz., numbness on both sides of the body, and paralysis on neither side. In saying that paralysis without loss of sensation, on the same side of the body, and loss of sensation without paralysis, on the other side of the body, is produced by cutting across a lateral half of the spinal cord, all is not said that has to be said. In such a case there is, in addition, in- creased temperature and sensibihty on the side on which sensation is preserved, and diminished temperature on the side on which sensation is lost, especially if the section be made high up near the medulla oblongata. It would seem, in fact, that the injury has acted upon the vaso-motor nerves contained in the cord as well as upon the common motor and sensory nerves, causing paralysis of vaso- motor nerves on the side on which there is increased temperature and sensibility, and irritation of vaso-motor nerves on the side on which there is diminished tempe- rature and ansesthesia. At any rate this mode of explanation is neither impossible nor improljable. The experiments of Professor Claude Bernard, Dr. Brown- Sequard, and others upon the cervical sympathetic, prove that when this nerve is paralyzed by dividing it, a state of hypersemia, of which the most conspicuous signs are a bloodshot state of the conjunc- tiva and of the lining membrane of the nostril and ear, with a contracted pupil, and with increased temperature, is at once set up on the same side of the head : and also that when the end of the divided nerve below the section is irritated, the immediate result is dilatation of the pupil, with an almost complete blanching and cooling of the parts which were bloodshot and warm a moment before. The vessels in these parts evidently relax and receive more blood when their nerves are para- lyzed, and contract and receive less blood where their nerves are irritated ; and the increased temperature and sensibility which happen in the one case, and the diminished temperature and sensibility which happen in the other case, are nothing more than the natural conse- quences of the increased or diminished quantity of blood in the parts in each case respectively. All this is plain enough. Moreover, there are other facts which go to show that phenomena in every way analogous to those which result from paralysis or irritation of the cervical sym- pathetic are produced by paralyzing or irritating vaso-motor nerves in other parts. There is, therefore, no reason why it may not be inferred that the increased temperature and sensibility of one side of the body, and the diminished temperature of the other side, which happen when a lateral half of the spinal cord is cut across, are the result of vaso-motor nerves being paralyzed in the one case and irritated in the other case. ISTay, such an assumption is well-high inevitable, for the structural connection between tiie spinal and sym- pathetic systems of nerves is such as to make it scarcely possible to believe that a lateral half of the cord can be cut across without paralyzing and irritating vaso- motor nerves. 9. Motor and sensory tracks. — The con- ductors concerned in voluntary motion, PHYSIOLOGY OP THE SPINAL CORD. 945 and those belonging to common sensation, botli intercross in the cord, but not at the same place. From the right side of the brain, voluntary impressions pass to the motor nerves of the left side of the body, their course thither being, first, down the right anterior pyramid, then across to the left lateral column, then for a short dis- tance down the left lateral column, then down the left anterior column, and to some extent also down the left side of the gray substance and the left lateral column, and so out at the left anterior roots : from the left side of the brain, these impres- sions pursue a similar course, only pass- ing to the right side of the body instead of the left. Entering at the right pos- terior roots of the spinal nerves, the im- pressions which give rise to common sen- sations pass to the left side of the brain, up the left side of the gray substance, and to some extent also up the left lateral column and the left anterior column, the crossing to the other side of the cord being at the level of the entrance of the conductors into the cord, or thereabouts : entering at the left posterior roots of the spinal nerves, the impressions in question take a similar course to the right side. Both sets of conductors Intercross in the cord, but not at the same place. The conductors concerned in voluntary motion intercross at the decussation of the an- terior pyramids. The intercrossing in this case is at this place, and at this place only : there is none above it, none below it. The conductors belonging to common sensation, on the other hand, intercross below the decussation of the anterior pyramids, and throughout the whole length of the cord. These are the main points to be remembered with reference to the tracks of these two forms of con- ductors in the cord. The conductors which have to do with coordination of movement appear to be confined to the posterior columns of the cord, and to the parts which connect these columns with the cerebellum, the resti- form bodies, and the small posterior pyra- mids. They are quite distinct from the conductors concerned in voluntary move- ment, and they also differ from these con- ductors in this, that those belonging to the two sides of the body do not inter- cross anywhere. The vaso-motor conductors which enter into the composition of the cord appear to lie chiefly in the gray substance, for the dilatation of vessels resulting from paralysis of these nerves is brought about by dividing the gray substance rather than the white. Moreover, the fact that this dilatation of vessels is on the same side as that on which the gray substance is divided, must be taken as a reason for believing that the vaso-motor conductors belonging to the two sides of the body, voi,. I.— 60 like the conductors which have to do with the coordination of movement, do not intercross in the cord. And so likewise with certain other con- ductors of a vaguer sort. These lie in and about the olivary bodies, and in the upper third of the lateral column ; and there is, as it would seem, no intercross- ing between those belonging to the two sides of the body, for the simple fact is this, that the persistent spasm which is brought about by irritation, which spasm is the only fact pointing to the existence of these conductors, is always on the same side as that to which the irritation is applied. On the other hand, there appears to be nothing pecuhar in the sensory conduc- tors which are not concerned in common sensations— those which have to do with pain, tickling, temperature, and the rest. Wliat has been said of the common sen- sory conductors would seem to apply to them in every respect, and indeed if may be doubted whether difterent conductors are required for the transmission of the different kinds of impressions. 10. Increased reflex action. — When the continuity of the cord is entirely inter- rupted by being cut, torn, compressed, or injured in any other way, voluntary move- ment and sensation are abolished in the parts below the injury ; and at the same time the paralyzed muscles, especially in the lower extremities, become much more prone to reflex action. This increased proneness to reflex action is developed immediately, or all but immediately, and it may continue with little or no change for days, weeks, or even months. It makes its appearance before there is time for the development of inflammation or congestion ; it continues after the time when any inflammation or congestion re- sulting from the injury which led to it maybe supposed to-have come to an end ; and therefore it is difficult to look upon it as an indication of inflammation or con- gestion. Indeed the history of inflamma- tion or congestion of the cord is opposed to this idea, for most certainly increased reflex action does not figure among the symptoms of unequivocal instances of these disorders. And this is all that need be said now, except this, that the history of increased reflex action would seem to be more intelligible on the view of muscu- lar action which recommends itself to the writer, than on that which is commonly accepted. 11. Increased temperature.— In a paper on injuries of the spinal cord, published more' than thirty years ago,' Sir Benja- min Brodie says : " M. Chopat has given an account of some experiments on ani- mals, in which he found that the division Med.-Chir. Trans., vol. xx. 1837. 946 DISEASES OF THE SPINAL CORD. of the superior portion of the spinal cord produced a remarkable evolution of ani- mal heat, so that it was raised much above the natural standard. I have made experiments similar to those of M. Cho- pat, and have met with similar results. I have also seen several cases in which an accidental injury of the spinal cord has produced the same effect. The most re- markable of them was that of a man who was admitted into St. George's Hospital, in whom there was a forcible separation of the fifth and sixth cervical vertebrffi, attended with an effusion of blood within the theca vertebralis, and laceration of the lower part of the spinal cord. Respi- ration was performed by the diaphragm only, and of course in a very imperfect manner. The patient died at tlie end of twenty-two hours ; and, for some time previously to his death, he breathed at very long intervals, the pulse being weak and the countenance livid. At last there were not more than five or six inspira- tions in a minute. Nevertheless, when the ball of a thermometer was placed be- tween the scrotum and the thigh, the quicksilver rose to 111° of Fahrenheit's scale. Immediately after death the tem- perature was examined in the same man- ner, and found to be still the same. " A Russian observer, Dr. Tscheschechin,' has also ascertained that considerable ele- vation of temperature, with quickened pulse and breathing, follows a section of the pons at its junction with the medulla oblongata, and that these symptoms go on increasing for two or three hours, until the state is that of high fever. Moreover, increase of temperature on one side of the body and decrease on the other has been seen to be one effect of dividing one-half of the gray substance of the cord. There is, indeed, reason to believe, not only that increased temperature is one effect of divi- sion of the cord, but that this change is in some way connected with paralysis of vaso- motor nerves ; for in speaking previously of the experiment last mentioned, it was shown that this paralysis may well be sup- posed to lead to this result. 12. Hints for delerminmg the level of the injury in certain forms of spinal paralysis, &Q,.- — If the injury be at the upper limit of the sacral region of the cord, the muscles of the bladder and anus will be paralyzed, and so will the muscles of the lower ex- tremities, with the exception of those which are supplied by the anterior crural and obturator nerves (the psoas, iliacus, sartorius, pectineus, adductor longus, a. magnus, a. brevis, obturator externus, vas- tus externus, v. internus, rectus femoris, &c.), which nerves come off from the second, third, and fourth lumbar pairs of ' Reichert's and Du Boia-Reymond's Ar- chiv f. Anat. u. Phys. 1866. spinal nerves. If the injury be very low down in the sacral canal, the compressor urethrse and the accelerator urinte, as well as the sphincter ani, will be paralj'zed, but not the muscles of the legs ; for the nerves of the three muscles, specified by name, come off almost from the extreme end of the cord, and below those which go to form the great sciatic. When the injury to the cord is higher up in the cord, in addi- tion to the loss of voluntary power in the lower extremities and in the bladder and anus, the respiratory muscles will be more or less paralyzed. If the injury be at the upper limit of the lumbar region, the lateral muscular walls of the abdomen will be paralyzed, and so will all the muscles of the lower extremities, and one effect of the paralysis of the abdominal walls will be to compromise greatly the expiratory movements of respiration. If the injury be high enough to paralyze intercostal muscles, inspiration will be interfered with as well as expiration, and the degree of interference will he in proportion to the number of intercostal muscles implicated. If the injury be low down in the cervical region, all the intercostals will be para- lyzed, and so will the muscles of the upper extremities, except those of the shoulders, which receive their nerves from higher portions of the cervical region. If the injury be at or above the middle of the cervical region — at or above the level of the fourth cervical pair of spinal nerves — death will at once result from the suspen- sion of all inspiratory movements. In this latter case it is customary to ascribe the stoppage of breathing to paralysis of the nerve which supplies the diaphragm — that is, the phrenic ; but this explanation does not go far enough. The injury which paralyzes the diaphragm paralyzes the scaleni, the inter-costales, and the serrati magni, which muscles elevate the ribs in ordinary respiration, and in so doing play a part which is scarcely less important than that played by the diaphragm ; and not only so, but it paralyzes also the greater number of those accessory respi- ratory muscles which, acting upon and from the shoulders, come to the rescue when a great effort at inspiration is neces- sary, and produce additional expansion in the upper part of the chest. Not only is there a great difference between calm res- piration and forced respiration, but there is a great difference also between the res- piration of males and that of females. "In males," says Dr. Hutchinson, "the abdomen first bulges outwards, and the ribs and sternum nearest to the abdomen quickly follow this movement, until the motion, like a wave, is lost over the tho- racic region. In females, the breathing commences with a gentle heaving of the upper part of the thorax, more or less ap- parent according to the fulness of the PAIN AND SPASM. 947 mammse, and with some slight elevation of the shoulders ; and this movement of expansion spreads from rib to rib in a downward direction, and any bulging of the abdomen from the descent of the dia- phragm is distinctly after this heaving of the lateral wall of the chest, not before it. " In females also this bulging of the abdo- men is so inconsiderable that the number of respirations cannot be counted by the hand resting on that region as it can be in the male. In calm breathing, in fact, the diaphragm does more and the ribs do less in males than in females : and this differ- ence is so real that, for tlie sake of distinc- tion, calm breathing may be spoken of as diaphragmatic in males, and as costal in females. This difference is such, indeed, that respiratory movements which are healthy in women are morbid in men ; and vice versa, that movements which are healthy in men are morbid in women. "In forced' breathing," Dr. Hutchinson again says, " the greatest enlargement of the thoracic cavity in both sexes is made by the ribs and not by the diaphragm, as is generally believed ;" and that this statement expresses what really happens, appears to be evident in the fact that in such breathing the liollow at the pit of tlie stomach, instead of being filled out and protruded, as it must be if the diaphragm descended in any marked degree, is actu- ally drawn in and depressed. In forced breathing, indeed, the costal inspiration of women becomes more costal, and the diaphragmatic inspiration of men changes from this form to the costal. It is cer- tain, however, that tliere may be forced diaphragmatic breathing as well as forced costal breathing, and that the one may be made to take the place of tlie other by an easy effort of the will, or by changes of position which interfere with tlie action of the diaphragm on the one hand, or of the ribs on the other. There is, indeed, no difflculty in understanding why dis- eases which interfere with the action of the diaphragm or ribs should make the breathing costal or diaphragmatic, as the case may be. As regards the expiratory movements of respiration there is little to say. In tranquil breathing, in males and in females alike, expiration is performed by the relaxation of the diaphragm allow- ing the abdominal viscera to press up into the position from which they had been depressed in inspiration by the con- traction of this muscle, by the relaxation of the costal muscles allowing the ribs to spring back into the position from which they had been pulled up in inspiration by the contraction of these muscles, and by the resiliency of the air-passages them- selves. In forced expiration the lateral and inferior muscular walls of the abdo- men will help to empty the chest by pull- ing down the ribs and by contracting upon the abdominal viscera, so as to cause them to push up the diaphragm more eftectually. It IS easy, indeed, to see how a lesion of the spinal cord which paralyzes the late- ral and inferior abdominal walls must in- terfere with the movements of expiration, and especially with such violent move- ments as coughing or sneezing. In a word, the whole case of the respiratory movements is one which makes it impos- sible to continue in the belief, that the one reason why the division of the cord at or above the origin of the phrenic nerve proves fatal, is because the diaphragm is paralyzed ; for the plain fact is, that the injury whieh paralyzes the diaphragm paralyzes the muscles which elevate the ribs, both ordinary and extraordinary, and so puts an end to movements which are quite as important as those of the dia- phragm, if not more so, in carrying on respiration. Of the other phenomena which may be present when the injury which interrupts the continuity of the cord as a conductor is in the neck, but not so high as to destroy life immediately, and which are not likely to be present when the injury is much below the cervi- cal region, difficulty of swallowing, diffl- culty in vocalization, contraction of pupils, palpitation, and priapism appear to be the most important. II. On the Practical Significance OF Pain and Spasm, and of certain OTHER Symptoms more or less akin TO Pain and Spasm. Have these symptoms to do with in- flammation, or with a state which, though not unfrequently passing into inflamma- tion, is in reality diametrically opposed to inflammation ? This is the question to which I propose now to seek the answer, first, in relation to pain and the symp- toms akin to pain, and, secondly, in rela- tion to spasm and the symptoms akin to spasm. 1. On the practical significance of pain and the symptoms oMn topain.— There are some points in the history of common neuralgia— the beginning and ending of the paroxysm periodically at a given time, the 'association of the pain with rigors, the frequent ending of the pain in an obscure fit of feverishness, and others —which are calculated to suggest some relationship between this disorder and ague. It would seem, indeed, especially in that form of neuralgia which is met with in aguish districts, as if the neu- ralgia and the rigors were companion symptoms— as if there was some connec- tion between the pain and a depressed state of the circulation such as is met with in the cold stage of ague. There is also some reason to believe that neuralgia 948 DISEASES OF THE SPINAL CORD. is antagonized ratlier tlian favored by in- flammation and fever. It is no uncom- mon thing for tlie liistory of facial neu- ralgia or tic-douloureux to be this : first, neuralgia, without local tenderness and swelling, and redness, and with frequent chills and shivers, and a decidedly de- pressed state of the circulation ; after- wards, cessation of neuralgia, cessation of chills and shivers, with local tender- ness, redness, and swelling, and with some slight feverish reaction. What I have experienced in my own person, as well as what I have witnessed in others, enables me to speak with all confidence upon this point. It is also the rule, rather than the exception, for the neu- ralgic pain of toothache to come to an end when the face becomes swollen and in- flamed ; and it does not seem to be other- wise with the stabbing neuralgic pains which so generally precede the inflamma- tory eruption of herpes, for it is usual for these pains to subside concurrently with the development of the eruption. Nay, I know of several cases of sciatica, in which the relief to the neuralgic pain was coincident with the development of a tenderness which seemed to betoken neu- ritis at one or more points in the course of the painful nerve, and in which, after this change the patient was comparatively free from pain so long as the lame limb was kept still and let alone. With re- spect to neuralgia, in all its manifold forms, indeed one thing is certain, and this is, not only that neuritis is not neces- sary to its production, but also that this form of inflammation is at most a very exceptional complication. Nor is a different conclusion to be drawn from the history of rheumatic and gouty pain. In acute rheumatism it is generally found that the pains which had been tor- turing the patient for days, or weeks, or months previously, preventing him from being at ease in the daytime, and causing him to toss about in sleepless misery at night, come to an end when the feverish reaction and local inflammation of the fully-formed disorder make their appear- ance. After this, the joints are tciicZcr enough ; but if the patient keep as still as he is very likely to do under the cir- cumstances, he is comparatively or ac- tually at ease so far as his old rheumatic pains are concerned. Or, if it be other- wise, the pains will generally be found to be in a part in which the signs of rheu- matic inflammation are imperfectly es- tablished or absent, or else at a time when there is a decided remission in the feverish reaction — an event which hap- pens more frequently in this disorder than is commonly supposed. And certainly it is impossible to look upon the local inflammation of gout as essential to the racking pain of this dis- order. " About two o'clock in the morn- ing," says Sydenham, who knew full well from personal experience what he ought to say, " the patient is awakened by a severe pain in the great toe, or, more rarely, in the heel, ankle, or instep. The pain is like that of dislocation, and yet the parts feel as if cold water were being poured over them. Then follow chills and shiverings, and a little fever. The pain, which was at first moderate, be- comes more intense ; and with its inten- sity the chills and shivers increase." After tossing about in agony for four or five hours, often till near daybreak, the patient suddenly finds relief, and falls asleep. Before falling asleep, the only visible change in the tortured part is some swelling in the veins ; on waking in the morning the part has become swollen, shining, red, tender beyond measure, and more or less painful, but painful only to a degree which is as nothing in comparison with the torture of the night past. It seems, indeed, as if the pain which now exists may in great measure be referred to the mere tension and stretching of the inflamed ligaments, for it may be re- lieved, or even removed, by judiciously applying support to the toe and sole of the "foot. On the night following, and not unfrequently for the next three or four nights, the sharp pain may return, reappearing and disappearing suddenly, or almost suddenly, and resulting in the development of additional inflammatory swelling in the interval between falling asleep and waking in the morning. The pain in these relapses, like the pain in the first attack, is accompanied by chills and shivers, and by the most distressing irritability and excitability ; but, until unequivocal signs of inflammation are de- veloped in it, the painful part is not tender in the true sense of the word. The infiammation, moreover, is attended by no fever, or by very little ; or if it be otherwise, as it is occasionally, the in- flammation runs higher than usual, and the characteristic pain is less urgent than usual. Dr. Garrod points out this latter fact in his excellent work on Gout. From its history, then, it would seem as if the pain went hand in hand with the rigors which belong to the cold stage of gouty inflammation. It would seem as if the inflammation, as inflammation, had little to do with the pain ; for if it were other- wise, it is scarcely to be supposed that the pain should be less urgent in the cases of gout in which the inflammation is most marked, and that the unequivocal signs of inflammation should make their appearance during sleep without waking the patient. Nay, it would even seem as if the pain were put an end to by the es- tablishment of inflammation— as if, in PAIX AND SPASM. 949 fact, the pains were antagonized rather than favored by the inflammatory condi- tion. Moreover, the suddenness with which it begins and ends in the majority of cases must be looked upon as a reason for referring the pain to the category of neuralgia — a disorder with which, as I have already shown, inflammation has no necessary connection. There is also reason to believe that pain holds the same relation to fever and in- flammation in other kinds of fever besides the rheumatic, and in other kinds of in- flammation besides the gouty. The pain in the back, often very severe, which ushers in smallpox, disappears be- fore the hot stage is fully established. It comes and goes hand in hand with the rigors, and it belongs to the cold stage as evidently as do the rigors. And this would seem to be the case also in other fevers ; for it is the rule, and not the ex- ception, for the pains which attend upon the onset of these disorders to pass away or to become greatly mitigated as soon as the cold stage gives place to the hot. Nay, it would seem as if pain gave place for the time to what may be called arti- ficial feverishness. At any rate, I have more than once felt tic-douloureux in my face pass away as soon as I could set my blood in brisk motion by violent bodily exercise ; and on two occasions I have put a stop to a sudden attack of lumbago while in the saddle, by a practice which is not unfrequently adopted in such a case in the hunting-field — that is, by leaning forwards, and beating the loins with the hands until the whole body was aglow, and the perspiration dropped from the forehead. The acute pain of a dislocation or sprain — the pain to which Sydenham likens that of gout — does not, as a rule, remain after the parts have begun to be hot and tender and swollen ; and as a rule, also, the pain of idiopathic inflam- mation goes before, and not along with, the redness and heat and swelling. In the idiopathic, as well as in the traumatic forms of inflammation, it would seem, indeed, as if the pain were related to the cold stage of the disorder, and not to the hot. Nor is a contrary conclusion to be drawn from the history of those cases in which the pain continues after the hot stage of the inflammation is fully estab- lished, for in these cases this persistent pain is evidently (in great measure at least) due to the stretching of parts made tender by the inflammation. Thus, for example, the pain which remains after the hot' stage is fully established in or- chitis and pleuritis, is at once removed or relieved by means which obviate this stretching, — in the former case by the free use of the knife, in the latter case by the application of a roller around the chest so as to prevent the movement of the ribs over the seat of inflammation. Even in inflammation of the membranes of the brain, severe pain in the head can- not be looked upon as a symptom of this inflammation. About six years ago I had a youth in the Westminster Hospital with well-marked symptoms of acute cerebral meningitis. When I first saw him, he complained of frequent rigors and of a constant agonizing pain in the head, and at this time his face was pale and perspir- ing, his ears and his head generally were below the natural temperature, his pupils somewhat dilated, and his pulse con- tracted and feeble. Eight hours after- wards, when I saw him the second time, his face was flushed, his head burning hot, his pupils contracted, his eyes ferrety, his skin hot and dry, his pulse strong and full, and fierce delirium had taken the place of the pain. And this, so far as my experience goes, is the regular history of pain in this disorder. It is pain ceasing, not pain beginning, as the symptoms of active determination of blood to the brain make their appearance. It is pain in association with an ansemic rather than with a hypersemic condition. For these among many reasons it is that pain (with the exception of that form of pain which is dependent on tenderness, and which is accidental only) does not ap- pear to be a symptom of inflammation or fever. In inflammation or fever the pain would seem to be connected with the cold stage preceding the hot stage, and not with the hot stage itself — with a state of capillary contraction and deficiency of blood, and not with a state of capillary relaxation and excess of blood — with a state of vaso-motor irritation, and not with a state of vaso-motor paralysis : in other cases, the pain would seem to have to do with a state of circulation which is in reality closely akin to that which ex- ists in the cold stage of inflammation and fever. Pain, however, must not be re- garded as a symptom of inflammation or fever because it happens to be associated with the so-cahed cold stage of these dis- orders. In point of fact, this so-called cold stage of inflammation or fever is a state which is diametrically opposed to the so-called hot stage. In this cold stage, the vaso-motor nerves (and not these nerves only) are in a state of irritation, and, as the result of this irritation, the capillaries are contracted and compara- tively bloodless ; in the hot stage, on the contrary, the vaso-motor nerves are para- lyzed, and, as the result of this paralysis, the capillaries are relaxed and bloodshot,' Instead of being stages in the same pro- cess, the so-called cold stage and the so- called hot stage are conditions diametri- cally opposed to each other. Instead of being stages in the same process, it would 950 DISEASES OF THE SPINAL CORD. rather seem that the hot stage has a re- medial relation to the cold stage — that, within certain limits, the hot stage is the salutary refluence of a tide of life which has ebbed too low in the hot stage. It is not difficult to see that there is an inti- mate connection between the so-called cold stage and the so-called hot stage, and that the first may easily change into the second. It is not difficult to see that there must be this relation between these stages ; for if, as there is good reason to believe, irritation of vaso-motor nerves may bring about the cold stage by causing contrac- tion of vessels, it is easy to understand that the paralysis of vaso-motor nerves, which follows when this irritation is car- ried beyond a certain point, may lead to the hot stage by causing relaxation of ves- sels. At any rate, be this as it may, the plain fact would seem to be that pain, with the exception of that form of pain which is dependent on tenderness, is a symptom belonging to the so-called cold stage of inflammation and fever, or to a state of circulation closely akin to it, and not to the hot stage of inflammation and fever, or to a state of circulation akin to it. Nay, it may even be supposed, and not without some show of reason, that pain must be associated with contracted and empty capillaries; for, the sympathies of the nervous system being what they are, it is not easy to believe that the vaso- motor nerves do not participate in the irritation of the sensory nerves, for which pain is the expression in words. And if this be so — and this is the prac- tical conclusion to which these remarks tend — it follows that pain is likely to be relieved by measures which are calculated to rouse the circulation and increase the quantity of blood in the capillaries of the painful part, and not by those which have a contrary action. With regard to tingling and other synip- toms which are more or less akin to pain, there is little to say. Indeed all I can say is that the history of these symptoms, so far as is known to me, would seem to agree rather than to disagree with that of pain, in connecting them with a state of irritation, and not with a state of actual inflammation. 2. Of the significance of spasm and the symptoms alcin to spasm. — The violent and general epileptic form of convulsion which attends upon death by hemorrhage or suffocation is associated with a defective and not with an excessive supply of arte- rial blood to one or other of the great nerve-centres. Nor is it otherwise with ordinary epileptic or epileptiform convul- sion. The deathly paleness of the counte- nance which precedes the convulsion is, indeed, a plain proof that the fit com- mences in a state of circulation which is the very opposite to that of active deter- mination of blood to the head, and the strong pulse which is usually perceptible in the arteries as the tit progresses is no contradiction to this conclusion. This strong pulse is usually regarded as a sign of arterial excitement— as a proof that more arterial blood is being injected into the arteries at this time, and that, on this account, certain nervous centres are ex- cited to an unwonted degree of activity : but the simple fact is, that the strong pulse which is present under these circum- stances derives its strength, not from arte- rial blood, but from venous. Black blood is being pumped into the arteries at the time ; and because black blood moves less readily through the capillaries than red blood, the arteries become distended and the pulse endowed with a counterfeit power. The strong pulse in question is caused by the suffocation which is a part of the fit : it is a pulse of black blood and not of red, as may easily be proved by making an opening into the artery : it is nothing more, in fact, than the natural pulse of suffocation. Hence, the strong pulse of the epileptic or epileptiform paroxysm is no proof that this form of convulsion is connected with an excited condition of the circulation ; on the con- trary, when rightly read, it points only to the opposite conclusion. It would seem also that convulsion is not associated with an over-active con- dition of the circulation, even in those cases in which at first sight it might ap- pear to be so. In the fevers of infancy and early childhood, especially in the ex- anthematous forms of these disorders, convulsion not unfrequently takes the place occupied by rigor in the fevers of youth and riper years. It occurs in the initial cold stage, or else in the last mo- ments of life, not in the intermediate hot stage. Again in inflammation of the membranes of the brain, convulsion, when it occurs, is connected with the cold stage before the hot stage, or with the cold stage after the hot stage, and never with the hot stage itself. Nay, I am disposed to think that there is something altogether uncongenial between convulsion and a state of febrile reaction in the circulation, for it is a fact not unfrequently verified that fits of common epilepsy are often sus- pended during the continuance of such reaction. As indeed I have endeavored to show at length elsewhere,' the physiology and pathology of muscular action, so far as I can read them, serve only to connect all ' Epilepsy, &c. ; Lectures delivered at the Royal Coll. of Phys. lu London. Post 8to. Churchill, 1862. — "Dynamics of Nerve and Muscle," and "Electrophysiologica," in "Na- ture," Jan. 4, 11, and 16, 1872. Post 8vo. Maomillan & Co., 1872. SPINAL MENINGITIS. 951 the varied forms of tremor, convulsion, and spasm, with diiiiiuished and not with increased activity of the circulation ; and thus the practical significance of spasm and the symptoms akin to spasm would appear to be the same as that of pain and the symptoms akin to pain — namely this, that the measures calculated to afford re- lief are likely to be those which will rouse the circulation to greater activity and in- crease the quantity of blood in the capil- laries, and not those which have a con- trary action. B. On Diseases of the Spinal Cord. Under the head of diseases of the spinal cord there is no lack of subjects. As of primary importance may be mentioned spinal meningitis, myelitis, spinal conges- tion, tetanus, locomotor ataxy, and spinal irritation ; as of secondary importance, reflex paraplegia, infantile paralysis, hys- terical paralysis, hemorrhage, white soft- ening, induration, atrophy, hypertrophy, tumor, concussion, compression, vertebral caries, spina bifida, &c. I sliall take each of these subjects in the order in which it has been enumerated, and, as far as I can, apportion the limited space at my com- mand (very limited for such a purpose) so that there may be room for saying most where most is wanted. I. Spinal Meningitis. Inflammation of the membranes of the spinal cord is usually associated with in- flammation of the substance of the cord (myelitis) or with inflammation of the membranes of the brain, but uncompli- cated cases do occur now and then, and with care it is not difficult to discriminate between the symptoms which are essential to spinal meningitis and those which are only accidental. 1. Symptoms. — In order to arrive at a knowledge of the symptoms of spinal me- ningitis, I will relate as a text one of five cases verified by post-mortem examina- tion which have come under my own no- tice, and then proceed to see wherein it agrees with or differs from other cases of the kind. I choose an acute case rather than a chronic one, for it is only in the acute form of the disease that the symp- toms are to be defined with certaintj'. Case. — A lightly-made, delicate-looking youth, nineteen years of age, a cigar- maker by trade, was admitted into one of my wards in the Westminster Hospital on the 27th December, 1864. (a) When I saw him first— this was on the dav after his admission — he complain- ed chiefly of pain in the back and great j general weakness and weariness, and ex- pressed his belief that he had got rheu- matic fever. He was then sitting by the fireside, and looking very ill. On telling hun that he had better lie down, he got up and walked towards his bed, or rather he attempted to do so, for the first step brought on a severe pain in the back and legs, with a feeling of faintness and want of breath, and he would have fallen if assistance had not been at hand. Very soon after lying down he passed about a quart of water without any difficulty. (b) The account he gives of himself is this. A week ago, after being very tired by a long walk, he was seized by shiver- ings and sharp pain between the shoul- ders. During the next three days he was feverish and without appetite, but still able to go about and do his work. All this while he had very little pain, and his nights were not disturbed. On the night of the fourth day from the commencement of the illness, he was awakened by violent pain along the whole course of the spine, in the groins, and in the right leg. Next day the pain occurred several times in paroxysms, and was accompanied by a good deal of starting and jerking in the legs ; and so also on the two days follow- ing. On the day before admission to the hospital, some difficulty in opening the jaw was experienced, and the paroxysms of pain, and jerking, and starting had become more frequent and urgent. All this wliile the bowels and bladder acted properly. Dec. 28. — There is no material change since yesterday — not for the worse, cer- tainly. Dec. 29. — Last night, after three or four hours' sleep, the patient awoke with very severe pain along the spine and down both legs, and since that time the pain has recurred several times. These attacks are separated by intervals of com- parative or complete ease, and instead of the jerks and starts, which went hand in hand with it previously, the pain is now accompanied by stifthess in the muscles of the back and legs. At the present moment (about 2 P. M.) the head is drawn back on the pillow, and considerable pain and stiffness in the neck is caused by moving it. Before making such move- ment the patient was free from pain and stiffness in this region. Asking him to try and sit up, he a'ttempted to do so, but was stopped at once by a severe paroxysm of pain along the whole length of the spine and down the legs, and by the mus- cles in the painful parts becoming stiff. The action of the muscles produced in this way arched the body backwards al- most as much as in ordinary cases of tetanus, and at the same time pursed up the mouth and eyes, and gave a set ex- pression to the features generally, so that 952 DISEASES OF THE SPINAL CORD. the patient for the time had the appear- ance of a person considerably older than himself. The pain went off in a few minutes, and soon afterwards the stiffened muscles relaxed. The effort to move one of the legs spontaneously gave rise to a sharp pain in the thigh and loins, and the limb became somewhat stiffened in a serai-flexed position, and this state of things did not pass off for several minutes : and passive movement produced the same result. There was no numbness : on the contrary, the condition of the skin as to sensation everywhere, as judged by prick- ing and pinching and by differences of temperature, was plainly that of shght over-sensitiveness. Pressure along the spinal column failed to detect tenderness anywhere, and the result of applying a sponge wrung out of hot water was equally negative. In the course of the examination it was evident that any movement of the body, or neck, or legs, active or passive, gave rise to pain and stiffness in the muscles moved ; and also that there was little or no pain or stiffness so long as the patient kept quite still. It was evident, in fact, that the muscles were relaxed, except perhaps in the neck, in the intervals be- tween the paroxysms. The poor sufferer was evidently in a great strait, dreading all movement, because he knew full well what the effect of movement would be, and at the same time continually prompted by an intolerable feehng of unrest and fidgetiness to wish to have his position changed in a way which he could not or dared not compass by his own efforts : and it is difficult to avoid the conclusion that the stiffness is, in the main, an in- stinctive act to prevent the movement which gives rise to the pain, rather than spasm like that which is met with in teta- nus. The arras are affected as well as the legs, but not to the same degree. They are weak — so weak that it is not easy to find strength to carry the food to the mouth, the left arm being somewhat the weaker of the two. The left arm also cannot be moved, either actively or pas- sively, without giving rise to pain and rigidity, to pain shooting up between the shoulders, to rigidity flexing the limb somewhat at the elbow, and bending the thumb sHghtly into the palm : not so the right arm. There is no numbness in either arra, and no very decided over- sensitiveness. Mastication is difficult, and deglutition still raore so, apparently frora the muscles set in movement becom- ing stiff in moving. The breathing is shallow and slow ; the pulse quick (130) and very wanting in strength ; the skin profusely perspiring after a paroxysm, and hot and moist at other times. Thirst is much complained of. The bladder is full, and it cannot now be emptied voluntarily. The urine is acid. The penis is flaccid, and has been so ever since the coraraence- raent of the illness. The bowels have not acted. The pupils are equal and natural, and there is no headache or other "head sympiora." Dec. 30. — A tolerably good night hrs been passed, and this afternoon the pa- tient thinks himself a little better. Dec. 31. — There has been a bad night, and much ground has evidently been lo>t since the last visit. In a paroxysm which is just over, want of breath was experi- enced rather than pain. Sensation is still somewhat exaggerated everywhere. Urine cannot be passed without the catheter, but the bowels have responded to-day to a dose of castor-oil and spirits of turpen- tine which was administered yesterday. During my visit I had an opportunity of seeing the patient after a paroxysm as well as in it, and I quite satisfied myself that the muscular stiffness of the parox- ysm soon passed off, and that in the in- terval between the paroxysms the muscles were relaxed, except perhaps at the back of the neck — with this possible exception, because all along the head remained drawn back to some degree upon the pillow. Jan. 1, 1865. — The night has been per- fectly sleepless, with now and then some trifling light-headedness. The paroxysms of pain, stiffness, and difficulty of breath- ing are not so frequent (three hours have passed since the last), but the respiration is certainly shallower and less sufficient, and the pulse more rapid and unsteady. There is the same want of power over the bladder. When I left the ward, it was plain enough that the patient was sinking : when I returned two hours later all was over, death having happened in a fit of choking and suffocation caused by at- tempting to swallow a spoonful of beef-tea with a morsel of bread sopped in it. In the agony, the patient not only sat up in bed, hut got ovt of bed and stood for a moment with his hands bearing upon the shoulders of the nurse who hud been feeding him. The body was carefully examined after death by Dr. Bazire, and the following notes were taken at the time from his dicta- tion : — "Time, twenty-four hours after death. Weather frosty. Cadaveric rigidity well marked. The muscles of the back dark and highly congested. On cutting through the posterior arches of the vertebrae the vertebral vessels are seen to be gorged with dark fluid blood. There is no effu- sion of blood outside the meninges in the interior of the canal. The meninges are highly congested throughout the whole length of the canal, but to a considerably greater degree in the region between the scapulae. In this latter region, in addition to the thickening, opacity, and intense SPINAL MENINGITIS. 953 red color of the dura mater elsewhere, there are streaks in its substance of hlack coagulated blood. The arachnoid is in- tensely red, and the pia mater extremely congested in the same region. Beyond it, the dark red color of the dura mater ^gradually passes into a lighter shade, and becomes a bright pink near the cauda equina in one direction, and near the me- dulla oblongata in the other. The arach- noid is whitish again near the cauda equina. There is no effusion of serosity, blood, or pus, either between the meninges or on the surface of the cord ; indeed, there seems to be a smaller quantity than usual of cerebro-spinal fluid. The substance of the cord itself looks normal in consistence, color, and size. The central vessel of the cord is highly congested, and on section of the cord there exudes from the centre fluid black blood in minute drops. The cerebral meninges are normal. The cere- bral sinuses are highly congested, and the same appearances of congestion (due prob- ably to the mode of death) are met with intlie substance of the brain. The organ itself is normal." The symptoms of acute spinal meningi- tis are plainly exhibited in this case, and there need be no difficulty in distinguish- ing those which are of primary importance from those which are secondary. As symptoms of primary importance may be enumerated these : — fits of pain produced by movement along the spine and in the extremities : fits of muscular stiffness in the painful parts along with the pain ; intervals of comparative or complete freedom from pain and muscular stiffness so long as movement can be avoided ; absence of paralysis ; some ex- altation of sensibility ; loss of power over the bladder ; partial loss of power over the bowel ; absence of spinal tenderness. Fits of pain along the spine and in the extremities, produced by mwement. — This pain, as I think, must be regarded as the most prominent symptom in acute spinal meningitis. It rnay be confined to the region of the spine, but more generally it shoots into the extremities, into the legs especially. As a rule, it does not shoot beltwise round the trunk. It is brought on by any movement of the trunk, and, in great measure at least, it may be pre- vented by avoiding such movement. It is often brought on also by moving one of the extremities, the pain in this case be- guming in the limb, and extending thence to the spine. It seems to depend, in part at least, upon the same cause as the pain of pleurisy, viz. the dragging of an in- flamed and therefore exquisitely tender serous membrane, and its character is cer- tainly more like the pain of pleurisy than like that of rheumatism (to which latter it has been likened), for it occurs in the same sharp, sudden, breath-stopping catches. Fits of muscular stiffness in the painfid parts along with the puin.— It is usual to regard this stifthess as analogous to the spasm of tetanus : it is necessary, as I believe, to look upon it as expressing an instinctive act of muscular contraction, of which the object is to prevent pain by arresting certain movements which pro- duce pain. The spine and extremities cannot be moved without causing pain : the stiffness prevents the pain by pi-e- venting the movement ; this would ap- pear to be the true view. This explana- tion, originally given by M. Dance as applying to the muscular stiffness in a case of acute spinal meningitis observed by him and recorded by M. Ollivier, applies perfectly to the muscular stiffness of the case which has been related as the text, and it applies, as I believe, with the same exactness to all cases of the kind. In- deed, I believe there can be no greater mistake than to confound the stiflhess in question with the spasm of tetanus. This will be seen more particularly when speak- ing of tetanus : and here I will only say that tetanus in its most violent form is constantly present where there are no signs of spinal meningitis, and that, in the few cases in which such signs chance to be met with, it may be sujjposed that the inflammation is a consequence rather than a cause of the irritation which gives rise to the tetanic spasm — a consequence of the irritation in the vaso-raotor nerves having proceeded until it has issued in paralysis of the vaso-motor nerves. Nay, after what has been said in the prelimi- nary remarks, it is not impossible that the spinal meningitis which is occasionally associated with tetanus may have servetl to counteract the spasm rather than to cause it. At any rate, it is certain that spasm of the spinal muscles is not so marked aphenomenon m acute spinal men- ingitis as in tetanus, and that it is not to be regarded " comme indiquant positive- ment la phlegmasie des membranes de la moelle ;" and it is, to say the least, highly probable that the muscular stiffness which simulates true tetanic spasm is in great measure an instinctive act of muscular contraction to prevent a movement which produces pain. Intervals of complete or comparative free- dom from pain and muscular stiffness so long as movement can be avoided. — These intervals are sometimes of considerable length, even for days. According to my own experience, indeed, the rule would seem to be that as long as the patient can keep still, so long is he, comparatively at least, free from pain and stiffness— a rule which is very different from that which obtains in tetanus. Absence of parah/sis.— The patient is weak, very weak, and he seems to be pa- ralyzed, but in reality he fears to move 954 DISEASES OP THE SPINAL CORD. because movement brings back the pain. " Les mouvemenls, qui sont en quelque sorts enchaines par la douleur, ont moins de force, mais ilsne sont point paralyses."' (OUivier, p. 595.) Let this fear be forgot- ten, and it is possible not only to sit up, but to get out of bed and stand, as hap- pened in the final agony of the patient whose case I have given. This power of movement has been noticed in several cases, of which one is related by Ollivier, and another referred to ; and I believe it would be witnessed in all cases of uncom- plicated acute spinal meningitis in which the fear of suffering pain from movements was not the one absorbing feeling. Some exaltation of sensibility. — In the case which I have given there was son.e exaltation of sensibility as to touch, pain, and differences of temperature, but to no very marked degree ; and this would ap- pear to be the rule in cases of the kind. It would seem, indeed, that numbness is a purely accidental symptom, which is never present unless the substance of the cord is implicated in the meningeal inflamma- tion. Loss of power over the bladder. — In acute spinal meningitis, when the symp- toms are fully developed, this particular symptom is scarcely ever absent, if ever. Before this time it may be absent, as it was in the case on which I am comment- ing ; but this absence must certainly be looked upon as the exception rather than the rule. Not nnfrcquently the inability to empty the bladder is preceded by a state of irritability which makes it neces- sary to pass water almost incessantly. Partial loss of power over the bowel. — On this point M. Ollivier makes a remark which is certainly true: "Je ferai re- marquer que I'abolition des fonctions de la vessie persiste toujours au meme degre depuis le commencement jusqu'^ la Sn, tandis qu'il n'en est pas de meme pour I'intestin, puisqu'il y a assez souvent des garderobes naturelles dans les derniers temps de la maladie." (Vol. ii. p. 601.) Absetice of spinal tenderness. — This ab- sence is certainly a common, if nofr a con- stant, feature of acute spinal meningitis. In some chronic cases, no doubt, there may be some local spinal tenderness, but on inquiry these prove to be cases in which the phenomena of spinal irritation are mixed up with those of spinal inflam- mation—in which the inflammatory affec- tion is complicated with that condition of which, as will appear in due time, local spinal tenderness is the distinctive rfea- ture. These are the points which may be re- garded as of primary importance in com- parison with those which have still to be considered, namely — absence of marked spasmodic symptoms, difficulty of masti- cation and deglutition, difficulty of breath- ing, no Increased reflex excitability, no priapism, fits of perspiration, no active inflammatory fever, no marked "head- symptoms." Absence of marked spasmodic symptoms. —The rigidity which attends upon the paroxj'sms of pain has been seen to be in the main an instinctive act of muscular contraction to prevent a movement which produces pain, and there appear to be no other symptoms of a spasmodic character which occupy a conspicuous place in the history of spinal meningitis. Or if there be any such symptoms, these are in all probability confined, as were the jerks and starts in the case under consideration, to that early period of the disorder in which it may be supposed that actual meningeal inflammation was not developed — to the so-called cold stage of the disorder prob- ably. Difficulty of mastication and. deglutitioTi, ^This difficulty is often absent, and when present it is at most a trifling trouble com- paratively. There is no true trismus as in tetanus ; there is at most only stiffness which prevents the jaws from opening easily and moving freely. This stiffness, moreover, is late in making its appear- ance, whereas in tetanus trismus is one of the very first symptoms. In a word, difficulty of mastication and swallowing would seem to occur only in those cases of spinal meningitis in which the higher portions of the cord are implicated. Difficulty of breathing. — This difficulty is always present in some degree, and especially during a parox3'sm of pain and stiffness. In some cases, indeed, the movement of the chest may be actually suspended at this latter time, and death may happen from this cause, as indeed was the case in a patient whom I saw not long ago with Dr. Julius of Richmond. No increased reflex excitability. ■ — This is not, perhaps, what mignt be expected theoretically : but, be the explanatioh what it may, the fact would seem to be that reflex irritability is not increased in acute spinal meningitis in the way in which it is ordinarily increased in tetanus. So far as I have been able to ascertain, there would seem to be no material change of reflex excitability in the meningeal in- flammation. Wo priapdsm. — The cases in which erection of the penis would seem to be a symptom appear to be those in which the substance of the cord is affected rather than the membrane— cases, too, in which the seat of the disease is in the cervical and upper dorsal region rather than in the lumbar region. At any rate, it would seem to be the rule for the penis to be flaccid in uncomplicated cases of acute spinal meningitis. Fits of perspiration. — As in tetanus these follow a paroxysm almost invari- SPINAL MENINGITIS. 955 ably, especially in the latter stages of its disease. Of this there appears to be suf- ficient evidence. No active inflammatory fever. — Thirst is a frequent symptom throughout, and there may be at first some heat of skin, but in the most acute cases there is little or no active sympathetic fever. On the contrary, there is usually, even in the cases which have most claim to be con- sidered as acute, a decided want of febrile reaction from the beginning to the end. JTo marked head - symptoms. — In very manjf eases inflammation of the spinal menmges is only a part of a more general disorder in which the cerebral meninges are also implicated, and, therefore, ' ' liead- symptoms" of one kind or other will often enough be mixed up with the spinal symptoms ; but in cases like the one un- der consideration, where the spinal men- inges were alone inflamed, " head-symp- toms" do not figure at all, or figure only as phenomena of very secondary import- ance. Upon this point there is no lack of evidence. Where spinal meningitis is chronic in its course, its symptoms are often so mixed up with the Protean symp- toms of spinal irritation (of which more in due time) as only to be detected with great difficulty. It may be suspected that the meninges are affected by inflamma- tion rather than by simple irritation if fits of pain and stiffness are produced by movement in the spine and extremities, and if there be at the same time no spinal tenderness, no paralysis, and no tingling or numbness ; and this is all that can be said except this, that this suspicion will gather strengtli if there be chronic dis- ease in the bones and ligaments of the spine. But it may be questioned whether long-continued contraction of the muscles of one or more of the extremities or of the cervical muscles can be reckoned among these symptoms, for such contraction is certainly common enough in cases where the only condition of disorder in the spinal cord or its membranes is one which, from the sudden way in which it begins and ends, and for other reasons as well, would seem to be one of simple irritation. 2. Post-mortem Appeakances. — As Ollivier pointed out, the traces of spinal meningitis after death are met with usu- ally, not in the arachnoid membrane, which is non-vascular, but in the subja- cent vascular tissue. The arachnoid is so thin and transparent as to allow the vas- cular injection produced by the inflamma- tion in the deeper structures to appear through it, and that is all. This injection is generally less evident on the surface of the cord than on that of the dura mater, because in the former place it is hidden by the effusion of turbid, sero-purulent, or purulent fluid in the space between the arachnoid and pia mater— in the space naturally occupied by the rachidian fluid —is hidden by an eflusion which, before the arachnoid is opened, often causes the cord to have a swollen, opaque, yellowish- white, or yellowish appearance. Any fluid effusion is usually in this space, but sometimes there may be fluid, in this case often sanguinolent, in the space outside the dura mater, especially if there be dis- ease in the bones or ligaments of the spine. Sometimes the rachidian space is obliter- ated here and there by inflammatory ad- hesions ; sometimes the surface of the arachnoid is roughened or otherwise altered by calcareous or other deposits in patches ; sometimes the opposed surfaces of the arachnoid are more or less ad- herent : but generally these surfaces are smooth and free, and the inflammatory products are met with below this mem- brane, and not above it. Very often, also, the proper signs of spinal meningitis are mixed up with those of cerebral men- ingitis or myelitis, or with those of disease in the bones or ligaments of the spine. 3. Causes. — The causes of spinal men- ingitis are often very obscure. In some cases it is rheumatism, or syphilis, or the suppression of some menstrual, hemor- rhoidal, or other habitual discharge, or the spreading of cerebral meningitis downwards, or of disease in the bones and ligaments of tlie spine inwards, which would seem to figure as a cause ; in other cases it is a casual injury to tlie back, or a chill caught by lying on the back on the cold and damp ground, or some particular disease, as tetanus, chorea, or hydro- phobia, to which blame appears to belong. In fact, the causes are legion, and it is impossible to connect spinal meningitis with any particular cause or set of causes. 4. Diagnosis. — One or two points of diagnosis have been mentioned incident- ally when dealing with the symptoms of spinal meningitis, and with these it is best to be content at present, for before this matter can be gone into advantageously materials must be had which can only be forthcoming when the phenomena of mye- litis, spinal congestion, tetanus, and other spinal maladies' have been passed in re- view. 5. Prognosis.— Acute spinal menin- gitis is, without a doubt, a very formida- ble and fatal disease. There are, indeed, few well-authenticated instances of re- covery on record, and by some it is doubted whether there be any. Life may be cut short in four or five days, or it may be prolonged to twenty or thirty days, but not often— not often indeed— beyond six or seven davs. In the subacute and chronic forms of "the disease, the prognosis 956 DISEASES OF THE SPINAL CORD. is of course less gloomy, but even here it is far from cheeriug. 6. Treatjibnt. — In all cases of spinal meningitis, rest in the recumbent position, more or less strictly enforced according to the urgency or leniency of the symptoms, is indispensable, the best position, per- haps, being not strictly on the back, but rather upon the side, and with the limbs a little lower than the back, so as to favor the draining away of blood from the con- gested parts, and, at the same time, to facilitate the use of the local applications to the spine which may be necessary. Upon this point there can be little or no difference of opinion ; upon all other points, in all probability, few will think alike. For my own part, I should be dis- posed to place most confidence in iodide of potassium and opium, with the local application of ice to the back in acute cases, and to bichloride of mercury, with counter-irritation in one form or other to the spine, in chronic cases. At the same time, I am inchned to think that the pres- ent fashion has set very unwarrantably against the old practice of giving calomel and opium, so as to affect the gums slightly and speedily, and of using local, if not general, bleeding in acute inflamma- tory disease. There can, I think, be little doubt as to the marked influence for good of calomel and opium in acute inflamma- tion of serous membranes ; and it would require very little persuasion to induce me to prefer this mode of treatment to that of iodide of potassium in acute spinal meningitis ; and, further, I can readily believe that in such a case recovery would be promoted by judicious abstraction of blood. I have twice seen symptoms, so closely resembling those of acute spinal meningitis as not to be distinguishable from them, disappear coincidently with the occurrence of local hemorrhage, once from piles, once in the form of menstrua- tion ; and I can well believe that a similar result might be furthered by the applica- tion of leeches around the anus or to the cervix uteri— to these parts rather than to the back, because their vessels would seem to communicate more directly with the deep spinal vessels. It is very proba- ble, however, that the time will soon pass in which depletion in any form, or depress- ing remedies of any kind are required, and that the indications will rather be towards brandy, or ammonia, or turpen- tine, or ether, than towards the remedies which have been mentioned, for all acute diseases of the spinal cord would seem to have a rapidly devitalizing influence upon the system. In acute cases the catheter will be necessary to empty the bladder ; in chronic cases, aching and stiffness of the limbs may point to friction and shampoo- ing as likely means of relief In every case there is sure to be some peculiarity to which attention must be directed if the plan of treatment be all that it ought to be ; and, in short, every case must be treated on its own merits. II. Myelitis. Myelitis, or Inflammation affecting the substance without involving the mem- branes of the cord, is a well-defined and not very uncommon disease. It may oc- cur in an acute or in a chronic form : it may be general or partial : and, to say the least, its features are quite as well marked and distinctive as those of spinal meningitis. 1. Sysiptoms. — As an instance of acute myelitis, and as a text for what has to be said under this head, I take the notes of the case of a hospital patient under my care some time ago. Case.— Charles K., a draper's assistant, twenty-six years of age, unmarried, a pa- tient admitted into the National Hospital for the Paralyzed and Epileptic on the 9th of January, 1864. (a) The chief symptoms complained of are paralysis and ansesthesia below the waist, a disagreeable feeling of tightness around the waist, inability to pass water, involuntary stools, and pain in the left side of the chest. Above the waist, the power of movement and the power of sen- sation are natural ; below the waist, all the voluntary muscles are entirely para- lyzed, and the sensibility to pain, to tick- ling, to differences of temperature, as well as to touch, are completely lost. Pressure along the spine is felt above the point to which the ansesthesia reaches, but not be- low it, and where felt the patient bears it without wincing. In other words, there is no tenderness on pressure In that part of the spine which preserves its sensibility. The feeling of warmth produced by pass- ing a sponge soaked in moderately hot water along the spine is felt above the point to which the anaesthesia reaches, but not below it ; and, where felt, the feeling of heat is natural, except at the line of junction between the sensitive and insensitive parts, and there the feeling produced is that of burning. Moreover, the warm sponge produces the same feel- ing of burning all around the body in the course of this line of junction, and thus it is plain that this local over-sensitiveness to heat is not confined to the spine. No reflex movements are produced by tickling the soles of the feet. The ate nasi work very much, the lips are somewhat dusky, the lower intercostal muscles are motion- less, and the accessory inspiratory muscles are in full work ; the air-passages (espe- cially on the left side) are loaded with MYELITIS. 957 phlegm, the pulse is hurried and weak, ttie skiu is moist and somewhat cooler than natural, and the voice is so low as to he scarcely audible. A cough of the feeblest sort is almost incessant, but the expiratory power at command is alto- gether insufficient to bring about the ex- pectoration which is so much needed. All appetite is gone, but food can be taken, and there is no thirst, or none to speak of. The urine, which is acid, and of the spe- cific gravity of 1015, has to be drawn off by the catheter. There is no priapism. A stool has just passed without the pa- tient heing aware of it until his nose took account of the accident. (6) A week ago, on awakening from a short nap, the patient found that his toes had gone to sleep, and that he had to '■ take long breaths. " Instead of passing off, the feeling of tingling spread rapidly from the toes to the feet, from the feet to the legs, from the legs to the thighs, until it reached the seat, becoming less and less endurable as it spread, and being at last accompanied by a feeling of tightness around the waist aud around the left in- step, and by a state of restlessness which made it scarcely possible to sit still for a moment. After suffering in this way for a couple of hours, an attempt to pass water, which failed altogether, was fol- lowed by an almost intolerahle uneasiness at the end of the penis, and by a sudden weakness in the legs which made it neces- sary to remain on the bed upon which he had fallen. Up to this time there had been no difficulty in standing, or walking, or even in going up and down stairs. A friend of the patient's now present says : — ^" I saw him on the evening of the day on which he was attacked, a couple of hours or so after he had been obliged to take to his bed. I thought he was suffer- ing from severe rheumatic pains. For some hours those pains were excruciating. I had never before seen any one suffer so much. He tossed about in dreadful agony ; he roared out with pain often, and, when not roaring, he groaned." Having thus passed seven or eight miser- able hours, he fell asleep, and slept until breakfast-time next day. Upon waking in the morning he could neither move his legs nor empty his bladder ; he had lost all feeling below the waist, and all the miserable feelings which had kept him in a state of continual unrest before he fell asleep were gone. On inquiring whether these feelings were of the character of pain, he says, "ISTo, not exactly; worse than pain, one continued numb stinging feeling, as if the parts were asleep;" so that the friend's words which have just been given must be taken as meaning not exactly what they seem to mean in this particular. Por the six days preceding his admission to the hospital a state of imperfect priapism was apt to come on of itself, or to be brought on by introducing a catheter to draw off the water, and this is the only point reuiaining to be noticed here, for in other respects the condition seems to have remained stationary, ex- cept, perhaps, that a little ground was lost every day. The patient seems to have come of a healthy family, and, though never very strong, to have himself always enjoyed tolerably good health. He was confined to the house for a few days about two months ago by "influenza," and this is the only illness of any kmd he remem- bers to have had. He says, "I was fatigued by a long walk on the day I was taken ill, and for a month and more I had felt more tired in my back and legs than usual in an evening, and more rheumatic — less up to the mark;" and also, ''My back always ached at the end of the day's work, and so did my legs, and I was al- ways glad to go to bed soon, for in bed I was comfortable :" and besides these statements there appears to be nothing at all calculated to throw light upon the history of his present malady. Jan. 10. — Early this morning, after a sleepless night, a severe rigor commenced in the right arm, and then extended first to the back, and afterwards to the whole body. This rigor continued a full quarter of an hour, and was followed by profuse perspiration. During its continuance the paralyzed parts were very cold : after it had ceased the warmth returned, and brought with it a considerable mitigation of the cough and trouble of breathing. Indeed, after the establishment of reac- tion, difficulty of breathing ceased to be an urgent symptom, except for a moment or two after waking from an occasional and very brief doze. The anfesthesia in the trunk has mounted full an inch higher since yesterday, but it has not extended to either of the upper extremities. Pria- prisni occurs frequently. The pulse is 1.50 ; the respirations are 36 in the minute. Jan. 11.— There has been no sleep in the night. The engorged condition of the lungs has gained headway, and the harassing suffocative cough has returned. Hiccough is frequent and distressing. Once during the day the passage of the catheter was obscurely felt, tins being the first sign of feehng in this part since the commencement of the illness. The urine is decidedly acid. The electro-contrac- tility and electro-sensibihty of the para- lyzed muscles are annihilated. Jan. 12. -- For the last twenty-four hours the increased difficulty of breathing attending sleep has caused the patient to wake immediately if he for a moment forsjot himself. '' I can't breathe except I keep awake," he said in a voice scarcely 958 DISEASES OF THE SPINAL COED. audible; and also, "I hope I have not long to live." The passage of the cathe- ter is still obscurely felt, and the escape of flatus and feces is ' perhaps not so en- tirely unfelt as it has been since the com- mencement of the illness. In other parts the anfesthesia, like the paralysis, re- mains as complete as ever. The urine is still acid, distinctly so. For the last twenty-four hours there has been no pria- pism, and scarcely any cough. At present hiccough is almost constant, the pulse is fluttering, the hands are cold and clammy, and, in short, the signs of the near ap- proach of death are not to be mistaken. Jan. 13. — The patient lingered through the night, and died about daybreak ; his mind unhappily remaining too clear to the very last. The notes of the post-mortem exami- nation are as follow : — Jan. 14, 4.30 P. M. — Eigor mortis is fully established everywhere. The de- pendent parts present considerable signs of suggilation, especially along the course of the spine, and there is incipient break- ing of the skin on both the nates. The arachnoid covering of the cord every- where is clear, smooth, and without any traces of inflammation. The outside of the lumbar enlargement is curiously no- dulated. On making a longitudinal sec- tion, the whole substance of the cord, from the brachial enlargement to its in- ferior extremity, is found to be of a yel- lowish-red color, softened in a remarkable manner, and in the lumbar region almost like cream in consistence. Several small patches of extravasatcd blood are scat- tered in the softened structure, these patches being undefined in outline, more numerous in the lumbar than in the dor- sal region of the cord, and situated chiefly in the posterior columns. The red dis- coloration which has been mentioned is most marked in the neighborhood of these patches. The examination did not ex- tend further, the friends of the patient consenting to it only on condition that it should be thus partial. Jan. 15. — On examining some portions of the diseased cord under the microscope, the natural structure is found to be alto- gether broken down, and mixed up with blood-corpuscles, exudation granules, and (in fewer numbers) pus-corpuscles. "With a view to arrive at a knowledge of the general features of myelitis, I select as the principal points for comment in this particular case the following : Paraplegic anaesthesia, ushered in % tingling or some similar sensation in the parts which eventually became anajsthe- tic ; paraplegia ushered in by uncontrol- lable restlessness ; a disagreeable feeling of tightness around the waist and else- where ; absence of pain in the spine or extremities— of pain produced by move- ment especially ; absence of tritsmus and other spasmodic or convulsive symptoms ; retention of urine ; involuntary stools ; absence of pain on pressure (spinal ten- derness) in any part of the spine ; increased sensibility to differences of temperature, by which moderately warm or iced water gave rise to a feeling of burning in&tead of the natural feeling over the vertebra which marks the upper limit of the mye- litis ; annihilation of reflex excitability in the paraplegic parts ; priapism ; acidity of urine ; comparative voicelessness ; im- peded respiration ; engorgement of lungs and other viscera ; tendency to bed-sores ; loss of electro-contractility and electro- sensibility in the paralyzed muscles ; ab- sence of head-symptoms ; absence of fever. Paraplegic ancBsthesia, vshered in hy tin- gling or some siniilar sensation in the parts which eventually iecame ancesthetic. — In this case the anaesthesia was developed sud- denly during the first night's sleep; it was deep-seated as well as superficial ; it im- plicated the sensibility to pain, tickling, and differences of temperature, as well as that of touch ; it had a paraplegic dis- tribution : and this would seem to be the rule in cases of acute myelitis. In chronic cases it is developed more gradually, and it may not extend to all the various forms of sensibility ; moreover, it may in some instances be quasi-hemiplegic instead of paraplegic ; but the rule in acute cases appears to be what it is found to be in this. The anoesthcsia seems to be usually ushered in by tingling or by some analo- gous sensation, disagreeable enough, but not amounting to actual pain. In this particular case the preliminary sensation was not pain, but an unbearable "numb stinging," as if the parts were asleep, with a feeling of tightness around^the waist, and around one of the insteps. In acute cases it is right to speak of ansesthe- sia as ushered in by tingling or some simi- lar sensation, but scarcely so in chronic cases. In chronic cases, indeed, these anomalous sensations may never exactly come to an end, because in these cases the destruction of sensibility may never get beyond numbness — may never reach nearer to anaesthesia ; that is to say, than dysaesthesia. Paraplegia vshered in hy uncontrollahle restlessness. — The paralj'sis was thus ush- ered in in the case under consideration, and in six similar cases which have come specially under my notice, by restlessness, and not by any more marked tremulous, convulsive, or spasmodic symptom. Nei- ther does it appear that a different rule obtains in other cases, acute, subacute, or chronic. In the great majority of cases, no doubt, the paralysis has a para- plegic form, but in a few cases it is not MYELITIS. 959 so. In the great majority of cases, the paralysis is acuonipaiiied by numbness, but not absolutely in all. Sometimes, for example, as in the case in which the paralyzing lesion is limited to a portion of one lateral half of the spinal cord, — the case about which enough was said in the preliminary remarks, — there is paralysis without numbness on one side, and numb- ness without paralysis on the other side. Several cases of this kind are on record, and the number of them which I have myself met with is sufficient to convince me that they are scarcely to be looked upon as out of order and exceptional. Sometimes, also, as in tlie case where the paralyzing lesion is confined to a portion of one of the anterior columns, the paraly- sis may be divorced from numbness, and not only so, but it may be hemiplegic in its distribution ; and in such a case it may, in fact, be no easy matter to say whether it is dependent upon a cerebral or upon a spinal cause. In some cases, also, the paralyzing lesion may be so lo- calized as to affect only, or chiefly, an arm on one side and a leg on the other side. Usually, however, the paralysis is distin- guished by being associated with numb- ness, and by being paraplegic in its dis- tribution. A diiagreeable feeling of tightness around the waist and elsewhere. — A feeling of cir- cular constriction around the trunk, or around some part of an extremity, around the trunk especially, is so common as to deserve to be considered as an almost constant symptom in myelitis. I do not recall a case, acute or chronic, in which it was entirely absent at all times. Absence of pain in the spine and extremi- ties — of pain produced by inoveinent more especially. — In chronic cases of myelitis. Dr. Brown-Sequard speaks of "a constant pain in the part of the spine correspond- ing to the upper limit of the inflammation of the cord" as a characteristic symptom; but I question very much whether this statement is in accordance with well-sifted clinical facts. Pain, either in the spine or elsewhere, is not mentioned, for exam- ple, in the nineteen cases, acute or chronic, given by Ollivier, except in three ; and of these three the myelitis was complicated with meningitis in two, and in the one remaining the symptoms justify the pre- sumption (and there was no post-mortem examination to set it aside) that the same complication existed. At any rate, it is certain that there is not in uncomplicated myelitis that severe pain in the back and limbs which is brought on or aggravated by movement in spinal meningitis. Absence of spasmodic symptoms. — Ollivier speaks of continuous contraction of the limbs as being met with "assez ordinaire- ment," in chronic myelitis ; buc the cases cited by this excellent observer do not substantiate this statement. Thus, out of nineteen cases of myelitis, complicated and uncomplicated, acute and chronic, there are three only in which these con- tractions were present, and not one of the three can be cited correctly as a case of myelitis. In one of the three (No. 87) the sensibility was intact, and the disease of the cord confined almost exclutsively to the anterior column ; in another (No. 93) there was obtuse sensibihty, and the dis- ease was chiefly in the gray matter ; and in the third (No. 94) sensibility remained, and there was no post-mortem examina- tion to show what the disease in the cord really was. In each one of these cases, also, there were "head-symptoms" which do not figure in uncomplicated myelitis. Again, prolonged contraction of the ex- tremities is a not unfrequent symptom in cases in which there is neither myelitis nor spinal meningitis — cases which come properly under the head of " spinal irrita- tion," and about which more will have to be said in another section of this article. In these cases the contraction, instead ol pointing to inflammation of the cord or its membranes, is really no more than one of a series of so-called hysterical phenom- ena. It is a sign of functional disorder only, and that it is so is evident (these among other proofs) in the sudden and complete way in which it passes off, as well as in the fact that it does not leave behind it any permanent organic traces. It depends, as it would seem, upon a state of irritation in some part of that track in which irritation gives rise to prolonged spasm — a state issuing, it may be, now and then in inflammation, but in itself, so far as the condition of the bloodvessels is concerned, diametrically opposed to in- flammation. Nay, even in those excep- tional cases of myelitis in which there is increased reflex excitability in the para- lyzed limbs, it is difficult to connect these spasmodic symptoms with the inflamma- tion. Dr. Brown-Sequard says: "AVhen the dorso-lumbar enlargement is inflamed, reflex movements can hardly be excited in the lower limbs, and frequently it is im- possible to excite any. On the contrary, energetic reflex movement can always be excited when the disease is in the middle of the dorsal region, or higher up. " And again, when speaking of the reflex con- vulsions which may happen in the cases where the inflammation is in the middle of the dorsal region or higher up, he says, "Convulsions do not take place at the beginning of the inflammation, but some time after, and they recur by fits for months and years after." And this is precisely what happens. In a word, the truth would seem to be that these reflex spasmodic movements must be referred, not to inflammation in the lumbar enlarge- ment of the cord, nor yet to inflammation 960 DISEASES OF THE SPINAL CORD. higher up in the cord ; for in this case, to repeat wliat has just been said, "the con- vulsions do not take place at the begin- ning of the infianimation, but some time aJ'Ur, and they recur by fits for months and years after." They happen,- as it would seem, after the infiammator'y disor- ganization has interrupted the continuity of the cord, and produced a state of things analogous to that of a guinea-pig, or other animal, whose spinal cord has been cut across experimentally — a state of things of which increased reflex excitability in the paralyzed parts is one of the consequences. !Nor is a different conclusion to be drawn from the occasional presence in the para- lyzed muscles of a state which is analogous to or identical with the " late rigidity" of Todd. This "late rigidity" is very dif- ferent from " early rigiditj'. " In "early rigidity" the electro-motility of the mus- cles is increased, and the muscles relax, during sleep, and to a less degree under the influence of warmth. The muscular contraction is evidently of the nature of spasm. In "late rigidity," on the con- trary, the muscles are wasted, their elec- b-o-motility annihilated, and sleep or warmth do not tell in causing relaxation. This form of muscular contraction, indeed, if not identical with rigor mortis, is, as it would seem, more akin to this state than to spasm. In the case of myelitis which serves as my text, there was none of the painful muscular rigidity produced by movement which is so prominent a symp- tom in spinal meningitis. There was, indeed, no spasmodic symptom of any kind, with the exception of the rigor which ushered in the extension of the dis- ease on the day after the admission of the patient to the hospital. And this absence of spasmodic symptoms would seem to be the rule in all cases of myelitis, acute or chronic. In children, it is true, myelitis may be ushered in by convulsion — in which case the convulsion manifestly represents the rigor which may usher in myelitis in adults, and as manifestly be- longs to the precursory stage of irritation, and not to the state of actual inflamma- tion — but even in children, unless there be some meningeal complication along with the myelitis, this preliminary con- vulsion would seem to be a rare phenome- non. Want of control over the bladder.— This appears to be the earliest as well as the most constant of the symptoms of myeli- tis. It usually depends upon paralysis of the accelerator urinae and compressor ure- thrse, but now and then it would seem to be connected, for a while at least, with a state of spasm in the latter of these mus- cles, in which case the dribbling away of the water or the introduction of a cathe- ter will sometimes produce marked reflex spasms in the legs. I remember one case — a case in which the myelitis seemed to have interrupted the continuity of the cord high up in the back — where an attempt to use the catheter often gave rise to strong reflex spasms in both legs, and to a state of spasm in the urethra strong enough to prevent the passage of the instrument. Want of control overthe rectum.— Iw mye- litis, paralysis of the sphincter ani is usu- ally associated with paralysis of the accele- rator urinse and compressor urethras. Now and then also, the sphincter ani, instead of being paralyzed, may be in a state of reflex spasm : thus, in the ease to which I have just referred, the administration of an enema was sometimes rendered impos- sible by the spasm set up in the sphincter ani and in the femoral muscles by the pipe. Absence of local spinal tenderness. — As in spinal meningitis, so in myelitis, absence of tenderness on pressure in any part of the spine would seem to be the rule, and not the exception. Ollivier, speaking of pain in the back in myelitis, says, "Elle n'est jamais rendue plus aiguepar lapres- sion," and my own experience in the mat- ter is, without question, to the same effect. Altered sensibility to heat and cold, by which a feeling of burning is felt when a sponge soaked in moderately warm water or a piece of ice is applied to the spine immedi- ately above the seat of inflammation.— Seve- ral years ago it was pointed out by Mr. Copeland that, when a sponge soaked in water a little above the temperature of the blood was passed along the spine from above downwards, it gave rise to the natural feeling of heat until it reached the inflamed part, and that then this feeling changed to that of burning : and more recently Dr. Brown-S^quarcl has shown that a similar result is arrived at by pass- ing a piece of ice down the spine, the natural feeling of cold being felt until the inflamed part is reached, and then an unnatural feeling of burning. In many cases, no doubt all this would seem to be quite true, but not in all, perhaps not in the majority ; and therefore it is impossi- ble to look upon the feeling of burning thus produced as more than an occasional occurrence in myelitis. Annihilation of reflex excitability.— What has to be said under this head has been anticipated when speaking of the absence of spasmodic symptoms in myelitis. It has indeed been seen to be the rule for all reflex movements to be annihilated or greatly weakened in the paralyzed parts, and that the apparent exceptions to this rule are to be explained, not by referring the increased reflex movement to myeli- tis, but by supposing the inflammatory disorganization to have interrupted the continuity of the cord and produced a state of things analogous to that of a MYELITIS. 961 guinea-pig whose spinal cord has been cut across for experimental purposes. Biminution of electro-motiiitij and eJcctro- sensibility in the paralyzed niusdes. — Ex- cept in those few, very few, cases in which the rellex excitability is increased, the electro-motility and electro-sensibility of the paralyzed muscles are invariably diminished in myelitis. Where the re- flex excitability is increased the electro- motility may also be increased, and so also may the electro-sensibility, but more generally the increase in the former pro- perty is without a corresponding increase in the latter. The paralyzed muscles are wasted in almost all cases, and relaxed also, except in those few cases in which the paralysis has lasted for a very long time and become associated with that state of '"late rigidity" which, sooner or later, is often found to seize upon paral- yzed muscles. Marshall Hall noticed the impairment of irritability in spinal paral- j'sis, and was of opinion that an opposite state of things existed in cerebral paraly- sis. As was pointed out by Todd, how- ever, this supposed distinction between spinal and cerebral paralysis does not hold good, the simple fact being that in the great majority of cases of cerebral paralysis the irritability of the paralyzed muscles, instead of being increased, is either not materially altered or else more or less diminished — most generally dimin- ished in a very marked degree. In a word, the investigations of this very ac- complished physician show most clearly that in cerebral paralysis the irritabihty of the paralyzed muscles is only increased in those comparatively few cases in which the paralysis is associated with "early rigidity." Priajjism.—lt is difficult to attach any diagnostic value to this symptom. As in acute spinal meningitis, so in acute mye- litis, it is sometimes present and some- times absent, less frequently present in the latter afl'ection perhaps than in the former. Acidity of the urine. — Dr. Brown- Sequard says : " One of the most decisive symptoms in myelitis is alkalinity of the urine. There is no patient attacked with luyehtis in the dorsal region of the cord whose urine is not unfrequently alkaline. At times, especially after certain kinds of food, the urine is acid, but the alkaUnity soon returns." And no doulit the urine is very generally alkaline in myelitis, es- pecially in those cases in which the paralysis of the bladder has led to secon- dary disease of this organ ; at the same time, as in the case under consideration, the urine Is too often acid to make it pos- sible to insist upon alkalinity of the urine as a necessary feature in myehtis. J)?/sp»icea.— Difficulty of breathing was a very urgent symptom in the case which VOL. I.— CI serves as my text, and so it must be in every case where respiratory muscles are so gravely implicated in the paralysis, and where the lungs are so much engorged. Indeed, the usual way in which myelitis proves fatal is by compromising the suffi- ciency of the respiration. Now and then, especially when chronic inflammation af- fects the higher regions of the cord, the difficulty of breathing may occur in parox- ysms not unlike those of asthma, but usually the difficulty shows itself rather as simple shortness of breath, — shows it- self in a way wliich supplies another proof of the absence of the spasmodic element in the history of myelitis. Want of power in the circidation. — There is little or no sympathetic fever in the most acute form of myelitis ; and in the ordinary chronic forms, the feeble pulse, the oedematous condition of the paralyzed extremities, the disposition to passive en- gorgement in the lungs and elsewhere, and other symptoms of like meaning, show very plainly that the state of the circulation is eminently asthenic. It would even seem as if there were some- thing in the very fact of myelitis which has a positive influence in subtracting power from the circulation — which exer- cises a devitalizing influence upon the system generally. A tendency to bed-sores, wasting, and other signs of defective nutrition in the piaralyzed parts. — Sooner or later, gene- rally at a very early date, a marked dis- position to bed-sores in places where paralyzed parts are subjected to pressure is apt to show itself in myelitis, and so also are other signs of defective nutrition in the same parts, such as oedema, dry- ness and scurfiness of the skin, and a wasted and flabby state of the muscles. So marked, indeed, is this impairment of nutritive power in these paralyzed parts, that it is only by very great care that bed-sores and the other lesions which have been mentioned can be prevented. Absence of head-symp)toms. — In cases where acute myelitis attacks the higher portions of the cord, there may be, and there in all probabihty will be, various "head-symptoms" — vertigo, singing in the ears, grinding of the teeth, delirium, convulsion, coma, or others— but these cases, to say the least, are not common. Whether acute or chronic, indeed, mye- litis is much more apt to attack the lower portions of the cord than the upper, in this respect differing from spinal menin- gitis ; and when it attacks the upper por- tions of the cord, and its symptoms present cerebral complications, the chances are that the case is not simple myelitis, but myelitis with more or less spinal menm- gitis in addition. When the cord is affected generally, the symptoms of myelitis will not differ 9G2 DISEASES OF THE SPINAL CORD. greatly from those which are present in the case which has been given ; when tlie inflammation is more localized, the symp- toms will vary accordingly. If, for exam- ple, the inflammation be limited, as it usually is, to the lumbar enlargement of the cord, the level of the paraly.^is and an- ffisthesia will be proportionallj' low down ; and if the extreme end of the cord only be affected, it is possible that the legs may escape altogetber, and the bladder and anus be alone at fault. As indeed the level of the inflammation in the cord falls or rises, so must the level of the paralysis and ansssthesia fall or rise also. Exaggerated reflex movements in the in- ferior extremities will also (in all proba- bility) be associated with the paralysis and anaesthesia, if the lower part of the cord be sound and the inflanunation con- fined to a portion of the cord higher up. Again, the symptc < j which are present when the inflammacion is limited to a part only of the thickness of the cord will be different in many respects from those which are met with when the whole thickness is affected. If, for example, a portion (the upper half inch of their course excepted) of the anterior columns be af- fected solelj', there would be paralysis without ana?sthesia ; or if the posterior columns were alone affected, there might be incoordination of movement and some hypersesthesia instead of paralysis and antesthesia. In short, the variations of symptoms, which occur where myelitis is restricted to particular parts of the cord, can only bo properly intelligible to him who has clear notions respecting those physiological matters which were glanced at in the preliminary remarks,' — which were then glanced at chiefly in order to avoid perplexing physiological digression and discussion in the present place among others. I will, therefore, assume that what was said in the preliminary glance at some points in the physiology of the spinal cord, will serve to explain suflfi- ciently the variations of symptoms which may be expected to exist when the integ- rity of particular parts of the spinal cord is destroyed by myelitis or in any other way : and, for the rest, I will only say that myelitis may be chronic and sub- acute as well as acute in its course, and that these several varieties interblend in- sensibly the one with the other. 2. Post - moetem Appeaeastces. — Myelitis may result either in softening or in hardening of the spinal cord. Most frequently the core" "s broken down, re- duced to a yellowisL cr reddish cream-like consistence ; the color, derived from the admixture of pus or blood-corpuscles, being more yellow or more red according as the one or the other of these corpus- cles predominates. This softening may affect the whole thickness of the cord, or certain parts more than others, the gray matter especially ; it may extend Irom one end of the cord to the other, or it may be confined to certain regions, in which latter case the part most likely to be affected is the lumliar enlargement ; and it would often seem to have its start- ing-point in the central gray matter, which is the most vascular part of the cord. In the first stage of myelitis this central gray matter has a rosy or vinous tinge, which is not natural to it ; it is plainly more vascular than it ought to be; and, in short, it has undergone the very same change which is met with in the §ray matter of the brain in encephalitis, ometimes the spinal cord is considerably swollen, and sometimes the surface may have a nodulated appearance in certain parts, from the membranes having yielded at these points to the blood which may have escaped, or to the pus or other fluid which may have coLected, underneath. Not unfrequently small collections of blood are met with in the softened nerve tissue, especially in the position of the central vessel, so that the first impression upon opening the cord may be that of hemorrhage rather than that of mj'elitis. One remarkable feature of inflammatory softening, says Dr. Todd, Is that "it ex- hales a marked odor of sulphuretted hy- drogen, and so indicates a rapid advance of putrefaction;" and again, "It is a fact deserving of attention that the substance of the spinal cord softens very rapidly after death, the lapse of half an hour, during which the nervous substance has been exposed to the air, often producing a manifest alteration. " Indeed, there are reasons for believing that the amount of disorganization met wi*h in the cord after death does not necessarily represent the exact amount which existed during life, and that a cord which is found to be broken up after death almost utterly, may have retained during life sufficient integrity to allow of the transmission of certain sensitive and motor impressions. On this view the return of slight sensa- tion in the urethra and rectum shortly before death, and the preservation of the power of moving and feeling in the arras, which were noticed in the case which serves as my text, are not altogether un- intelligible. Induration, the other result of myelitis, is looked upon by some as a stage always preceding softening, but it would rather seem, to mark, as Ollivier supposed, a less acute form of inflammation. In it the fibrinous products of the inflamma- tion seem to have been more organizable. The cord thus indurated varies greatly In appearance ; it may be almost as pale, bloodless, crisp, and hard as cartilage ; it may be more or less red and vascular ; MYELITIS. 903 and in either case, -when examined under tlie microscope, its proper tissues are found to be brolcen up and destroyed al- most as eftectually as tliey are wlien tiie cord is softened. A cord wliicli is indu- rated has usually a shrunken appearance, but it may be swollen considerably. There is no doubt an induration of the cord, as well as a softening, which cannot be referred to myelitis, and which must not be confounded with that which is the result of inflammation ; but I must not stay to point out the differences, nor yet to do more than say that in myelitis there will in all probability be found, in addi- tion to the signs which have been indi- cated, engorgement of the lungs, kidneys, and other viscera, possibly more marked vascular changes, with bed-sores, ojdema, dry and scurfy skin, wasted muscles, and other signs of defective nutrition in the paralyzed parts. 3. Causes. — N"othing very much to the point can be said under tliis head, and the only remark I feel called upon to make is this, that as in spinal meningitis a rheumatic habit has been found to figure more or less conspicuously among the causes of the malady, so here a like position would seem to be due to a stru- mous habit. I would also confess to a growing impression that myelitis may not uufrequently be connected more with ex- cess of sexual indulgence than with any other single cause, but I cannot say that this impression has yet taken the form of a definite conviction. 4. Diagnosis. — In dealing with the symptoms of myelitis it has been shown that these are very different from those of spinal meningitis — so different as to make it difficult to confound them, if only mod- erate care be taken in realizing them. In spinal meningitis the most prominent symptom is pain in the back and extremi- ties, produced or aggravated by move- ment ; in myelitis pain of any kind has scarcely a title to be reckoned among the symptoms, pain produced by movement certainly not. In spinal meningitis the sensibility is somewhalt exalted, in mye- litis it is abolibhed. In spinal meningitis , there is muscular weakness, and the mus- cular movements are fettered by pain, but there is no true paralysis : in myeli- tis, paralysis is the symptom of symptoms. In spinal meningitis there is a state sim- ulating trismus and tetanus, a state of muscular rigidity half voluntary as to its character, of which the object is to pre- vent certain movements which give rise to pain ; in myelitis the muscles are lim- ber, and there is usually an utter absence of any symptom akin to tremor, convul- sion or spasm. Jifor need the symptoms of common paraplegia (resulting from chronic mye- litis) be confounded with those of loco- motor ataxj-. In common paraplegia there is paraplegia more or less marked of the lower extremities, and the nutrition and irritability of the paralyzed muscles are, as a rule, unmistakably impaired ; not so in locomotor ataxy. In common paraplegia the paralysis extends to the bladder and sphincter ani, and the sexual power is greatly weakened, if not alto- gether abolished ; not so, or not to any- thing like the same degree, in locomotor ataxy. In common paraplegia the cha- racteristic neuralgic pains of locomotor ataxy are wanting, and numbness is no- thing like so prominent a symptom as in the ataxic disorder. In common para- plegia, where walking is possible, the gait — instead of being precipitate and stag- gering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step, as in locomotor ataxy — is hampered and slow, each leg being brought forward with evident difficulty, even with the help of an upward hitch of the body on the same side, and the part of the foot first coming in contact with the ground being, as a rule, not the heel, as in ataxy, but the toes. In common paraplegia, impair- ment of sight or hearing, or strabismus, or ptosis, or injection of the conjunctivae, or contraction of the pupils, frequent if not constant symptoms in locomotor ataxy, form no part of the history. In fact, in these respects, and in others of minor importance which might be men- tioned, the histories of common paraple- gia and locomotor ataxia are so different that it is not easy to see how, with only a moderate amount of care, the two can be confounded. Now and then, it is true, instances oc- cur in which it is not so easy to distin- guish this gait of common paraplegia from that of locomotor ataxy — cases in which the weakened muscles contract somewhat spasmodically when put in action, but, as a rule, the gait in common paraplegia and in locomotor ataxy is sufficiently charac- teristic to make it difficult to confound these two affections. In cases where the myelitis is confined to the posterior columns of the cord, the symptoms will be those of locomotor ataxy rather than those which have been ascribed to myelitis ; foft so far as the production of symptoms is concerned, it is of no moment whether the disease dis- organizing the posterior columns be in- flammatory or non-inflammatory, acute or chronic ; and in other cases of local myelitis symptoms are sure to be present which cannot fail to lead to a correct diagnosis, if what was said in the pre- liminary remarks upon the physiology of different parts of the spinal cord be borna 964 DISEASES OF THE SPINAL CORD. in mind in interpreting them. Indeed, with what is l^nowu of the physiology of the spinal cord, there need not be much difficulty in determining the whereabouts of local mischief in the cord. That myelitis cannot well be confounded with other spinal disorders— spinal con- gestion, tetanus, spinal irritation, and tlie rest— will be seen readily enough when a clear idea of these disorders has been realized, and only then ; and this being the case, it is best to waive these ques- tions in diagnosis until the fitting oppor- tunities for dealing with them present themselves. 5. Peognosis. — Acute myelitis affect- ing any considerable extent of the spinal cord is, without doubt, a very grave dis- order. It may be fatal in fifteen or twenty hours, and it is seldom that life is pro- longed beyond the end of tlie second week. Instances of recovery are on record, it is true, but these are very few in number, and of them there is, perhaps, no single one in which tlie correctness of the diag- nosis may not be impugned. Even chronic myelitis is a very grave disease; for though life may be prolonged, especially where the disease is confined to the lower part of the cord, the mischief once done seems to be in a great measure irreparable. At the same time it is only right to say that of late years the results of treatment have been much more satisfactory, and that it is possible now to hope where there was little room for hoping formerly. 6. Tbeatment. — There appears'to be little room for what is called active treat- ment even in acute myelitis. The in- flammation is evidently of a very low type, and, reasoning trom what is known of its beneficial action in erysipelas and in some other low forms of inflammation, it seems to me that sesquichloride of iron would be likely to be of more real service than iodide of potassium. Indeed, I should be disposed, until I know of a better plan, to trust chiefly to full doses of this prepa- ration of iron, to food and wine, and to the position recommended by Dr. Brown- Sequard for draining away blood from the spine — a position in which the patient is made to lie upon his abdomen or side, with his hands and feet in a somewhat dependent position. With regard' to the good or bad effects of belladonna, or ergot, or strychnia, it is not very easy to arrive at a satisfactory conclusion. I agree with Dr. Brown- Sequard in thinking that belladonna and ergot may have the effect of counteracting a hypersemic condition by causing con- traction in the vessels, and that the ves- sels of the spinal cord may, perhaps, re- spond most readily to their action, but not as to the indications for employing these remedies. Pain and spasm are, to Dr. Brown-Sequard, signs of hyperemia : to me, except the pain produced by move- ment, they are signs of irritation only — of a state which is connected, not with hy- persemia, but with ansemia, a state of con- traction of the vessels which may pass into relaxation, but which need not neces- sarily do so ; and, therefore, to me pain and spasm, instead of being indications for the employment of belladona or ergot, are in very deed contra-indications. Nor can I agree in thinking that str}'chnia acts by increasing the amount of blood in the spinal cord and in its membranes, and that on this account it is contra-indicated in hypersemic conditions of these parts. Strychnia, without doubt, produces tetanic spusms and other unequivocal signs of spinal irritation, but it is begging the question altogether to suppose that the strychnia increases the amount of blood in the cord and its membranes, that this increase of blood augments the vital ac- tivity of the cord, and that the spasms and other signs of irritation attest this augmentation of vital activity. Indeed, so far from this being a necessary conclu- sion, all the evidence presented in the preliminary remarks, as it seems to me, points in the opposite direction, and con- nects the state of irritation of which the spasms are the signs, not with a hyper- semic condition, but with an ansemic ; and most assuredly I know of nothing in the history of myelitis or spinal men- ingitis which is calculated to invalidate this conclusion. Moreover, the investi- gations of Dr. Harley upon the action of strychnia upon the blood go to show that this action is really equivalent to loss of blood in that it directly interferes with the proper arterializali(in of the blood. In a word, I cannot find any fundamental difference between the action of bella- donna, ergot, and strychnia upon the bloodvessels, neither can I understand why strychnia, properly used, might not be of as much service as belladonna or ergot in lessening a hypersemic condition of the cord. For my own part, however, I confess to a feeling which makes me hesitate to employ either belladonna, or ergot, or strychnia in myelitis, or in any analogous condition, until I know more, of their action, or until I have more un- equivocal empirical evidence of the good resulting from their use. In chronic cases the one grand indica- tion of treatment, as it seems to me, is to improve the nutrition of the cord, and the medicines best calculated to carry out this indication are cod-liver oil, sesqui- chloride of iron, phosphorus in one form or other, arsenic, and possibly bichloride of mercury, which latter preparation, when properly used, I believe to be tonic and antiseptic in a high degree, and in SPINAL CONGESTION. 965 many respects much more analogous in its action to arsenic tlian to any of tlie proto-compounds of mercury in common use. The local means for promoting the re- covery of the paralyzed muscles are cer- tainly of not less importance than the general means, possibly of much greater importance, and these local means are very various. The efficacy of frictions and shampooings appears to be indisputa- ble. The efficacy of proper movements can only be doubted by those who are un- acquainted with the results arrived at by the " movement cure," and by systematic movements of one kind or another, with or without the help of mechanical appa- ratus. The efficacy of faradization has been abundantly proved, and there is good reason to believe that this is not the only mode of using electricity which will be of great service ; that in fact statical positive electricity, or the interrupted gal- vanic current, or the application of the galvanic current in such a way that the paralyzed nerve is acted upon chiefly by the positive pole — a mode of using elec- tricity about which I have spoken else- where, and which I have used extensively during the last five or six years — will often be of ^reat service in proper cases. In- deed I should think that the treatment was wanting in very essential particulars if these local means, one and all, were not associated with the general means of treatment, and employed systematically and perseveringly ; and especially I should regard it as a great blunder if these local means were deferred so as to allow the paralyzed muscles to lose what when lost is not easily recovered — that is, their irri- tability and healthy organization. There are also oclier local measures which are of great service in the treat- ment of paralysis, and one of these to which I am disposed to attach especial importance is to protect the paralyzed parts from cold. In many cases, as is well known, these paralyzed parts are cool, and in not a few instances, where the paralysis is incomplete or associated with early rigidity, this paralysis and rigidity is greatest when these parts are coldest. For example, it is no uncommon thing for a partially hemiplegic patient whose paralyzed fingers are contracted, stiff, and altogether useless when acted upon by cold, to be able to open his hand and use his fingers with comparative freedom when the hand is warm in bed, or placed in a warm bath, or held a while before the fire. At any rate, I have long been satisfied that the well wrapping up of the paralyzed parts in woollen, or silken, or india-rubber coverings is an important help in treatment. It would also seem that good of the same kind, much good, may be got from an exhausting apparatus made on the principle of Junot's boot. The effect of sucli an apparatus, properly used, is to make the paralyzed parts warmer at the time, and to enable them to preserve this waruith for a considerable time— to pro- duce a change in the circulation, which must have a good ellect upon the nutri- tion and irritability of the paralyzed muscles. It is also more than probable that elec- tricity may be of service in improving the condition of the circulation in tlie para- lyzed parts, for an increased feeling of warmth in the paralyzed parts is the re- sult of faradizing these parts, orof electri- fying them with statical electricity; indeed I have been more than once disposed to think that the beneficial eflects of elec- tricity in the resuscitation of paralyzed parts are as much brought about indirect- ly by changes produced in the circulation as by changes wrought directly in the nerves and muscles. As regards the necessity for tenotomy and the use of orthopsedic apparatus in certain cases, it is difficult to speak to any good purpose. I shall have to refer to these subjects when speaking of infantile paralysis, and here I will only sa}', that in many cases, in children especially, the cure will be greatly facilitated by tenoto- my and orthopaedic apparatus, and that it is not always easy to decide between the cases in which these measures are desirable and those in which they are not desirable. [For Polio-myelitis (inflamma- tion of the gray substance of the cord) see Infantile Paralysis. — H.] III. Spinal Congestion-. Spinal congestion, or plethora spinalis, is not less definite in its history than myelitis or spiual meningitis, neither is it of less practical interest. In the sequel, indeed, it may appear, not only that spinal congestion is fully entitled to the place which has been assigned to it in the catalogue of diseases, but also that it really comprehends more than one spinal disorder which is now known under a different name. 1. Symptoms.— As an instance of well- marked spinal congestion, I take the notes of a case under my care not long ago. Case.— Mary L., aged 28, but looking very much older, married but never preg- nant, was admitted into the Westmmster Hospital on the 12th of June, 1866. (a) With the exception of being able to turn her head on the pillow and to move the fingers and toes a little, all power of voluntary movement appears to be want- ino-. The symptoms chiefly complained of "are tingling in the tips of the fingers 966 DISEASES OF THE SPINAL CORD. and toes, a dull burning aching along the hack and in tlie limbs, and a feeling of being ' ' tired to death. ' ' If altered in any- wise, the sensibility to touch, pain, tick- ling, and differences of temperature, is somewhat more acute than natural. The spine is nowhere tender on pressure, but the dull burning aching in this region is increased by the application of a sponge soaked in hot water. The soles of the feet may be tickled without giving rise to un- due reflex movements. The bladder and bowels act properly. The mind is not at all affected. Tlie state generally is evidently one of great exhaustion and prostration without fever, the pulse being quick, unsteady, and very compressii^le, the respiration shallow, and curiously interrupted by sighs. (6) Three weeks ago, menstruation, which had only just begun, was suddenly checked by an alarm of tire. This was shortly before bedtime. The next morn- ing, after a very sleepless and miserable night, the state had become very much what it now is. Up to this time the pa- tient had never been obliged to remain in bed a single day on account of illness. She had often been weak and ailing, and she had suffered a great deal at the men- strual periods from pain and weakness in the back and legs, and that is all. She also appears to have sprung from a toler- ably healthy stock. (c) AVithin tlie first fortnight after ad- mission to the hospital, the tingling in the tips of the fingers and toes came to an end, and so did the aching in the back and limbs. A week later the arms as well as the hands could be moved a little. At the end of six weeks the legs remained almost as helpless as at first, but the arms and trunk had so far recovered power as to allow of a change from the lying to the sitting posture without any great diffi- culty. At the end of twelve weeks it was possible to get out of bed, and, with the help of a stick, to move to the table in the centre of the ward. On the 3d De- cember, five months after admission, the patient left the hospital convalescent. All this while the appetite was tolerably good, and the bladder and bowels acted properly. Kow and then, in the progress towards recovery, especially about the menstrual periods, there were short relapses in which the tingling in the tips of the fingers and toes, and the aching in the back and limbs, came back, and the paralytic weakness of the muscles was almost as great as at first, —in which the ground already gained seemed all but lost. Now and then, also, the nights were disturbed by a distressing state of shortness of breath, not amount- ing to asthma. Before the legs recovered power their muscles were somewhat wasted, hut not considerably so ; indeed, neither here nor elsewhere was the paraly- sis accompanied by any marked wasting of the muscles, or by any appreciable im- pairment of electro-sensibility or electro- contractility. Moreover, any movement, whether active or passive, had always the effect of relieving rather than of increasing the aching in the back and limbs, when this symptom was present. The treat- ment pursued was chiefly rest, good liv- ing, hypophosphite of soda, nux vomica now and then in small doses, cod-liver oil, and faradization. Assuming, as I well may, this to be a case of well-marked spinal congestion, I take as points of comparison between it and other cases of the kind, general and partial, these: — suddenness of access ; in- complete paralysis in a paraplegic form ; no numbness ; tingling in the tips of the fingers and toes ; no exaggeration of reflex excitability in the paralyzed limbs ; no want of control over the bladder and bowel ; no spinal tenderness ; aching in the back increased by warmth ; pains in the back and limbs not increased by move- ment ; no marked impairment of the elec- tro-contractility and electro-sensibility, and no material wasting, of the paralyzed muscles ; nofeverishness ; breathleisness ; no bed-sores ; proneness to relapses. Suddenness of onset. — To he well, or comparatively well, on going to bed, and to be paralyzed in the morning, as in the case which I have given, is no uncommon thing in spinal congestion. It is indeed the rule rather than the exception for tlie illness to be spoken of as a '^ stroke" by the sufferer. Incomplete paralysis in a paraplegic form. — Paralysis, often all but complete, but never quite so, and taking the paraplegic form, must be looked upon as the rule in spinal congestion. The paralysis is de- cidedly paraplegic in the end, and it may he so from the beginning, but not unfre- quently one leg or one arm is affected he- fore the other, and occasionally the leg and arm of the same side may for a short time be affected, as in hemiplegia, before the disease extends to the leg and arm of the other side. Not unfrequently there remains a difference in the degree of paralysis on the two sides, one leg or arm being more affected than its fellow. In cases where the congestion of the cord is general the arms as well as the legs are paralyzed, the former perhaps as much as the latter ; but in the common run of cases, where the congestion is confined chiefly to the lumbar region of the spine, the legs are exclusively or chiefly affected. No ancesthesia. — Numbness is a symp- tom of myelitis, but not of spinal conges- tion. In the latter disorder, indeed, instead of numbness there is occasionally a state of things which may be spoken of as hypersesthesia : thus, in a case very SPINAL CONGESTION. 967 like the one I have given, which came under my notice in pri\-atf practice about three years ago, the weight of a single bed-sheet was distressingly heavy to tlie patient, and long-coutinued aching of the paralyzed arms and legs was produced by handling them ever so lightly. Tingling in the tips af tlw fingers or toes of the paralyzed limbs. — This symptom is ahnost always present at (me time or other, coming and going and staying a longer or shorter time, often, as it would seem, very capriciously. One is glad to get rid of it, for while it remains it is difficult altogether to put aside the fear lest the state of the cord should pass out of simple spinal congestion into the graver disease of myelitis. No exaggeration of reflex excitability in the paralyzed limbs. — Increased disposition to retlex movement is usually regarded as one of the symptoms in spinal congestion. It is supposed that the greater afflux of blood to the spinal cord must bring with it greater reflex excitability. I believe, however, that this supposition is not at all borne out by the facts. I believe, in- deed, that the moderate reflex excitability in the case under consideration is not at all exceptional, and that it is the rule in all cases of spinal congestion for this man- ifestation of muscular contractiUty to be, if altered at all, dimmislied rather than increased. No paralysis of the bladder or sphincter ani. — In myelitis, paralysis of the bladder or sphincter ani, more or less complete, is a prominent symptom : in spinal conges- tion, on the contrary, these symptoms are absent, except in those mixed cases where tliere is reason to believe that some degree of myelitis is also present. In the case which 1 have given there was not the least want of control over the bladder or bowel from the beginning to the end. No tenderness on pressure along the spAne. — Absence of spinal tenderness I believe to be the invariable rule, not only in spinal congestion, but also in myelitis and spinal meningitis. I believe, indeed, that spinal tenderness is a sign of the presence of that functional disorder of the cord which is usually called spinal irritation, and that it does not accompany the graver diseases of the cord which have been named when they are uncomplicated with spinal irritation. Upon this subject I shall have more to say presently. Dull aching along the spine increased by luarmth.—l have noticed this symptom in three cases of well-marked general spinal congestion which have come under my own observation, and in many cases of partial consestion ; and I am disposed to think that this will prove to be one of the points of diflerencc between spinal conges- tion and spinal irritation. I have also noticed the same symptom in myehtis and spinal meningitis, and therefore I cannot regard it as having any special connec- tion with spinal congestion. In fact, so far as my experience goes, I can say that this symptom is hkely to be met with in congestive or inflammatory diseases of the cord, but nut in spinal irritation simply ; and that in this latter case, the local ap- plication of warm,th to the spine is more likely to relieve pain than to cause it. Pains in the back and limbs not increased by movement. — This symptom has some claim to be regarded as constant. The aching would seem to go and come with the congestion ; and the fact, for fact it seems to be, that H is not increased by movement, may hcl'u to distinguish spinal congestion from spmal meningitis, for in the latter atfection movement of the limbs, whether passive or active, is at- tended with pain in the parts moved aud in the back. No marked impairment of electro-contruv- tility and electro-sensibility in., and no uast- ingof, the paralyzed muscles. — In myelitis the paralyzed muscles are prone to waste and to lose their electro-coutraetihtj- and electi-o-sensibility, and herein, therefore, would seem to be a marked ditlerence be- tween this disorder and spinal congestion ; for, so far as I know, the contrai-y state of things invariably holds good in spinal con- gestion. No feverishness. — This is no special fea- ture ; indeed, fever would seem to have little to do with any affection of the cord, not even excepting meningitis in its most active form. No bed-sores.— A- marked disposition to bed-sores would seem to be the rule in myelitis, but not so in spinal congestion or spinal meningitis. Upon this point, more than upon many others, there is tolerable unanimity of opinion. Shm-tness of breath.— Where the spinal congestion is" at all general, this state of things may be readily accounted for by the paralytic i^cakness of muscles con- cerned in respircdon. In the case which serves as my text, the occasional short- ness of breath is noticed as n(3t amounting to asthma ; and this is a point of some interest, for it may be supposed that the difficulty of breatiiing would have taken this form— would have had something of a decidedly spasmodic character— if the congested condition of the cord involved, as i't is supposed to do, an exaggeration of reflex excitabilitv. Prmwness to relapse.— Whether this may prove to be a constant feature in spinal congestion remains to be seen. That it is iiot an uncommon one is, to say the least, highly probable. . Spinal congestion varies greatly m its decree and 'in the extent of cord im- plicated. Limited to tlie lumbar region, and carried to a degree which produces. 9G8 DISEASES OF THE SPINAL COF.D. not paralysis, but weakness more or less approaching to paralysis in the legs, it is common enough ; indeed, many women seem to suffer from it before every men- strual period ; and between this partial and incomplete form and the general and complete form, of which the case which has been given is an instance, there are all possible grades of transition. It would seem to be most common in women, but it is not peculiar to the female sex or to any age. The onset of the disorder is generally sudden, in relapses as well as in original attacks ; and the cases do not at all'divide themselves into acute and chronic as do the cases of many other disorders. 2. POST-MOKTEM APPEARANCES. — These appearances are very vague and unsatisfactory, at most being simply some engorgement of the veins of the spinal cord and membranes, with some excess of the spinal fluid, both of which phe- nomena, as will be easily understood, are not very unlikely to escape detection un- less the post-mortem examination be con- ducted with unusual care. With the exception of this engorgement and serous effusion, the only morbid sign which has been noticed (and this by no means con- stantly) is slight infiltration with blood of the cellular tissue exterior to the dura mater. In all uncomplicated cases, the structure of the cord and of its mem- branes is in nowise altered. 3. Causes. — As in the case which I have given, the suppression of the cata- menia would seem to figure most con- spicuously among the causes of spinal congestion, and next to this the cessation of hemorrhage from piles. Beyond this it is difficult to single out any one cause which has a just claim to be considered as at all special : and, for the rest, no- thing further need be said except this, — that spinal congestion is not unfrequently a consequence of pulmonary or abdominal congestion or inflammation — a conse- quence, perhaps, which has often more to do in compromising the safety of the pa- tient than the primary disorder itself. 4. Diagnosis. — Paraplegic paralysis is a symptom common to spinal congestion and myelitis, with this difference, that it is less complete in the former affection than in the latter. The paralysis is as- sociated with anaesthesia in myelitis ; not so in spinal congestion. The control over the bladder and bowels is lost in mye- litis ; not so in spinal congestion. The paralyzed muscles are prone to waste and lose their electro-contractility and electro- sensibility in myelitis ; not so in spinal congestion. The absence of anaesthesia would seem, indeed, to connect spinal congestion more closely with spinal men- ingitis than with myelitis, and so also would the pain in the back and aching in the limbs ; but the pain and aching in spinal congestion cainiot well be eon- founded with the pain which is met with in spinal meningitis, for the pain in this latter affection is produced by movement and accompanied by rigidity, whereas the pain in the former aflection is not pro- duced and accompanied in this manner. Hysterical paralysis, so called, agrees ' with the paralysis depending upon spinal congestion in some respects, but not in others. It agrees in that the paralyzed muscles are neither prone to waste nor to lose their electro-contractility ; it dis- agrees in that numbness is a prominent symptom, more prominent even than the paralysis, and that the electro-sensibility of the paralyzed muscles is either anni- hilated or very much diminished. 5. Prognosis. — Recovery is the rule, no doubt, in cases of spinal congestion, but there is no difficulty in finding cases in which the disease has been fatal, and quickly fatal too. In the partial form, affecting the lumbar portion of the cord only, spinal congestion may come and go quickly without any great damage being done ; but in the cases in which the cord is more extensively and more profoundly affected, as in the case which has been cited, recovery may occupy a considerable time. Thus, of the cases recorded by Ollivier, No. 55 remained in hospital nearly five months, No. 56 two months, No. 57 three months, and No. 58 " assez longtemps." Recovery is slow, it may be, because time is required for the ab- sorption of the excess of the spinal fluid to which the state of spinal engorgement had given rise. 6. Treatment. — What has been said respecting myelitis must be supposed to apply here equally. Indeed, the only special remark which appears to be called for in this place is this, — that in cases where, as very generally happens, the spinal congestion can be referred to sup- pression of a menstrual or hemorrhoidal discharge, the primary indication would appear to be the setting up of an equiva- lent discharge by applying leeches to the OS uteri or to the anus. IV. Tetanus. Tetanus is unhappily no rare or unfamil- iar malady. The name, from Ttii-u, I stretdi, refers to that rigid and cramped condition of the muscles whicli is the most charac- teristic symptom, and which, in sober earnest, is suggestive of rigor mortis, not only m posse but actually in esse; for there TETANUS. 969 are some cases in which, without any in- terval of relaxation, tetanic rigidity at once paisses into cadaveric rigidity. Hy- dropliobia alone excepted, tetanus is at once the most appalling and the most perilous of all spasmodic diseases. 1. Symptoms.— As an instance of well- marked tetanus, I take the notes of a case which I happened to see from the begin- ning to the end ten years ago. Case 1. — Patrick M , a fair, slightly- built, delicate-looking man, unmarried, aged 27, the coachman of a gentleman then under my care. On the 21st of April, 1861, meeting him as I was leaving the house of his master, he took the oppor- tunity of saying that he was not well enough to bring round the carriage, and of asking me what he had better do. What he complained of chiefly were a stiff neck and sore tliroat, with a feeling of weakness and illness. The stiff neck and sore throat made their appearance for the first time this day ; the feeling of illness and weakness has been present for the last three day.s. The mouth cannot be opened so as to allow a fair look at the tongue, and a meal, it appears, has just been left unfinished, not for want of appe- tite, but simply on account of the difficulty experienced in masticating and swallow- ing the morsels. There is no fe verishness. P. M. ascribes his second indisposition to having been out with the carriage seve- ral hours in the wet and wind three nights ago, and he says further that he is liable to colds. Before speaking to me, he had taken some opening medicine which a chemist had prescribed and prepared for him, and he thinks that this dose may ac- count for the fact of feeling so ill and weak at the present moment. Some simple treatment was recommended, and I took my leave, not at all divining what was so soon to follow. April 22. — Receiving information that this poor fellow was very ill, I went round to see him at his lodgings. I found him strangely altered. His teeth were firmly and inseparably clenched, and he looked literally like an old man — so like, that his mother, who lived with him, said that she could have thought his father had come back to life if only his hair had been gray. His voice had also become so low and in- distinct as to make it difficult to catch what he said. The medicine given by the cliemist yesterday, it appears, has purged him violently several times in the night, and more than once while at stool he has been seized with acute pain in the pit of the stomach, which took away his hreath, and made him think he was going to die. It was in the night, while at stool, that the jaws became closed. I wished him to go to the hospital, and he was willing to do so, but his mother would not consent. Eggs beaten up with brandy were ordered to be given repeatedly, aiid every three hours a draught containing five grains of quinine and half a drachm'of Ilotlinann's anodyne. I now noticed on one of the fingers, which was tied up in a piece of rag, a small wound, healing and appa- rently healthy, the result of a tear by a rusty nail about a fortnight ago. On a second visit, later in the day, t found that repeated attempts had been made in the interval to give the food and medicine, but with very trifling success. There was no great dilificulty in getting the food or medicine into the mouth, for almost all the teeth on the right side were gone, but the attempt to swallow brought on spasm in the throat, and on more than one occasion the spasm forced the greater part of what was taken back through the nostrils. And this difficulty was all the more distressing, because a feeling of hunger prompted the patient of his own accord to make frequent attempts to swal- low. The chief complaint now was of a dragging pain at the pit of the stomach, piercing through to the back. In answer to a question whether he could sit up in bed, ho said, " I tliink I am too stiff to do so," and then he tried to sit up, and suc- ceeded after making two or tliree abortive attempts. "While sitting up, I found that he could scarcely move his head, and that the muscles of the neck and back were very stift' and hard. I had only just no- ticed these phenomena when the noise caused by the upsetting of a chair brought on a fit of spasm, in which the patient was suddenly thrown backwards upon the bed with considerable force, and left rest- ing upon his head and heels, in a state of complete opisthotonos— a state so com- plete as to make it possible for me to pass my hand under the loins without touching either the body or the bed. This severe spasm lasted not less than a couple of minutes, and the only muscles which did not seem to be implicated in it were the abdominal, those of the arras and hands, and those of the eyeball. In this spasm the complexion became dusky and livid, and the features altered in a frightful manner, the angles of the mouth being drawn upwards and outwards so as to give the expression known as the risus sar- doniciis, the set teeth being slightly un- covered, the nostrils spread, the eyes staring and prominent, the brow Knit, the hair bristUng- the complexion and fea- tures became changed, that is to say, as they are changed in sudden suflbcation. All this while, too, the skin generally was dusky and hot and drenched in perspira- tion. For some time after this spasm had passed oft' the patient remained moanmg, and unable to speak audibly, and then he said, "that pain will kill me if it comes back." I noticed, also, that there re- 970 DISEASES OF THE SPINAL CORD. maiiied after this spasm a state of tetani- forni rigidity and contraction, by wliicli no inconsiderable degree of opisthotonos was still kept up. The eggs and brandy and the medicine were ordered to be given by enema. Ajjril 23. - Two attempts were made to administer the enemata ordered over night without success, tlie irritation of the pipe in each instance bringing on a tit of spasm ; indeed, all that it has been possi- ble to give since my last visit have been a few sips of wine and water. There has been no sleep whatever during the night. During the last eighteen hours several fits of spasm like the one described have oc- curred, and the permanent rigidity and contraction remaining between the tits have increased. The abdominal muscles, which were not at all implicated yester- day, are now as hard and stiff' as tliose of the neck, back, and legs. The pulse is quick (about 140), weak, and somewhat irregular : the breathing is shallow, hur- ried, and frequently checked by gasps and catches, even when it is not interrupted bj' the fits of spasm. No material change has taken place since the morning. On one occasion in the course of the day an egg Ijeaten up with some brandy has been swallowed, but all other attempts to administer food or medicine, whether by the mouth or by the rectum, have been rendered abor- tive by the tits of spasm to which they gave rise. Ajivil 24. — Again the night has passed without sleep, and to-day the constart tetaniforni contraction has become almost universal. In fact, the only muscles which are not obviously affected are those of the hands, and tongue, and eyeball. The fits of spasm, also, are now more fre- quent and severe, being not more than fifteen or twenty minutes apart, and last- ing until death from suffocation seems even more than imminent ; they are brought on by the most trivial causes — an attempt to swallow, a draught of air, the simple straightening of the bedclothes — or they come on without any apparent cause. There is no improvement in the breathing and pulse, but if anything a change for the worse. During the fits the skin is hot, dusky, and drenched in per- spiration : in the intervals it has an ominous, coolness and clamminess. The mouth is full of viscid frothy saliva, and there is much thirst. AVhile I was present a small quantity of dark urine was passed slow^ly and witli some difficulty, and this appears to be the only time the bladder has acted for at least twenty-four hours. The pupils are large, especially in the paroxysms. Shortly before I went again, at the end of the day, there had been a momentary snatch of sleep, which had been abruptly brought to an end by an attack of opis- thotonos, in which the tongue or cheek had been bitten, and now the frothy vis- cid saliva which filled the mouth to over- flowing was deeply crimsoned with blood ^a ghastly addition to a countenance already overcharged with horrors. Dur- ing the last six hours the paroxysms have been less frequent and severe, but the vital powers are evidently fast ebbing away. ''I cannot get my breath," was the answer slowly and almost inarticu- lately given to the question, "Have you muc'h pain?" Death happened about midnight, an hour after I had taken my leave, after a paroxysm of opisthotonos of no special violence, brought on, as it would seem, by an attempt to wipe away the bloody saliva from the lips. When I left the mind was perfectly clear and collected, and at no time, either before or after, was it otherwise. For the rest it only remains to add (for the objections made to a post-mortem ex- amination were insuperable) that the countenance appears to have retained after death the aged expression it had before death, and that the corpse when " laid out" was found to have stiffened without losing altogetherthe oi)isthotonic attitude. The mother of the patient is my only authority upon these points, for unfortunately it did not occur to me to make inquiries respecting them before the funeral had taken place. In order to realize the points of resem- blance and difference between this case and other cases of the kind, the course I propose to pursue is to take one after the other, as the points demanding attention, these — ]5ermanent muscular contraction, beginning by causing trismus, ending by causing opisthotonos, and implicating when at its height almost all the voluntary nmscles except those of the hands, the ej'eball, and the tongue : pain at the pit of the stomach, piercing through to the back ; difficult}' of swallowing, from the occurrence of spasm : fits of painful spasm in the permanently contracted muscles ; risus sardonieus, and an aged expression of countenance ; apnoea in the fits of spasm, and more or less dyspnoea at other times ; increased temperature, without true fever ; increased reflex excitability ; absence of sleep ; absence of numbness or tingling ; absence of " head symptoms ;" no marked want of control over the bladder and bowels ; comparative voicelessness ; the mouth clogged with viscid frothy sa- liva ; a bitten tongue or cheek ; dilatation of pupils; absence of priapism ; presence of a wound ; death by apnoea ; early if not immediate rigor mortis. TETANTJS. 971 Permanent imnscular rigidity, causing, first, trismus, then opisthotonos, and impli- catiitg, when at its height, ahiost all the voluntary muscles except those of the hands, the eyeball, and the ion j/ite.— Muscular rigidity, continuing witliout any marlvcd relaxation from the time of its first appear- ance, is the most characteristic symptom of tetanus. It would seem to be the rule for this state of stiffness to begin in the muscles of the jaws, causing trismus, and to extend from thence as a centre, first to the muscles of the face and neck, then to those of the back, causing opisthoto- nos, then to those of the lower extremi- ties, and lastly, to those of the upper ex- tremities, the progress in both extremi- ties being from above downwards ; but there are exceptions to this rule, for a few cases are on record in which the mus- cles of the neck have been atfected before those of the jaws, and others, also only few in number, where the muscles near a wound, as of a stump after amputation, have been the first to become rigid. Even in the most extreme cases, the hands and the tongue are found to remain lim- ber, and it is but very rarely, except per- haps in children with " head symptoms" in addition to the ordinary phenomena of tetanus, that a squint or a fixed stare shows that the deep muscles of the orbit are affected. Fits of spasm, of which more will have to be said presently, may seize upon the tongue, as they do very fre- quently upon tlie muscles of the throat in attempts to swallow, but there is no proof that either the tongue or the muscles of the throat are ever in a state of perma- nent contraction. Neither is there any certain proof that the heart or other in- voluntary muscles are in any degree per- manently contracted. The affected mus- cles are very hard, curiously so, feeling very much as they do in rigor mortis, and they are not unfrequently somewhat ten- der when pressed or squeezed. In the great majority of eases, without question, the first effect of tetanic rigidity is to close the jaws and cause trismus, and the next to bend the body backwards and produce opisthotonos. Opisthotonos, indeed, is almost as characteristic and constant a phenomenon as trismus. Now and then, it is true, instead of the body being bent backwards it may be bent forwards (em- prosthotonos), or sideways (pleurosthoto- nos), but these cases are quite exceptional, and opisthotonos may in reality be looked upon as the position which the body always takes or tends to take in tetanus. Pain at the pit of the stomach piercing through to the back. — This is reckoned by the late Dr. Chambers as the pathognomo- nic symptom of tetanus, and in fact it is scarcely ever absent, not even at the very beginning. This pain is especially severe in the fits of spasm, and then it is often agonizing, but it is present also, if not in a severe, at least in a mitigated form, in the intervals between those fits, scarcely ever ceasing altogether, even for a mo- ment, when once it has made its appear- ance. It depends, there is little reason to doubt, upon the diaphragm being im- plicated in the tetanic condition. Once it was looked upon as a certain death- warrant, but this opinion, as Mr. Curling has shown, is untenable. Difficulty of swallowing from the occur- rence of sjxmn.—This spasm, which is pro- yoked by the attempt to swallow, may be in the pharynx or gullet, or in the cardiac aperture of the diaphragm, one or all, making swallowing impo.^sible, and often leading to the violent ejection of fluids through the nose or from the mouth. The distress consequent upon it may some- times cause a horror of liquids not unlike that which exists in hydrophobia, and it always constitutes a grave diflScult)', for it not only incapacitates the patient from feeding in the usual way, but it prevents him from being fed by means of the stom- ach-pump. Fits of painfid spasm in the permanently contracted mnscles. — These fits become more frequent as well as more violent and painful as the disease progresses, re- curring when at the worst every ten or fifteen minutes, and lasting from one to two and a half minutes. So violent has been the muscular contraction in some of these fits, that the teeth and thigh-bones have been broken, and great muscles like psoas and recti femorales torn across. These fits of spasm are almost invariably very painful, the being that of cramp, but now and then the pain has been absent : thus, Sir Gilbert Blane mentions, on the authority of a surgeon in the navy, a case of severe tetanus, fatal in four days, in which the fits of spasm only gave rise to a sort of pleasurable tingling; and Mr. Curling instances an analogous ease. Most generally the pain in the fit of spasm is felt chiefly at the pit of the stomach, and very often the pain in this region may be so agonizing and stifling as to make the patient insensible to pain elsewhere. Sometimes the pain in the neighborhood of a wound, as in the stump after amputation, is that which is most complained of. liistis sardonicus and an aged expn-ession of countenance. ~T!he sneering expression, caused by the angles of the mouth being drawn backwards and upwards, and known as the risus sardonicus, in asso- ciation with spread nostrils, staring and prominent eyes, knitting of the brows, and bristling of the hair, is so often pre- sent as to be properly reckoned as pathog- nomonic of tetanus. In the fits of spasm the lips are often drawn apart so as to expose the set teeth, but sometimes they DISEASES OF THE SPINAL CORD. are kept tightly pressed together by the spasmodic action of tlie orbicularis oris. The aged expression which was present in the case I have given, is exceptional, but it has been met with in other cases. Tlius, Mr. Curling refers to a case of idio- pathic tetanus, related by Dr. W. Farr, in which the patient, who was only twen- ty-six years of age, looked at least sixty; and he says further that he himself has "observed the same circumstance in an equally remarkable degree." Dyspnoea with jits of coivpHrative apnoea. — When tetanus is fully developed, an ap- prehension of suffocation is often present even in the intervals between the fits of i spasm, and in these fits the suffused eyes, ; the livid countenance, and the agonizing struggle for breath show plainly enough that this is no sense a groundless fear. How this difficulty is brought about is not easy to say, arid probably the way is not always the same. Sometimes spas- modic closure of the glottis would seem to be a prominent cause ; sometimes the thorax is, as it were, held in a vice by the spasm of all its muscles generally; most commonly, perhaps, these two causes act together. From my own small expe- rience I should be disposed to attach more importance to the last cause than to the first, and I question whether much relief would be obtained in any case by carrying out Marshall Hall's suggestion of opening the windpipe in cases of tetanus. Increased reflex excitability. — In P. M., as the disease advanced, the fits of spasm were brought on by the most trivial causes — a draught of air, a sudden noise, an attempt to swallow, an attempt to admin- ister an injection, the arrangement of the bed-clothes, the lightest touch even — and hence it may be inferred that increased reflex excitability was an element in this case. Nor is this case at all exceptional in this respect. As the disease advances, in fact, the controlling influence of the nervous system is removed, and this is all, for what are counted as signs of in- creased reflex excitability are in reality no more than signs of nervous exhaustion, such as manifest themselves whenever the vital powers are sufficiently lowered by loss of blood, or in any other way. Greatly increased temperature, withotit triie fever. — In the fits of spasm, and in a lesser degree in the intervals between the fits, the skin is very hot and damp, this heat rising in some cases as high as 110 '75° Fahr., the sweat having now and then a peculiar pungent smell. Usually the skin is literally drenched in perspira- tion and covered with sudamina. Usually the pulse is quick and weak ; and if in the fits of spasm it acquires more force, the state of semi - suffocation then present shows very plainly that this change in its character is, as I have shown elsewhere, due, not to the injection of more red blood into the artery, but to the greater resist- ance which imperfectly aerated blood has to encounter in getting out of the artery. The increased heat of skin in tetanus at first siglit appears to show that fever is a part of tetanus, but further inquiry points to a very different conclusion. As death approaches, the temperature, in- stead of falling, as it might be expected to do, may actually rise higher, and, what is stranger still, the rise may not be at its maximum until the patient has been dead for some time. Dr. Wunderlich' gives three cases which establish this fact — which he was the first to observe — beyond all contradiction. The first of these cases is one of idio- pathic or rheumatic tetanus, the patient being a butcher, aged 29. The disorder, which presented nothing remarkable in its symptoms, run its course in five days. Shortly preceding death there was some delirium, with marked abatement in the spasms, death happening in the exhaus- tion following a bout of spasm of no spe- cial severity. Putrefaction was unusually rapid. The brain was healthy, the cord was injected, and its texture (neuroglia) considerably broken down. The temper- ature of the ward at the time of death was 77° Fahr. "What is of interest in the state of the breathing, the pulse, and the tem- perature, is as follows : — ' Archiv der Heilkunde, Bd. li., iil., and V. (1861, 1862, and 1863). TETANUS. 973 Date. Respirations 24th July, 1861 . 24 25 th " '* , , Tl 26th " " 9 A.M. 20 (( il " 6 P.M. 32 H <( " 9.20 P.M. 36 tt tl " 9.35 P.M. After death n (C ti u (( tl ti n (( u (( death 2' . 5' . 20' . 35' . 55' . 60' . 70' . 90' . 100' . 6 hours 9 " 12 " 13^ " The second case is one of traumatic tet- anus in a man aged 20, fatal tenth day. Up to twenty-four liours before deatli the tetanic symptoms were fully marked, and the mind quite clear ; at this time, and especially in the six hours immediately preceding death, unrest, talkativeness, jac- titations, and slight delirium were more prominent symptoms than the spasms. The appearances after death were like those found in the first case. In the last three days the mercury went up slowly and steadily from 100° to 105O-8, at which point it stood three hours before death ; at death and afterwards the notes made of the temperature are these : — At death . . . . 107-6 Fahr ]0' after death . 107-8 15' . . 108- 20' . . 107-8 38' . . lOu--!"^ 58' . . 105-8 1 hour 5' . . 105-31 " 20' . . 104-45 " 35' . . 103-55 2 hours . . 101-75 4 " . . 99-3 The third case is that of a man, aged 57, a bookbinder by trade, ■^^■ith idiopathic or rheumatic tetanus. Tetanic symptoms set in in the usual way on the 2Uth June, 1863, and were fully developed two days afterwards, when also symptoms of pneu- monia were detected. Death happened to- ward the end of the day following, as much or more from the pneumonia as from the tetanus ; and after death the only very marked appearances were those of pneu- monia. In this case the temperature, which was never higher than 104° -55, was— Other cases are also on record which show that this strange rise in temperature up to death and after it, is not peculiar to tetanus. Dr. Wunderlich gives three such cases: — (1) A case apparently of lead-poisoning in a plumber, ending fa- tally in 40 hours : the symptoms being sudden insensibility, and, later on, tetanic and epileptiform convulsions. In this case the temperature at death was 107°-7, and there was some slight increase afterwards; (2) a case of cerebro-spinal meniugiti:-, with unrest, delirium, and retraction of head for four days, and then sopor, in which the temperature was 107^-20 at death and 107°-37 after death ; and (3i a case of rheumatic fever, with cerebral meningitis, shortly ending in coma on the sixth day, in which the temperature ranged from 109°-G2 to 110O-75 in the five hours before death, and stood at 111° -87 thirty minutes after death. Dr. Erb' also gives three cases with fuller detail, name- ly, these : — A young man, aa;ed 22, with tubercular inflammation of the base of the brain, who died without convulsions, after havm" been in a state of profuse perspiration and unconsciousness for twenty-four hours, with rapid respiration (GO to 44), and a pulse quite uncountable, towards the end. In this case the temperature in the twen- ty-four hours before death, at death, and afterwards, was as follows :— 24 hours before death . . . At death . . ■ 13' after death - 25' 55' from IOlO-65 to lOJ-9 Fahr. .... 104-9 . . . 105.12 . . . 104-67 . . 104 3^ hours before death At death .... 10' after death . . 21' " • • 102-85 Fahr. rot stated 103-32 103-55 A woman, aged 22, six months gone in pregnancy, who died with symptoms ot 1 Deutscbes Archiv fur Klin. Medichi. vol. i. 1866. 974 DISEASES OF THE SPIRAL CORD. coma, without convulsions, the coma hav- ing set in suddenly an liour and a half be- fore death, and in wlioui signs of purulent meningitis were detected after death. During the comatose state the breathing was very labored, and the pulse fuU and frequent. The temperature, of which the notes arc as follows, was only taken after death : — At death . • • t ■ . Temp, not stated 6' alter death . . . . 103-45 Fahr. 10' . 104 15' . 104-(J7 20' . 104-9 25' " . 104-9 35' . 105-12 45' " . 105-12 1 hour 40' after death . 104 2 hours 40 ' " . 101-22 A woman, aged 22, who after having suffered from diabetes mellitus in its ordi- nary form for three and a half years, passed into a state of sopor, after having had headache and some delirium for twenty-four hours. Death happened in about forty-eight hours from the com- mencement of the head symptoms. Dur- ing the twenty-four hours of sopor preced- ing death, the degree of heat ranged from 102O-0.5 to 100° ; at death and afterwards the notes made of the temperature are these : — At death . . 5' after death 15' 25' " 106 Fahr. 106-25 106 105 The body has been found to become very hot before death, and to remain very hot after death, in cholera, in yellow fever, and in several other cases, of which in- stances are given by Dr. Erb and by sev- eral other writers in Germany, and by Drs. Einger,' Weber,^ Murchi'son,^ San- derson, < and others in this country ; the cause of death in the majority of these cases being some sudden affection of the brain, coma in others ; but there are but few cases in which the heat of the body has been found to rise after death. Inde'ed, I know of no such cases besides these I have quoted, except one, which came under my notice a short time ago— a case of a man, aged 60, who died from sunstroke in twenty-six hours, the symptoms being sudden coma, with great oppression of the pulse and breathing, without convul- sion. In this case the temperature was — 12 hours before death 3 " " At death 7 hours after death . . 103-25 Fahr. . . 104 not ascertained. . . 105-5 ■ Med. Times and Gazette, vol. ii. 1867. 2 Clinical Soo. Trans, vol. i. ISfiS. ' Ibid. 1 Ibid. If, then, the temperature rises in this manner under these circumstances, it is more than difficult to connect the increased heat of tetanus with increased activity of the circulation or with anything like fever in the ordinary form of the word. The temperature rises as the time of death ap- proaches, when the state of the circulation must every moment be becoming more and more the reverse of increased activity: the temperature continues to rise even after actual death, when the blood has come to a standstill. These are the facts ; and, these being the facts, it may be that the increased heat in tetanus may be con- nected, not with increased activity of the circulation, notwith true fever, but rather with the contrary state of things. Nor is it more easy to connect the increased heat of tetanus with the spasms. A part of the increase may be accounted for in this man- ner, but only a small part. Indeed, the simple fact that in one of the cases which has been instanced a marked abatement in the severity of the spasms was accom- panied by an actual rise in the column of mercury, and that the column continued to rise after death, when all spasm is at an end, is in itself a sufficient proof that it is not in muscular action that the explana- tion of the increased temperature of teta- nus is to be found. Moreover, the fact tliat tlie temperature rises in the same way before and after death, in cases where neither convulsion nor spasm was among the sjmptoms during life, must lead to the same conclusion. How to explain the increased heat of tetanus is another mat- ter. Increased heat, as was sliown in the primary remarks, is an effect of injuries by which the cord or medulla oblongata is torn or cut across. Increased heat, as is seen in some of the cases wliich have just been alluded to, is an accompaniment of certain diseases which annihilate, more or less completely, cerebral action. It seems as if one condition of this change in temperature was the paralyzing of a regu- lating cerebral influence ; and beyond this it is difficult to see further, except it be that this paralysis, reaching to the vaso- motor nerves, allows the minute vessels to dilate and receive more blood, and that the increased quantity of blood, even though this blood may be stagnant, may lead to increased molecular changes, of wliich increased heat is an effect. What is necessary, however, is not to find the cause of the increased lieat in tetanus, but simply to point out the fact that increased heat in this case does not imply increase^ activity of circulation — that true fever, in the ordinary sense of the word, is not a part of tetanus. And this, as it seems to me, is a legitimate inference from the evi- dence which has been cited, and the com- menis which have been made. Abacncc of sfejy.— In the acute cases, TETANUS. 975 sleep, as a rule, is banished altogether, and even in the subacute cases this bless- ing is only realized in unrefre.«hing broken snatches. Want of sleep, indeed, is one of the not least distressing features of this ' disease. "The muscles," says ilr. Curl- ing, "are observed to be relaxed during sleep, a striking example of which oc° curred to Mr. Mayo in a boy who recov- ered from the disease. On visiting his patient beibre the symptoms were sub- dued, Mr. Mayo found him asleep, and remarked that he lay perfectly relaxed. The abdominal muscles were soft and yielding, and had not the least tension. The boy was awakened, and at the instant the full tension of the muscles returned. N)t being farther disturbed, he fell asleep in a few minutes, wlien the muscles again became relaxed, and again, on his being awakened, resumed the state of spasm. I have, on several occasions, witnessed the same phenomena. ' ' Except the biting of the tongue, on waking from a brief nap, be a reason for believing that the musclos of the jaws had been relaxed during sleep, so as to allow the tongue to get between the teeth, there was no proof that the muscles were relaxed during sleep in the casj I have given ; but in other cases I have had proof suffi jient of this relaxation. AhieiKX of nuinbiicss and tinglinq. — Of this there can be no doubt— that numb- ness and tlnghng form no part of the his- tjry of tetanus. A'iseiice of '■^ head symptoms. " — The mind is jlear from the beginning to the end of the disease almost invariably, and not un- fre|uently it is a matter for wonder how wjU the patient bears up under his atro- cious sufferings — a mirked difference this between tetanus and hydrophobia. And in the few instances in which delirium or coma has made its appearance a short time before death, it is not improbable, as morj than one writer has observed, that this derangement is often more the result of the remedies employed than of the disease. No marked want of control over the blad- der or bowel. — In tetanus there is, as a rule, none of the difficulty with the blad- der which is almost invariably met with in acute spinal meningitis. The bladder may act seldom, but it is not incapable of acting. Constipation is a common but not a constant symptom, and when it is present it may be a question whether, like tlie " head .symptoms," it is not as much due to the medicines used as to the dis- ease. 'Now and then, however, there may be great difficulty in voiding the contents of the bladder and bowels, and in some of these cases the resistance to the intro- duction of a catheter or enema-pipe has Shown that a part of this difficulty is owing to spasm of the compressor urethrse or sphincter ani. Comparative vokelessness. —This phe- nomenon is readily accounted for as a re- sult of the spasmodic interference with the action of the chest and of the tio-ht shutting of the jaws. Indeed, it could not well be otherwise in the fully devel- oped disease. ^ The mouth clogged with viscid frothy sa- liva. — This is a common if not a constant symptom, though not so marked in degree as in hydrophobia, and there is no diffi- culty in accounting for it in cither case, for the inability to drink and swallow will explain at one and the same time why the saliva is viscid and why it accumulates in the mouth. A bitten tongue or e/ieefc.— This accident is of rare occurrence, and its rarity may be taken as an incidental proof of sleep- lessness as a symptom of tetanus, for it is to be supposed that the opening of the jaws, from the relaxation of their muscles during sleep, would allow the tongue or cheek to get between the teeth— to get into that position in which the spa^m which attends the moment of waking would be sure to crush it. Dilatation of pupil. — This condition was always present in the case which serves as my text, especially in the fits of spasm, and this has been the rule in several cases of tetanus in which I have examined the pupil. Mr. Curling, on the contrary, found the pupil contracted in the majority of his cases. Absence of priapiism. — Mr. Morgan states that priapism occurs occasionally; but this observation is not confirmed by other wri- ters on the subject. I have never seen it, and I am very much disposed to think that the case or cases in which Mr. Mor- gan saw it were cases, not of tetanus, but of acute spinal meningitis, in which dis- order priapism is an occasional symptom. Presence of a wound. — The great majo- rity of cases of acute tetanus appear to be in some way depending upon a wound or injury of one kind or another in one place or another. I shall have occasion to re- fer to this relationship elsewhere : and at present I would only notice, in passing, the presence of a wound which, to all appearance, presented no indications of an inflammatory or otherwise unhealthy character. Death by ajwosn.— Apnoea is one way, and perhaps the common way, in which death is brought about in tetanus. Not unfrequentlv, however, the patient sinks from asthenia, having been to a great de- gree free from fits of suffocative spasm for some time before death. Spasm of the heart has also been mentioned as a method of dying in tetanus, and the heart has not unfrequently been found to be curiously hard and contracted after death ; but an examination of the facts tends very much to discountenance this idea, and to show 976 DISEASES OF THE SPINAL CORD. that death is either by apnoea or asthenia, singly or together. The immediate occurrence of rigor mortis. — Sommer and others have noticed that rigor mortis may occur without any ap- preciable interval of muscular relaxation after death from convulsions, and Dr. Brown-Sequard has confirmed this obser- vation and given a definiteness to it which it had not before. He has indeed done more than this, for he has not only con- firmed the fact that rigor mortis may oc- cur without any appreciable interval of muscular relaxation, but he has estab- lished the law that rigor mortis is long in coming on and long in passing oif where death was not preceded by any long-con- tinued violent action of the muscles, and that it is quick in coming on and quick in passing off in direct proportion to the amount of long-continued violent action which preceded death. In many animals killed by strychnine, for example, in which death was brought about, not by one vio- lent spasm, but by many, he has found rigor mortis set up before the heart had ceased to beat. Nay, he even refers to the case of a man under his own observa- tion in which rigor mortis occurred before the heart had ceased to beat. I have never witnessed this phenomenon either in animals or in man ; but I have more than once failed to find any line of sepa- ration between tetanic stiffness and ca- daveric rigidity in animals killed by strych- nine, or by the shocks of a Ruhmkorff' coil : and I am therefore quite prepared to understand that in P. M 's case, where there were many convulsions before death, rigor mortis may have occurred without any appreciable interval of mus- cular relaxation, and in this way fixed in the corpse the age expression of the coun- tenance, and the opisthotonic attitude. Two distinct varieties of tetanus are usually recognized, and properly so — the traumatic, in which a hurt of some kind or other is believed to be the primary cause ; and the idiopathic, in which the only ob- vious cause would seem to be exposure to cold and damp. In each variety the symp- toms are much the same, any difference of moment being only one of "degree. In the acute form, the spasms come on sud- denly, occur frequently, and grow in vio- lence with each recurrence : in the less acute forms the spasms are more slowly developed in the first instance, the parox- ysms are comparatively far between, and they do not recur with increasing rapidity and violence. The traumatic, as a rule, is more acute than the idiopathic variety. Trismus nascentium. is considered by many as a distinct variety of tetanus, but this "appears to be a distinction without a real diffference. It is tetanus in newly- born infants, — traumatic, because the wound of the navel seems to have a good deal to do with its production, and at the same time idiopathic, for it is certain that cold and damp, and foul air and other general causes also figure conspicuously as sources. It is, indeed, to this form of tetanus that a remark of Sir Thomas Wat- son applies especially, which is applicable to all forms, namely this, that " although tetanus may be excited by a wound inde- pendently from exposure to cold, or by cold, without any bodily injury, there is good reason for thinking that, in many instances, one of these causes alone would fail to produce it, while both together call it forth." 2. Post-mortem Appearances. — There are no morbid changes in the ner- vous system peculiar to tetanus. ' ' Serous effiision with increased vascularity," says Mr. Curling, " is generally observed in the membranes investing the medulla spi- nalis, and also a turgid state of the blood- vessels about the origin of the nerves," and the same changes may also be met with in the cranium, but in a less degree, and less frequently. It is also a fact of considerable moment in relation to this point, that Majcndie, Ollivier, and Orfila failed to detect any perceptible lesion in the spinal cords of animals dying from the tetanus produced by strychnia. Out of se'N'enty fatal cases collected by Mr. Curling, there were only two in which changes in the nervous system unequivo- cally the result of inflammatory action were discovered after death, and these two were cases where there had been a blow or wound to the back, where the symp- toms had plainly to do with the inflam- mation of the cord or its membranes rather than with tetanus, and where the signs of inflammation found after death may, to say the least, be referred to the injury quite as easily as to the tetanus. Mr. Curling also points out, as a fact not to be overlooked, that the turgid state of the vessels of the pia mater, together with the effusion of serum which is met with in the spinal cord and brain after death from tetanus, is also met with in those persons who may have been poisoned by opium, hydrocyanic acid, and other power- ful agents often employed in the treat- ment of tetanus, as well as after death from delirium tremens, hydrophobia, epi- lepsy, and other diseases ; and as bearing upon these exceptional cases, in which unequivocal signs of inflammation in the cord or brain have been met with after death from tetanus, he says, "AVhether inflammation be the result of injury or arises spontaneously, it is worthy of notice that the spasms, though continued and severe, do not occur in such violent parox- ysms as in traumatic tetanus." Neither can the pretematurally injected state of TETANUS. 977 the minute vessels supplying tlie sympa- thetic ganglia, especially the cervicial and semilunar, met with by Mr. iSwan and others in some cases of tetanus, be looked upon as at all constant phenomena after death from tetanus. Nor do recent microscopic investiga- tions into the condition of the spinal cord in tetanus bring to light any clearer signs of inflammatory change. Mr. Lockhart Clarke' finds the vessels injected, and the substance of the cord in a state varyino- from simple softening to complete solu'^ tion, the softened or dissolved portions forming irregular "areas of disintegra- tion," filled with the debris of bloodvessels and nerves, or with a fluid finely granular or perfectly pellucid. These areas of dis- integration were chiefly in the gray sub- stance around the canal, but they were also in the white substance. They were, in fact, in no one part e.xelusively or par- ticularly. Here and there were extrava- sations of blood, and " other exudations," but pus corpuscles are not mentioned. "In the walls of the bloodvessels, " Mr. Clarke says, "there was no morbid de- posit, nor any appreciable alteration of structure, except where they shared in the disintegration of the part to which they belonged ; but the arteries were fre- quently dilated at short intervals, and in many places were seen to be surrounded, sometimes to a depth equal to double their diameter, by granular and other exudations, beyond and amongst which the nerve-tissue, to a greater or less ex- tent, had suffered disintegration. " "The appearances met with," says Mr. Clarke, are " exactly similar in kind to the lesions or disintegrations which I find in various cases of ordinary paralysis, in which there is little or no spasmodic movement." The cord is broken up, in fact, as at a certain time it is broken up by ordinary putrefaction, and, the dilated vessels and certain exudations of blood and serum excepted, this is all that is noticed. The case points to disintegration, not to in- flammation ; and what Mr. Clarke finds in six cases is substantially the same as that which Dr. Dickenson^ finds in the one case examined by him. Indeed the only peculiarity in this latter case is, in the presence, in addition, of an excessive quantity of a translucent, structureless, and finely granular, carmine-absorbing material, evidently the sero-fibrinous plasma of the blood, which has esca,ped from the minute arteries into various parts of the substance of the cord where the nerve tissue nas broken down, or which lies in pools here and there between the cord and its membranes. It is a state ' M«d.-Chir. Transactions, vol. xlviii. 1865 2 Ibid. vol. li. 18G8. VOL. I. — 62 of redema rather than anything else, cer- tainly not a state of inflammation. Traces of inflammation in the wound especially in the injured nerves, may be met with after death from tetanus, "and more frequently than in the spinal cord or other great nervous centres; but these again, mstead of being constant, are not even common appearances. In the great majority of cases, indeed, the wound, if there be one, is perfectly healthy and healing. jSTeither are there any other post-mortem facts which can be looked upon as essential to tetanus, for those which remain to be mentioned, as rup- tured muscles, broken or dislocated bones, engorged lungs, injection or contraction of the pharynx and palate, worms in the alimentary canal, and others, are plainly accidental and exceptional. 3. Causes. — The two great causes of tetanus are, as has been mentioned al- ready, cold and damp, and bodily injury of some sort. Exposure to cold and damp tells most in this manner when acting upon a body previously relaxed by heat and perspiring, and this is all that can be said, except that this exposure is more likely to issue in tetanus in a foul atmo- sphere than in a fresh one. As regards the hurt which may give rise to tetanus, it is difficult to know what to say. In the Peninsular war, as Sir James McGregor states, tetanus supervened on every de- scription and in every stage of the wounds, from the slightest to the most formidable, in the healthy and sloughing, the incised and lacerated, the most sim- ple and the most complicated ; and this statement expresses the opinion of all surgeons, military and others. Indeed, all that can be said is, that punctured wounds seem to be more likely to issue in tetanus than incised, and wounds in the extremities more than wounds in the head, breast, and neck. And certainly an inflammatory condition of the wound cannot be regarded as essential. In a great number of cases, in the majority perhaps, the primary wound was com- pletely healed and almost forgotten when the symptoms of tetanus made their ap- pearance ; and Dr. Eush, who had exten- sive opportunities for observation in the military hospitals of the United States, and wlio was unquestionably a most com- petent observer, remarks that there was invariably an absence of inflammation in the wounds causing the disease. John Hunter also says : " The wounds produc- ing tetanus are either considerable or slio-ht When I have seen it from the first, it was after the inflammatory stage, and when good suppuration was come on ; in some cases when it had nearly healed, and the patient was con- 978 DISEASES OF THE SPINAL CORD. sidered healthy. Some have had locked jaw after healing was completed. In such I have supposed the inflammation to be the predisponent cause, rendering the nervous system irritable as soon as it was removed. When tetanus comes on in horses, as after docking, it is after the wound has suppurated and begun to heal." There is, indeed, abundant evi- dence to show that an inflammatory con- dition of the wound is not necessary to the production of tetanus, and some evi- dence even which is calculated to lead to a contrary conclusion, by showing that where an inflammatory condition of the wound has been present, this condition has passed off before the tetanic symp- toms made their appearance — the inflam- mation, to repeat the words of John Hunter just used, "rendering the nervous system irritable as soon as it was removed,^'' not rendering it irritable as long as it was present. The interval between the hurt and the development of the tetanic symp- toms varies considerably. In eighty-one of the cases collected by Mr. Curling, the symptoms made their appearance between tiie fourth and fourteenth days, both in- clusive, and in nineteen on the tenth day. Four cases are also given in which the symptoms came on more speedily, one (somewhat doubtful) almost instanta- neously, another in one hour, a third in two hours, and the fourth in eleven hours, and, at the other extreme, one in which they were deferred as late as the tenth week. In traumatic tetanus the sooner the symptoms show themselves the more acute and dangerous is the malady. In idiopathic tetanus the symptoms, as a rule, commence sooner than in traumatic tetanus, often in a few hours ; but the idiopathic, notwithstanding, is generally of a more chronic kind than the traumatic, and far less dangerous. Tetanus is not a malady peculiar to any country, or climate, or people, but it is more common in hot countries than in cold. It would appear, also, that negroes are more likely to be attacked than whites. Great atmospheric changes, especially from heat to cold and damp, as to a cold and dewy night after a sultry day, are evidently most favorable to the develop- ment of tetanus, and so in a less degree are foul air, despondency, terror, physical exhaustion. It must be confessed, how- ever, that cases of idiopathic tetanus, as compared with those which are trau- matic, or partly idiopathic and partly traumatic, are, to say the least, extremely rare in this country. 4. Diagnosis. — The differences be- tween tetanus and acute spinal menin- gitis are sufficiently marked to prevent any confusion as to diagnosis if only a moderate degree of attention be paid to the subject. In tetanus the jaw is firmly set from the first, and, in addition to the fits of spasm, there is permanent nmseular rigidity between the tits : in spinal menin- gitis, if the jaw be set at all, it is rather at the close of the disease, and then only in an inconsiderable degree, and spasms or muscular rigidity are neither constant nor conspicuous phenomena. In spinal meningitis, indeed, it is plain that the muscular rigidity and seeming spasms are in great measure voluntary or semi- voluntary acts to prevent the pain in the back and limbs which is produced by movement, and that the muscles are re- laxed almost as long as the patient can keep perfectly still. In a word, the true involuntary fits of spasm and the perma- nent muscular rigidity which are constant and characteristic phenomena in tetanus, are not present in acute spinal menin- gitis. Nor can hydrophobia be very well con- founded with tetanus. In tetanus the features are drawn into the risus sardon- icus, the eyes are natural, and the whole countenance is expressive of pain and suffering, — nothing more : in hydrophobia there is an impress of excitement and distress and horror and unrest upon the features which has no counterpart in the tetanic countenance. In tetanus the body is for the most part rigidly fixed in one position by tonic spasm ; in hydro- phobia the spasmodic movements are clonic, and the body is in a state of per- petual unrest until the stage of final ex- haustion. In hydrophobia, noisy attempts are continually made to spit and hawk away the viscid phlegm which clogs the mouth and throat — the noises being some- times not altogether unlike the bark of a dog — and any effort to relieve the tor- menting thirst, or even the bare thought of such an effort, brings on the fit of fear and convulsive agitation which has given rise to the name hydrophobia : in tetanus there are no symptoms which can be con- sidered as strictly comparable to these. In tetanus, finally, the mind is clear to the last, whereas in hydrophobia there is almost from the first a peculiar and often very wild delirium. The tetanic symptoms produced by strychnia and some other poisons may be more easily confounded with traumatic tetanus, but even here it is possible, with care, to make a correct diagnosis. It is possible, as Dr. Christison pointed out, for strychnia to be given in repeated doses so regulated as to produce a train of symptoms scarcely, if at all, distinguish- able from traumatic tetanus ; but not so if, as is usually the case, an amount suffi- cient to produce death be given in one dose. In this latter case, indeed, the dif- ferences of the symptoms are sufficiently marked. In the toxic tetanus the symp- TETANUS. 979 toms run a rapidly fatal course, death happening in a quarter of an hour, half an hour, and usually within the hour : in traumatic tetanus, with very few excop- tions, life is prolonged for two or three days at least. In the toxic tetanus the arms are stretched stiffly out, the hands clenched, and the legs separated widely from each other and rigidly extended : in traumatic tetanus the hands are usually free from spasm, and the arms nearly so, and even the legs are scarcely ever af- fected to the degree which is seen in toxic tetanus. In the tetanus caused by strych- nia, Mr. Poland says, "The patient can open his mouth to swallow ; there is no locked jaw :" in traumatic tetanus, locked jaw IS the first and most constant mani- festation of the spasm. The jaw may be locked for a long time, and various muscles in other parts may be affected with continuous spasm, in cases in which hysteria is supposed to figure largely as a cause— cases in which there is the condition called spinal irrita- tion : but these cases, as will appear in due time, even when most like, are in reality so unlike tetanus as scarcely to deserve even this passing mention. 5. Prognosis.— In the cases "in which the access is slow, the spasms by no means violent, the paroxysms slight and recur- ring at long intervals, and where the pa- tient can obtain sleep, whether traumatic or not, we may generally anticipate a favorable result;" and, again, "the longer the interval before the appearance of the symptoms, the more chronic the disease, and the greater the probability of recovery." So speaks Mr. Curling of the chronic cases of tetanus in contradistinc- tion to the acute ; and in illustration of the probability of recovery, he adds : "In thirteen cases, symptoms of tetanus oc- curred about three weeks after the wound, and four only were fatal ; and in seven cases in which they did not make their appearance till after a month, only two ended fatally. " In the cases, on the other hand, in which the spasms supervene rapidly upon the injury, and recur with increasing violence at decreasing inter- vals, and in which sleep is banished, a vast majority die — die, as Hippocrates noticed ages ago, within four days. Death may happen in a fit of suffocation in which sometimes there is obviously spasm of the glottis, but more frequently it would seem to be brought about by asthenia after a fit of spasm. The time occupied in recovery varies greatly, — one, two, three, four, five, six, seven, eight weeks, nr even longer. A certain degree of weakness and stiffness may also remain in the muscles long after recovery. In one case rigidity of the muscles of the jaw remained for six months ; in another it returned whenever the patient cauoht cold up to niue months ; and in a tliird, at the end of three years, it is stated tliat tne teatures retained the indelible im- pression of the disease. " These cases are given by Uv. Curling. 6. Treatment.— After passing in re- view the principal remedies that have been tried in tetanus— opium, blood-let- ting, the cold bath and cold affusion, ice to the spine, the warm bath, bark, wine and spirits, mercury, purgatives, fox- glove, tobacco, musk, prussic acid, carbo- nate of iron, oil of turpentine, strychnia, wooraU, ether and chloroform inhalations, amputation, division of nerves, tourni- quets—Sir Thomas Watson says : " In all cases, there being no special indication to the contrary, I should be more disposed to administer wine in large quantities, and nutriment, than any particular drug;" and this statement, I take it, ex- presses a very general feeling in this country. For my own part, I should certainly be more disposed to trust to alcohol than to any drug ; but, in saying this, I do not say that 1 should place no confidence in drugs. I should certainly place no confidence in any sedative or narcotic given by the stomach in sedative or narcotic doses ; but, on empirical as well as on theoretical grounds, I should say that opiunr can scarcely be dispensed with, and that chloroform or ether iuhala- tioif swill be of infinite service in relieving pain and spasm, and that too without compromising the chances of recovery, if care be taken to pour in wine and to sup- ply nourishment at the same time so as to prevent the patient from waking up almost immediately after the inhalation. If the rationale of spasm be that which is hinted at in the preliminary remarks, the great indication of treatment must be, not to depress the circulation, but to rouse it into greater activity ; and one reason why the treatment of tetanus has been so eminently unsatisfactory may be that this indication has not been fully re- alized and carried out. In tetanus much wine may be given without producing anything like intoxication, or without re- laxing the spasms in any degree. The system in this disease is altogether insen- sible to the action of wine in ordinary doses. As to this there can be no doubt. Whether a different result would have been arrived at if alcohol had been given more boldly, ardent spirits in place of wine, ardent spirits undiluted rather than diluted, is yet an open question, but I am disposed to think that the spasms might have been conquered without compro- mising the safety of the patient if this had been done. There are now not a few cases on record which show that the bite of a rattlesnake or cobra or other deadly 980 DISEASES OF THE SPINAL CORD. serpent may be prevented from killing by at once giving ardent spirits in sutlicient quantity, and I am disposed to think that these facts have an important bearing upon the treatment of tetanus. There are, undoubtedly, great difl'erences be- tween the condition in tetanus and the condition in these poisoned bites, but there are also certain resemblances which must not be lost sight of. There is the same insensibility to the action of alcohol in ordinary doses ; there is an exhaustion to be counteracted, -which is more rapidly fatal in the poisoned bite than in tetanus, but which in acute tetanus is sufficiently rapid to create the gravest fears, and to justify the most heroic measures ; there may even be a poison at work in both cases as well as a wound, a poison intro- duced into the wound in one case, a poi- son generated in the wound in the other case. There are resemblances between the two cases, indeed, which, though not very close, may be close enough to justify the hope that a practice which has been found to answer in the bite of a poisonous serpent may also be found to answer in acute tetanus. In speaking thus, it is not intended to imply that ardent spirits are the only way of fulfilling what has been said to be the primary indication of treatment in teta- nus. Eau de luce has been found to be of great service in the bites of serpents, and it might be of service in tetanus. Ether, also, might be of use, or turpen- tine, or camphor, or ammonia. But to my mind these and other medicines of a like nature are more likel}' to disorder the stomach and system generally, and in other respects are less manageable and less certain in their action, than ardent spirit. As regards local measures it is less dif- ficult to arrive at a conclusion. In many cases, no doubt, tiiei-e is an eccentric irri- tation, starting from the wound or some other point, and much good would be done if this could be removed. It is probable, also, that this end might be gained in more ways than one, and that one very direct way is by the subcutane- ous injection of various substances — mor- phia, atropine, woorali, conia (which seems to be strictly analogous in its action to woorali). Calabar bean, &c. The results of these injections in causing the relaxa- tion of spasm in conection with the minor forms of spinal irritation are very en- couraging. One thing, however, ought to be borne in mind, and that is, that these injections should be used so as not to produce a general depressing or para- lyzing effect upon the nervous system. All that ought to be aimed at is to obvi- ate local irritation merely ; and, to my mind, to go beyond this point is both wrong in principle and dangerous in practice. [Dr. Joseph Hartshorne called atten- tion many years ago to tiie value of vigor- ous counter-irritation along the spine, in tetanus. He employed a solution of can- tharides in oil of turpentine for this pur- pose. — H.] Eor the rest, it is, of course, desirable that the patient should be carefully guarded from cold, and from anything wliich would excite or disturb him, as too much light or noise, or too meddlesome nursing. In a word, quiet and warmth are not only desirable ; they are indis- pensable. Y. Locomotor Ataxy. Until very recently the disease which forms the subjec't of the present article was confounded with paraplegic diseases. The difficulty in locomotion, which is the most characteristic symptom, was sup- posed to be owing to simple paralytic weakness of the legs. It was not per- ceived that the legs, in the earlier stages of the disease at least, had lost little, if any, of their power to act separately — so little, indeed, that it might require all the force of a strong man to bend or straighten them against the will of the patient — and that what they had lost was that power of co-ordination by which the two limbs are enabled to act together, as they have to do in standing and moving about. The credit of having first drawn this distinc- tion, and at the same time shown that this want of co-ordinating power is so associated with a definite group of other symptoms as to deserve to be regarded as a distinct disease, is due to Dr. Duchenne (of Boulogne). Before this time, no doubt, the characteristics of such a dis- ease had been more or less clearly realized. They had been described, in fact, under the old name of Uihes dorsalis, especially in the sketch of this disease given by Dr. Romberg. They had been detected by the late Dr. Todd, and not only so, but associated with that particular lesion with which they are now known to be con- nected, namely, with chronic disease of the posterior columns of the spinal cord. "Two kinds of paralysis of motion," wrote Dr. Todd, "may be noticed in the lower extremities, — the one conisisting simply in the impairment or loss of volun- tary motion ; the other distinguished by a diminution or total loss of the power of co-ordinating movements. In the latter form, while considerable voluntary power remains, the patient finds great difficulty in walking, and his gait is so tottering and uncertain, that his centre of gravity is easily displaced. The cases are generally of the most chronic kind, and many of them go on from day to day without any increase of the disease, or improvement LOCOMOTOR ATAXY. 981 of their condition. In two examples of tbis variety of paralysis I ventured to predict disease of the posterior columns the diagnosis being founded upon the views of the functions of the colunms which I advocate ; and this was found to exist on a post-mortem inspection ; and in looking through the accounts of re- corded cases, in which the posterior columns were the seat of lesion, all seem to have commenced by evincing more or less disturbance of the locomotive pow- ers. ' ' (Cyclopajilia of Anatomy and Phvs. , vol. iii. p. 721, 8.) -^ ' Dr. Todd published these remarks in 1845 ; Dr. Duchenne's first memoir ap- peared in 1857. Dr. Todd must, there- fore, have the credit of having anticipated Dr. Duchenne ; but still the lion's share of honor must be assigned to the latter, for the plain fact is that Dr. Duchenne has developed in a series of formal memoirs what Dr. Todd has only indicated in these few sentences. In a word, it must bo allowed that Dr. Duchenne deserves al- most the entire credit of being the first to detect the exact features of the disease now known as progressive locomotor ataxy, and to call the attention of others to the subject. The name of progressive locomotor ataxy [ataxia locomotrice progressive), from u, privative, and rciftj (order), is that which was chosen by Dr. Duchenne. It is not a very fortunate one, but it has been adopted, and must be retained, until a better one is found. It is certainly to be preferred to tabes dorsalls, for this name is commonly supposed to imply past inconti- nence on the part of the patient. How far it is right to perpetuate the cheerless af&x progressive is, however, very question- able. At present, no doubt, the prognosis is full of gloom. From bad to worse is the common course of things, but, at the same time, there are cases — and their number is increasing every day — in which the symptoms have been long stationary, and others in which there has been unequivo- cal amendment. But even if the element of hope were wanting, it is surely desira- ble not to bring this unhappy fact into undue prominence. It is surely not neces- sary to continue to use an epithet of which the effect must be to frighten the patient and discourage the practitioner, and this too without compensating advantages of any kind. As it seems to me, indeed, everything is gained by the name loco- motor ataxy which is gained by the name progressive locomotor ataxy; and nothing is lost but what can well be spared ; and therefore in what I have to say I shall drop the term "progressive," and speak simply of "locomotor ataxy. " 1. Symptoms. — As a text for what I liavo to say upon the symptoms of loco- motor ataxy, I take from my note-book a case which was some time ago (April, Ibbo) under my care in the National Hos- pital for the Paralyzed and Epileptic. Case.— A sailor, thirty-four years of age, by name J. C , well proportioned, unusually well developed as to muscle everywhere, very lean, and much bronzed by long exposure to sun and sea. (a) This man is capable of walking with- out a stick, but his gait is peculiar— stag- gering, precipitate, the legs starting about vaguely and spasmodically, and the heels coming down heavily at each step. AVith his eyes shut, or in the dark, he reels over at once and falls to the ground, if left to himself. Sitting or lying down, he can lift either log steadily into any position, and fix it there so firmly that it is out of my power to bend or straighten it against his will. In order to do this, however, he must see what he has to do, for if his eyes are shut, his limb at once becomes uncertain and unsteady in its movements, and comparatively powerless. His right leg is a little weaker than the left, but not in any well-marked degree. He finds it very difficult to come downstairs, or to turn round, or to quicken his pace much, and he is speedily fatigued by the acts of standing or walking. On being told to shut his eyes, and touch his nose with the forefinger of each hand in turn, he does so with tolerable accuracy, especially with the forefinger of the left hand. On being told, to stretch out his arms, and keep them out, he does so, but only so long as he is allowed to see what he is doing ; for, on holding a book up before his eyes, the arms, shoulders, neck, and head — the up- per part of his body generally — at once became afflicted with convulsive agitation. "When the book was taken away, these movements speedily came to an end, but not before they had issued in a fit of cry- ing and sobbing which was not a little distressing to witness. This fit took the jiatient quite by surprise, and it could not be accounted for by the examination hav- ing been conducted roughly, or carried on for an undue length of time ; indeed, the holding of the book before the eyes, which was the immediate cause of the fit, did not occupy more than a minute at the most. The muscles of the lower limbs stand out firm and hard when made to contract by the will, and the contraction seems to be not at all wanting in force. Indeed, as has been already stated, it is out of my power to bend or extend the limb against the will of the patient. There is no tremu- lousness in the legs or elsewhere, and there are no marked reflex movements when the soles of the feet are tickled. What are complained of chiefly are severe pangs of pain, stabbing, boring, in flashes like" lightning, flitting from one spot to anothcn- in a" very erratic manner, recur- 982 DISEASES OP THE SPINAL CORD. ring in paroxj-sms varying in length from a few minutes to twelve, twenty-four, or forty-eight hours, and generally remain- ing at the same spot during the same paroxysm. These pangs are most fre- quently felt in the two feet, especially along the outer side of the metatarsal bone of the little toe ; and they also are not unfrequently met with at the back of the thigh, in the nates, and in the upper arm about the lower part of the belly of the biceps. They are scarcely ever absent, especially at night ; at night, too, there is often a sensation of great coldness, with some degree of constriction at the seat of pain. Tactile sensibility, measured by the compasses, is found to be much impaired in both feet, especially in the soles, in the calves of both legs, and to some degree also at the back of the thighs, in the nates, and in the palms of the hands. The ground is felt very obscurel}", but, so far as it is felt, the sensations are accurate — that is to say, it does not seem as if there were elastic cushions, pebbles, or other imaginary bodies upon the floor, or as if the feet had nothing under them but free air, as is sometimes the case. Very rough pinching is scarcely at all felt in the be- numbed parts, but elsewhere the sensibil- ity to painful impressions is keen enough. There is also evident impairment of the proper sensibility of the muscles, joints, and bones in the limbs, and especially in the legs. Thus, tlie patient never knows clearly where his feet are without looking at them, and now and then he has been so uncertain in this respect, that a foot has slipped out of bed without his being the wiser ; and thus, again, his finger has not the power of discriminating between a sovereign and a shilling by the weight merel}^ The sight of each eye is defective, and glasses afford no relief. The pupils are equal in size, and respond fairly to the light. The conjunctivas are very much injected. There is no a reus senilis. There is no squinting or ptosis. The hearing is so dull as to make it necessary to speak in a very loud tone in order to be heard, and one ear seems to be as deaf as the other. There are also constant singing and humming noises in the head — "I still hear the wind in the shrouds," he says. The memory is bad, the spirits are de- spondent, and of late (this statement is volunteered by the patient) there has been a frequent disposition to commit suicide. The pulse is feeble, and about 70 in the minute. The appetite is good. The bowels are somewhat constipated, and a long time is spent over a stool. The urine is voided slowly, and with difficulty, although there is no stricture, and now and then it escapes during sleep. Sexu- ally, the state may be spoken of as ap- proaching to spermatorrhoea. (6) Five years ago J. began to sufier from pains in the legs and back, and to be unsteady in his gait ; about the same time, also, his sight and hearing be- gan to fail ; and from that time to this he has continued to get gradually worse and worse. Four years ago he had sunstroke in the West Indies, of which the imme- diate symptoms were violent agitation and shaking, without loss of consciousness, and for which he was taken into a hos- pital and bled. But this accident was twelve months after his present malady had commenced, and therefore it is not possible to look upon it in the light of a cause. There never was either squinting or ptosis. He was at sea seventeen years in all, chiefly in hot climates, as the West Indies and the West Coast of Africa, and he remained on board three years after lie had begun to sufier from unsteadiness of gait, and from the other symptoms which have been mentioned. Once during the time he was at sea he had chancres, with- out constitutional symptoms; and repeat- edly he had diarrhoea ; but, with these exceptions, his health on all occasions ap- pears to have been pretty good. He says that he was always very careless, often sleeping, almost without clothes, on the bare deck, or on the ground, and that he was always "too much given to drink and women." For the last two years the sex- ual inclinations have been much damped, but before this time, from what he says, he appears to have been little better than a very i-atrr. Two years ago, when obliged to abandon his calling as a sailor, he was for a while treated in the hospital at Quebec for rheumatism. Afterwards he found his way to this country, and be- came an out-patient first at one hospital and then at another. During this time he appears to have been frequently blis- tered along the spine, and on one occasion to have been salivated. For the rest, I have only to add that his father died early in life of consumption ; that his mother died young of some unknown chronic dis- ease ; and that a brother, the only child besides himself, is now dying of the dis- ease which proved fatal to his father. This case has not yet ended in a post- mortem examination ; and of many other cases which have come under my notice, not one as yet is complete in this sense. All, therefore, that I can do is to say that in other cases of the kind the posterior columns of the spinal cord, and the pos- terior roots of the spinal nerves, are found to be diseased in the lumbo-dorsal region, and that the morbid appearances consist sometimes in a kind of gray degeneration, and sometimes in a gelatiniform and translucent condition, in a diminution of consistency, or in a state of induration LOCOMOTOE ATAXY. 983 called sclerosis. These changes are con- j rior horns, including Clarke's pillars, at fined to the posterior columns of the cord; | their bases, are also afl'ected. Lockhart or if they extend further, it is not to the Clarke has raised the question whether antero-lateral column, but only to the | the diseased action does not begin in the neighboring portion of the posterior cornu of the central gray matter. In the ma- jority of cases the disease is confined to the lunibo-dorsal portion of the cord, and it is only in quite exceptional instances that it extends upwards, so as to implicate the cervical portion. In the majority of cases, the diseased structure is more vas- cular than the healthy structure of which it has taken the place, the vessels being more or less deeply imbedded in oii- globules of various sizes, and when ex- amined further, it is found to be made vip of atrophied and degenerated nerve-tissue, of the connective tissue in excess, and of amorphous granular matter. Now and then, also, traces of degeneration have been found at the roots or in the course of the optic nerves, or of one or other of the nerves of the muscles of the eye. [The term sclerosis is now, by common consent, applied to the morbid change ob- served ia Locomotor Ataxy, as well as in several other spinal affections. (See In- duration, in a later part of this volume.) Charcot and Pierret have endeavored to Fig. 59. Pieri-et's ca?a of Locomotor Ataxy: transverse sectton of lumbar portioa of spinal cord. A. Posterior roots. B. In- ternal radicular fascicnli. On tlie riglit, the aclcrosis has extended to the anterior cornn, C, whic^ has suffered <3™i';«- tion in every diameter. Also, the external proup of motor cells has disappeared; there heing left a dense opaqne fibroid tissue, containing numerous myelocytes ' i h » root _ i show that, in Ataxy, the sclerotic altera- tion begins in the external hands (funiculi euueati) of the posterior columns, near to the posterior roots of the spinal nerves. The lumbar portion of the cord is the first seat of the disease, which afterwards ex- tends to the dorsal, and sometimes to the cervical region. In the upper part of the cord, the columns of Goll (funiculi gra- ciles) w-hich lie next to the posterior fis- sure become involved. The gray poste- posterior cornua. The conclusions of Erb' very well repre- sent the present state of knowledge upon this subject. "It is in the highest degree probable that in tabes we have to deal with a clironic inflammatory process ; that it merely represents, therefore, one form of chronic myelitis. "It is possible, and perhaps probable, that this chronic myelitis may take its origin in two different ways : at one time from a primary irritation and degenera- tion of the nerve-elements themselves (parenchymatous sclerosis), at another from a primary irritation and proliferation of the interstitial tissue (interstitial scle- rosis) — thus giving a double method of origination of tabes, as was believed by Kemak, Sr. " It is possible, and perhaps probable, that the sclerosis begins iu the external bands of tlie posterior columns, and spreads from thence further, and that the sclerosis of the fasciculi graciles, or GoU's columns, must, to a great degree, be^ re- garded as a secondary degeneration. "It is certain that the disease does not begin in the posterior roots. " It is, finally, prolmble that scle- rosis of the posterior columns is not the exclusive and essential change in tabes, but that a simultaneous involvement of the posterior gray horns and of certain portions of the lateral columns is constant, and, perhaps, equally essential — a state- ment which, it is true, finds its sup- port more in clinical observation than in the anatomical facts now be- fore us." — II.] In order to see how far the case of which the notes have just been given a."-rees or disagrees with other cases of the kind, I single out, as points to be noticed in turn, the following : — Difflculty in standing or in moving about from inco-ordination of move- ment in the lower extremities ; no true paralysis in the lower extremi- ties ; neuralgic pains, in the feet and lews more especially; more or less numbness in all forms of sensibility except that by which difference of temperature is recognized ; impaired sight and hearing; no strabismus or ptosis; some incontinence of urine, and some want of control over the lower bowel, without marked paralysis of the bladder or sphinc- ter ani ; no obvious impairment of sexual no tinwlinc or kindred phenonie- (Charcot.) power no marked "tremulous, convulsive, [1 Article, Tabes Dorsalis, Cyclopedia, vol. xiii.] in Ziemssen's 984 DISEASES OF THE SPINAL CORD. or spasmodic phenomena; no marked im- pairment of muscular nutrition and irri- tability ; some impairment of mental and moral power ; some injection of the cou- junctivfe with contraction of the pupils ; the sex and age; and, lastlj-, the frequent limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power, to the lower extremities). Difficulty in standing or 'luovinij about from want of co-ordinating motor power to the lover extremities. — This difficulty is very evident, especially in the act of rising from a chair or in turning round suddenly when walking. If the patient cannot avail himself of some sufficient support at the time, the disorder in the movements of the leg produced by the act of rising from the sitting position, or of turning round suddenly when walking, is apt to throw him down. Walking is possible without a stick, but the gait is precipi- tate, staggering, the legs starting hither and thither vaguelj^, and the heels coming down at each step in a way which has gained for such patients at Grafenberg the epithet of stampers. Moreover, it is less difficult to move on than to remain long in one position standing. In order either to stand or walk, however, the help of tlie sight is necessary. In less ad- vanced forms of the disease, it may be dif- ficult at first to detect inco-ordination in the movement of the legs, but this diffi- culty is not likely to last long. Often a first sign is reeling about upon getting out of bed in the dark. The patient may fall more than once under these circumstances, and think that he is only half awake or half sober. In that early stage of loco- motor ataxy in which there is no evident inco-ordination of movement while the eyes are open, there is likely to be such disorder when the eyes are shut : and in an eai'lier stage still, even when it may be possible to stand steadily with the ej^es shut, provided the patient be allowed to plant his feet where he pleases, it is more than likely that he will lose his balance if he be made to stand with the inner edges of the feet in close apposition. In more advanced stages of the disease, walking, or even standing, becomes alto- gether impossible, and it is curious to no- tice the extreme disorder in the move- ments of the legs when the patient is propped up under the arms, and made to try to walk or stand ; for under these circumstances the legs are seen to go every way but the right way — backwards, forwards, sideways, unless it happens, as it often does, that they got foul of each other, and become interlocked. In all cases, indeed, the inco-ordination of movement in the lower extremities, by which standing and moving about are in- terfered with in a greater or less degree, is a constant symptom in locomotor ataxy ; and in a case of average severity, like the one under consideration, the gait, arising from this want of co-ordination, is quite characteristic— namely, precipi- tate, staggering, the legs starting hither and thither, and the heels coming down with a stamp at each step. JVr> true paralysis in the lower extremities. —When the patient is sitting or lying, he I can, provided he sees what he is doing, move either leg singly, into any position with tolerable precision, and keep it there steadily ; and the muscular force at his command is such, that it is out of my power to straighten the limb if bent, or to bend it if straightened. There is plainly no paralysis. Nor is it otherwise in other cases of locomotor ataxia, not even in those extreme cases in which the inco- ordination of movement in the legs has proceeded to the extent of making stand- ing an impossibihty. And_, certainly, it is no objection to the conclusion that my ])a- tient was speedily fatigued by the acts of standing or walking, for in reality this fatigue may easily be accounted for by re- ferring it to the effort necessary to keep the ataxic movements of the leg in check. Paroxysms of neuralgic pain, in the feet and leejs principally. — My patient's chief complaint was of neuralgic pains— pains boring, stabbing, or shooting in their cha- racter, pains like those caused by a sharp electric shock — in various parts of the lower extremities, in the feet especialh', and sometimes in the arms and abdomen, occurring in parox3'sms varying in dura- tion from a few minutes to many hours, flitting from one spot to another, but gen- erally remaining at the same spot in the same paroxysm. And this was the chief complaint from the very beginning of the malady. Nor is this case at all excep- tional in this respect : on tlie contrary, pain of the same character is met with in the great majority of cases of locomotor ataxy. Moreover, Dr. Trousseau speaks of this symptom as the most constant pro- cursory phenomenon of the disease. In some cases, no doubt, pain is either ab- sent altogether, or present only as an oc- casional symptom of very secondary im- portance. I have myself met with four cases of well-marked locomotor ataxy in which there was no pain, or none to speak of. The pain may begin in a way in which it may be mistaken for rheumatism, and be slow in acquiring its special character, but it has, as a rule, these special neural- gic characters from the first throughout. Ifumbncss in all the forms of sensibility excepting that by which differences of temper- ature are recognized. — In the case under consideration the sense of touch is almost annihilated in the soles of the feet and in the lower parts of the calves of both legs, and it is impaired greatly in the back of the thighs, in the nates to a less degree, LOCOMOTOR ATAXY. 985 and in the palms of both hands. In the parts also which are thus benumbed tick- ling is felt very obscurely, or not at all, and very trilling pain or none at all is caused by pinchiiag or pricking. In the legs also the " muscular sensed" as well as the special sensibility of the joints and bones, are considerably impaired, as is evident in the fact that the patient does not know where his feet are unless he can see them. Indeed, the only form of sen- sibility which seems to he unimpaired, is that by which differences of temperature are recognized. In other cases of loco- motor ataxy, also, a similar state of things as to sensation would seem to he the almost constant rule, the numbness be- ginning, first in tactility, then in the sen- sibility to pain and tickling, afterwards passing to the " muscular "sense, " and always, curiously, skipping over, or leav- ing off before reaching, the sense by which differences of temperature are perceived. In some instances the sensibility of the mucous membrane of the anus and urethra is greatly deadened. The numbness is most marked in the lower extremities, especially in the feet, and very often it is confined to these parts, but now and then it may extend further. I know of one case in which the tip of the nose and the middle of the upper and lower lip are thus affected. It would seem to be the rule for numb- ness to make its appearance at the same time as inco-ordination of movement, and for the two symptoms to make pro- gress part passu; but there are cases of locomotor ataxy in which, to say the least, numbness in any form is a very in- conspicuous phenomenon. Moreover, it is certain that cases of well-marked loco- motor ataxy are met with in which the "muscular sense" is not affected. Out of nineteen cases, I have met with two such. I believe, also, that in cases of lo- comotor ataxy in which the "muscular sense" is affected considerably, it will be often found that this form of numbness makes its appearance after the inco-ordi- nation of movement, and not before it. In a word, I believe that the history of locomotor ataxy furnishes little counte- nance to a theory which has been ad- vanced — that the inco-ordination of move- ment in this disorder is nothing more than the consequence of loss of muscular sense. In some exceptional cases of locomotor ataxy there may be numbness in some parts, and an opposite state of things in others. Thus, I have myself met with a case in which there is antesthesia almost complete in the lower extremities gene- rally, and the most distressing hyperfes- thesia as to tickling in the thumb. But, as I have said, cases of this kind are quite exceptional. Impairment of sight and 7ieann(/.— Im- pairment of sight appears to be a com- mon symptom in locomotor ataxy ; iui- pairment of hearing an occasional symp- tom. In the former case. Dr. Hughlinc^s Jackson has shown that in the cases where sight is impaired or lost there is a gradual whitening of the optic disk with- out any marked change in the size of the retinal arteries and veins— a chronic form of atrophy which is more common in men than women, and which is not at all peculiar to locomotor ataxy. [T. Grainger Stewart reports the oc- currence of coIor-hUndness, in three out of twenty cases of the disease.' — II.] Strabismus and ptosis.~Dr. Duchenne and Dr. Trousseau both speak of strabis- mus or ptosis as frequently met with in the early stage of locomotor ataxy, as frequently passing off after a time, and not unfrequently as returning, to remain permanently, at a later period. Dr. Du- chenne has also twice met with paralysis of the fifth cranial nerve concurrently with paralysis of the third. Speaking of these symptoms. Dr. Trousseau ■ says, ' ' Some may bo absent, but it rarely oc- curs that they are all absent in the same case. I have nearly always found them, and Dr. Duchenne is right in attaching great importance to them for diagnosing the disease at the onset. Kemcmber, be- sides, that they may have been transi- tory, and been forgotten by the patient, so that the physician must needs make careful inquiries in order to discover their existence in the patient's previous his- tory." Ptosis or strabismus was not present in the ease which I have given, and never had been ; and the same may be said of seven out of eighteen other cases of locomotor ataxy which have come under my notice. In the remain- ing eleven cases, strabismus or ptosis, one or both, were either present at the time of observation, or had been present for a time at an earlier period, generally at the onset of the disease. I find, also, as Dr. Trousseau did, that these paralytic affections of the muscles of the eye, or the impairment of sight or hearing, may be present at an early stage of the dis- ease, may disappear for a while, and then reappear at a later stage. JVo very obvious parcdytic condition of the bladder or lower bowel. — Incontinence of urine at night, and now and then at other times, as after unusual fatigue, is a com- mon and often a very early symptom in locomotor ataxy, and a less common, and usually a comparatively late symptom, is some trifling want of control over the lower bowel. Dr. Trousseau, speaking of the phenomena of the fully developed disease, says, " Just as in confirmed cases [1 Brain, July, 1879, p. 189.] 986 DISEASES OF THE SPINAL CORD. of paraplegia, there is paresis of the blad- der aud rectum, or eveu paralysis of the sphincters." As it seems to me, how- ever, there is a marked dilference be- tween eases of confirmed locomotor ataxy and common paraplegia in these respects, the difference being that in locomotor ataxy there is not that obvious state of paralysis of the bladder, or sphincter ani, which is so generally present in para- plegia. Indeed, I have never met with a case of locomotor ataxy in which the way in which the bladder could be emptied in a steady stream, did not prove that this viscus retained a fair amount of power ; and in one or two cases of this disease, in which the feces have passed involun- tarily at times, I have found a state of things which enabled me to account for this accident without assuming the exis- tence of paratysis of the sphincter ani, namely, a want of sufficient sensitiveness about the anus. Moreover, I do not find in the cases which have come under my notice one in which the urine was re- tained, as it so often is in paraplegia, and where the consequences of such retention — cystitis, alkaline urine, and the rest — ■were present. Indeed, in all my cases the urine has been acid, and otherwise healthy — -a state of things which is scarcely compatible with the presence of paralysis of the bladder. JVb obvious impairment of sexual power. —From a sexual point of view, it is easy to see that, as a rule, there is a marked dilference between locomotor ataxy and common paraplegia, the difference being that in the former disorder there is not that impairment of desire and poiver which is so constantly met with in the latter. ISTot unfrequentty, indeed, it is plain that there is no impairment of sexual power in ataxy ; and now and then there is a curious exaggeration of virility, evi- denced, it may be, in the aptitude to re- peated acts of connection within a short period. Thus, Dr. Trousseau instances tvi'o cases in which these acts could be repeated as often as eight, nine, or ten times in a single night, and I have met with one case which is a fit fellow to these. In all these cases spermatorrhoea was a symptom. I also know of two cases of advanced locomotor ataxy in which fer- tilization has been successfully effected, and other cases of the kind are on record. No tingling or Mndred phenomena. — Tingling, or sensations analogous to ting- ling, are not among the symptoms noted in the cases of locomotor ataxy which have come under my own notice, and, so far as I know, they have not occurred in other cases of the kind. At any rate, I think it cannot be doubted that such symptoms are infinitely more common in common chronic paraplegia than in loco- motor ataxy. No obvious tremulous, c-Tiimdsive, or spas- modic phenoviena. — Dr. Trousseau says : "At an advanced period of locomotor ataxy, spasmodic contractions are fre- quently observed, not onlj' when the pa- tient wills a regular movement, but even in the state of rest. In the latter case, they consist in very powerful jerks of the limbs, and are an important symptom of this singular neurosis." But my expe- rience of the disease does not bear out this statement. Moreover, the cases given by Dr. Bazire, in the valuable appendix to his translation of Dr. Trousseau's lec- ture on locomotor ataxy, is not confirma- tory of the passage in the lecture which I have just quoted. Indeed, if I except certain attacks of convulsive agitation, in which one or two patients have now and then awakened out of sleep, and the feel- ing of constriction in the abdomen and lower extremities, which is occasionally met with, and ^vhich may possibly have some remote connection with spasm, I know of nothing in the history of locomo- tor ataxy which requires a place in the category of tremulous, convulsive, or spasmodic phenomena. No marked impairment of muscular nutri- tion and irritabiUtij. — This is another fea- ture of locomotor ataxy, and, therefore, another point of difference between this affection and common paraplegia. The electro-sensibility is impaired in the mus- cles in which the "muscular sense" is impaired, not the electro-contractility. Some impairment of mental and moral power. — Bad memory, despondency, sui- cidal tendency, are mentioned among the symptoms in the case which serves as my text, but troubles of this kind do not figure in the history of other cases of loco- motor ataxy. In fact, it would seem to be the almost constant rule for the mental faculties to be unscathed in this disease. Some injection of conjunctivce with con- traction of pmpils. — In the case under con- sideration, the pupils were contracted and comparatively disobedient to light, and the whites of the eyes were considerably bloodshot ; and this appears to be a not unusual state of things in cases of the kind. Dr. Trousseau says that he has often noticed in ataxic patients, in the in- tervals between the paroxysms of pain, injection of the conjunctivse, sometimes as marked as in the most violent conjunctivi- tis, sometimes amounting to a sort of che- mosis, and, in association with this, a state of extreme contraction of the pupils ; and he also tells us that he has seen this in- jection of the conjunctivae and contraction of the pupils disappear during a paroxysm of pain. In J. C , I failed to perceive this change during pain. Dr. Bazire also failed to perceive it in others who have come under his notice. I have observed it in two cases, of which that of my friend LOCOMOTOR ATAXY. 987 M. Ernst, the prince of violinists, was one. In these two cases, what I noticed was this — that the eyes ceased to he bloodshot, and the pupils opened when the pain reached a certain degree of severity and continued for a certain time, and not otherwise. This I observed on several occasions in M. Ernst while he was staying with me on a visit ; and I expect that the discrepancy which at present exists between the statements of Dr. Trousseau and his translator upon this point, will disappear as soon as the influence of the degree and duration of the pain is taken into account. [Occasional arthritic aff/xtions. — Charcot has described what he designates as the arthropathy of ataxic jiatients.^ Without known external cause, one of the limbs swehs considerably, without pain or febrile reaction. In a few days the tumefaction subsides, except at a joint ; commonly the knee, shoulder, or elbow, occasionally the hip-joint. Hydrarthrus exists, but within a week or two the fluid disappears, and crackhng sounds on motion show the oc- currence of change in the articular sur- faces. The joint is at the same time very movable ; luxations are not infrequent. 60. ITpper extremity of a healtliy liumerns, and of a humerus affected by ataxic artliropathy. (Charcot.) In a few months the ends of the bones at the joint may be almost entirely de- stroyed. Charcot has found these affec- tions to coincide with the extension of sclerosis to the gray matter of the anterior cornua of the cord ; a secondary trophic degeneration. Cutaneous eruptions. — Papular and even pustular eruptions, as well as bed-sores, are, according to Charcot and others, not rarely associated with the lancinating or "fulgurant" pains of locomotor ataxy. These eruptions often follow, tolerably closely, the track of the nerves which are the subjective seats of those pains ; and [' Lectures on Diseases of the Nervous System, Lecture III.] increase or disappear, from time to time as the painful attacks experience exacer- bation or remission. Bisapxjearancc of tendnn-i'eflex.~"W\t\i- in a few years Westphal,' Erb and others have called attention to the significance of the absence or modification of nheno- mena called those of tendon-reflex, in connection with spinal diseases. If a person in health sits with one leg crossed over the other, or upon a table with the legs dangling over its edge, and a smart blow is struck upon the tendon of the quadriceps femoris muscle, at its junction with the patella, the leg and foot will be jerked in\-oluntarily forwards. Experiments upon animals, by Schulze, Siirbringer, Tschirjew, Gowers and others, have shown the physiological relation of this movement to the nervous system. Section of the crural nerve will abolish it. Gowers found that the time between the tap upon the patella and the muscular movement was sufficient for a reflex pro- cess, through the spinal cord. Burk- hardt's experiments led him to question the sufficiency of this interval. It is shown, however, that, as there may be loss of cutaneous sensibility with persist- ence of the movement described (e. g. under the influence of ether spi-ay), and disappearance of it when the sensibility of the skin is exaggerated, the phenomenon must be concluded to be of a reflex nature. While some have thought it explicable by direct stimulation of the muscles, through their being suddenly made tense, the generally prevailing opinion is that the contraction is a true excito- motor nervous action, the centre concerned being low down in the spinal cord. Similar to this is the anTdc-cl'mus of recent authors. If the foot is firmly flexed by pressure on the sole, and then the teiido Achillis is tapped briskly, the foot at once undergoes flexion and extension, in rapid suc- cession, for a considerable number of times. Gowers found the average number of contractions to be a little more than six in a second. Joffl'oy has re- garded this as a cutaneous reflex. It has been shown, however, to be quite inde- pendent of the sensibility of the skin, or the liability of the muscles of the limb to reflex action from cutaneous excitation. By aid of the myograph, Gowers has as- certained that the commencement of the ankle-clonus occurs too soon after the blow upon the tendo Achillis for the im- pression to travel up to the spinal cord and back to the muscles of the leg. It is therefore concluded that, unlike the knee [' Arclaiv fiir Psycliiatrie und Nerven- kraukheiten, Bd. v. 1875, p. 819.] 988 DISEASES OP THE SPINAL COKD. phenomenon, the foot-clonus is produced by the direct stimulation of the muscles both on the front and back of the leg, through suddenly increased tension. Tlie foot phenomenon is less nearly always capable of being brought about in healthy Ijersons than that called the knee tendon- rettcx. Clinicalljf, it has been established, that the teudou-retlex of the knee is quite con- stantly abolished, early, in cases of Loco- motor Ataxy; while it is increased in cases of lateral sclerosis of the spinal cord (spasmodic spinal paralysis). Ankle- clonus has, as yet, been less fully studied in Locomotor Ataxy. It has been found to be produced with unusual facility and violence in lateral sclerosis of the cora. -H.] Tlie sex and age. — Locomotor Ataxy is, ■without doubt, more common in males than in females. As regards sex, indeed, it is with this as it is with other disorders of the spinal cord ; for out of 177 cases of all forms of disease of the spinal cord tabulated by Dr. Brown-Sequard, as Dr. Bazire pointed out, 1'28 occurred in men, and only 49 in women. Locomotor ataxy is also a disorder of adult life. In the cases which have come under my own notice the age ranges from 23 to 60, and but few cases are on record in which the patient was under 20. Indeed, the only cases under 20 would seem to be three reported by Dr. Friedrich of Heidelberg ; of which the ages are respectively 18, 16, and 15 years. The probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower ex- tremities. — In many cases of locomotor ataxy the upper extremities are not af- fected at all ; in others, their sensibility is blunted in one form or other, and their movements are wanting in precision, especially if the sight be defective, or the eyelids closed. In the cases in which the movements of the upper extremities are wanting in precision, there is always, so far as I know, more or less impairment of sensibility, of the "muscular sense" per- haps most frequently ; and my belief is, that the want of precision in movement is rather to be ascribed to the want of the proper guidance of sensation than to the loss of any co-ordinating motor power. One ground for this belief is the fact that the disease of the posterior columns of the cord which is met with in locomotor ataxy, and upon which, there is every reason to believe, the want of proper co-ordination in movement is dependent, is confined to the lumbo-dorsal region of the cord in the great mass of cases. Moreover, it is to be remembered that the movements of the arms in a biped like man are not so inter- dependent as the movements of the legs, and that, on this account, movements of inco-ordination are less likely to occur in the arms than in the legs. It is also very possible that some of the cases in which the irregular movements of locomotor ataxy would seem to have extended from the legs to the arms may not have been true cases of locomotor ataxy. I remem- ber one case of what at first seemed ex- treme locomotor ataxy, in which the arras were affected as much as the legs, but the patient in this case was totally blind and bedridden, and all but totally deprived of all kinds of sensibility in the arms, and of the "muscular sense" in the legs; and there was no difliculty in believing that the irregular movements of the arms (and possibly those of the legs also) were due, not to impairment in co-ordinating power, but simply to the muscular anaesthesia' and the blindness ; and I do not remem- ber any case in which the arms were affected in which the patient was not more or less in the same plight, as to mus- cular ansesthesia, if not as to blindness also. Looking back, then, at the case which has been cited, and at the comments to which it has given rise, it is not difficult to see that locomotor ataxy is character- ized by these symptoms : — A peculiar gait arising from want of co- ordinating motor power in the lower ex- tremities — a gait precipitate and stagger- ing, the legs starting hither and thither in a very disorderly manner, and the heels coming clown with a stamp at each step. No true paralysis in the lower extremi- ties or elsewhere. Characteristic neuralgic pains, erratic, paroxysmal, in the feet and legs chiefly — pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock. More or less numbness, in the feet and legs chiefly, in all forms of sensibility, ex- cepting that by which differences of tem- perature are recognized. Frequent impairment of sight or hear- ing, one or both. Frequent transitory or permanent stra- bismus or ptosis, one or both. No very obvious paralysis of the blad- der or lower bowel. No necessary impairment of sexual power. No tingling or kindred phenomenon. No marked tremulous, convulsive, or spasmodic phenomena. No marked impairment of muscular nu- trition and irritability. No impairment of the mental faculties. Occasional injection of the conjunctivae with contraction of the pupils. [Occasional secondary inflammations of the joints. 1 Vide article on Muscular Ansesthesla. LOCOMOTOR ATAXY. 989 Absence or diminution of tendon-reflex movements. — H. j Tlie probable limitation of the distinc- tive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities. For the rest, I will only say that a chronic disease with these characteristics, and without fever or other signs of disor- dered health, may safely be pronounced to be locomotor ataxy. Dr. Duchenne, whose description of the disease is the best as well as the first, marks out three stages in locomotor ataxy. In the first stage the patient suf- fers from paralysis, often only temporary, of one or other of the motor nerves of the eye, from some degree of amaurosis, usu- ally accompanied with unequal pupils, and from the peculiar neuralgic pains. In the second stage the characteristic un- steadiness in standing and moving about begins to show itself together with anes- thesia, the interval between the first stage and the second varying from a few mouths to several years. In the third stage the nralady becomes more profound and gen- eral, but the precise point at whicli tlie second stage ends and tlie third stage be- gins is not very clearly defined. Dr. Du- chenne does not regard the affection of the bladder, the rectum, and the genital apparatus as essential symptoms of the disease in any of these three stages ; lie regards them as epipkeivmisacs only. Dr. Trousseau does not divide the disease into distinct stages, but he speaks of a prenionitori/ stage in wiiich paroxysms of pain, spermatorrhoea or impotence, pa- ralysis of one orotlier of the m')tor nerves of the eye, and disorder of vision are the symptoms to be met with. As Dr. B.izire says, however, "it is hardly possible to regard these merely in the liglit of pre- monitory symptom?, because tliey form part and parcel of the fully developed dis- ease :" and, in fact, the various symptoms are so mixed up togetlier, and make their debut at such varying periods, that it i5 not easy to separate symptoms and ar- range them in this stage or that. [For Morbid Anatojni/, see ante, fit close of account of the case whose symptoms are described. — H.] 2. Causes. — In some cases sexual ex- ces5 would seem to figure as a cause, but not in others — not perliaps by any means in the majority. And this is one reason wliy it is not well to continue to use the name of tabes dorsaUs as the equivalent of locomotor ataxy, for rightly or wrongly it has com3 to this, that the name tabes dor- saUs is supposed to imjily past abuse of the sexual organs. Nor is it possible to speak of syphilis, or rheumatism, or gout, or struma' as a cause, for in a great many cases, to say the least, there is no evi- I dence of one or other of these morbid con- ditions. In fact, it is not possible to refer locomotor ataxy to any special cause. W hat predisposes to other diseases of the nervous system predisposes to this, family predisposition especially, and this is all that can be said. With regard to family predisposition some curious instances might be given. I know of one case in : which one brother is epileptic, another I brother hypochondriac, and two sisters I are sullering from dilterent tbrms of paral- j-sis ; and Dr. Marius Carre instances a ' tamily in which eighteen members have become ataxic in turn — namely, the grandmother, the mother, eight relations of the latter, seven children, and one cousin. 3. Prognosis.— The prognosis of the disease is unhappily full of gloom. Usu- ally, without doubt, the course is slowly but steadily in a downward direction— so slowly, often, that it is only after the lapse of many months, or even years, that the patient distinctly realizes the fact of having become decidedly worse ; but on the other hand, several cases are on record in which the disease has advanced to the extent of destroying the power of standing and walking in four or five months. Long pauses in the progress of the disease are not uncommon ; thus, for example, I know of one case in which the condition has remained stationary for fourteen years. Moreover, it is not im- possible to find a few cases in which the symptoms have changed for the better considerably, and arc still changing. Cases of this kind, it is true, are not very common, but they arc to be met with. I myself can testify to the existence of sev- eral of tliem. 4. Diagnosis. — Locomotor ataxy, it is said, may be confounded with several dis- eases, especially with common chronic paraplegia, with simiile loss of " muscular sense," with cerebellar disease, and with chorea, but this can scarcely be if only moderate care be taken. In common chronic paraplegia there is unequivocal paralysis in the lower ex- tremities, and the nutrition and irritability of the paralyzed muscles are, as a rule, unmistakably impaired. In these funda- mental particulars, indeed, the difference between this affection and locomotor ataxy is as complete as it can ^^e. In common chronic paraplegia the bladder and sphincter ani are implicated in the paralysis which affects the legs, and the sexual power is almost sure to be greatly weakened or entirely extinguished. In common chronic paraplegia the charac- teristic neuralgic pains of locomotor ataxy are wantins;, and numbness is nothing like so prominent a symptom as 990 DISEASES OF THE SPINAL CORD. in the ataxic disorder. In common clironic paraplegia, wliere walking is pos- sible, the gait, instead of exhibiting the want of co-ordination which is met with in locomotor ataxy, is hampered and slow, each leg being brought forward with evi- dent difficulty even with the help of an upward hitch of the body on the same j side, and the part of the loot first coming in contact with the ground being, as a rule, not the heel as in ataxy, but the toes. In common chronic paraplegia im- pairment of sight or hearing, strabismus or ptosis, injection of the conjunctivse, or contraction of the pupils, frequent, if not constant, sj'mptoms in ataxy, form no part of the history. In fact, in these re- spects, and in others of minor importance which might be mentioned, the histories of common chronic paraplegia and of loco- motor ataxy are so dilfereut that it is not easy to see how, with only an ordinary amount of care, the two disorders can be confounded. The ataxic movements which depend upon antestliesia nmscularis are only pre- sent when the patient does not see what he is doing : the ataxic movements which characterize simple, locomotor ataxy con- tinue whether the patient see what he is doing or not. Nor is this simple rule in diagnosis invalidated bj' the fact that in the majority of cases of locomotor ataxy the sight has a marked influence in keep- ing the unruly muscles in check, for the cases are almost exceptional in which loss of muscular sense does not form an im- portant element in the disorder. In some diseases of the cerebellum there appears to be, often at least, the same disorder of muscular movement which is met with in locomotor ataxy, but this resemblance is more apparent than real. In the next bed to that then occu- pied by the patient whose case has served as an instance of locomotor ataxy, was a boy, also under my care, whose cerebel- lum never seemed to have been properly developed, and whose gait was precisely that which I have seen in two cases of tumor of the cerebellum, and which seems to be associated with serious cerebellar disease in all cases. This boy reeled and rolled about in walking, hut there was nothing peculiar in the way in which he moved his legs and planted his feet ; on the contrary, these movements were those wliich would be instinctively made to pre- vent falling. He was not giddy, but merely unsteady, and the volitional and automatic movements of his legs were what they ought to be under the circum- stances, no more. His mode of progres- sion was widely different from that of the ataxic patient, as was at once apparent v^hen the two were set to walk side by side ; how different I need not again stay to say. In certain diseases of the cerebel- lum also, some symptoms are likely to he present which will assist in the formation of a correct diagnosis, especially violent pain, often augmented by movement, in one or other part of the head, and frequent and obstinate vomiting, and at the same time other symptoms are likely to be ab- sent which are present in locomotor ataxy ; namely, neuralgic pains and anaesthesia in the feet and legs, and else- where. In chorea there is great want of co-ordi- nating motor power, but the history is quite different from that of locomotor ataxy. Chorea is an affection of child- hood and early youth ; locomotor ataxy of adult life. The choreic muscular disturb- ances affect especially the head and arms ; the ataxic are chiefly confined to the legs. Moreover, there are not in locomotor ataxy those involuntarj- movements which in chorea keep the affected muscles in a state of almost perpetual unrest. And as to the other symptoms, it is, in fact, a question of difierences, not of resem- blances. It must not be forgotten, however, that the different diseases of the nervous sys- tem, like all other diseases, are not fenced in by any boundaries except those which have been fixed almost arbitrarily for the convenience of description, and that cases of a mixed character are continually being met with, which in reality lie across these boundaries in every direction. 5. Teeatment.— The treatment of locomotor ataxy is not a subject upon which much can he said at present. No specific treatment can he recommended on good grounds, not even that by nitrate of silver, about which so much has been said of late in Germany and Prance ; and the only treatment which finds favor in my eyes is one of a general character in which figure some preparation of phosphorus with or without cod-liver oil, or arsenic, or bichloride of mercury. [Althaus' says that he has "completely cured" two cases with drachm doses of liquid extract of ergot, three times a day, continued for six or eight months. — H.] I should endeavor to act upon general principles, meeting as well as I could any special indication, as syphilis, or gout, or rheu- matism, or struma. I should trust to a liberal allowance of stimulants rather than to sedatives for the relief of pain : and for the relief of pain also I should have much confidence in regular sham- pooing, in faradization, and the use of positive statical electricity. I am also disposed to think that good may be done hy the use of irons and crutches, one or both. "What is chiefly at fault is the [' Amer. .Tournal of the Med. Sciences, Oct. 1878, p. 348.] SPINAL IRRITATION. 991 motor power by which the two legs aot in concert in standing and moving about ; and what is wanted primarily is to do away, as far as possible, with the neces- sity for calling into exercise this power until it can have had time to recover by rest. This is an intelhgible indication, and the use of irons or crutches is aii intelhgible means of carrying it out. Perhaps it is too much to expect that great good can be done in any way in ad- vanced stages of the disease ; but in early stages I cannot but think that the disease, to say the least, might be arrested if the patient would consent for a lono-er or shorter time to the use of these iiieans. For surely it must go far to neutralize the good to be derived from treatment if the patient is continually trying to do, by walking about without help, or with only the imperfect support of a stick, what the diseased condition of his spinal cord inca- pacitates him from doing, i^or are these remarks alone apphcable to the treat- ment of locomotor ataxy ; on the con- trary, they apply equally to the treatment of all forms of spinal disease in which the acts of standing and moving about are at all compromised. YI. Spktal Ieritatiok. The first important work on the dis- order now generally known as spinul irri- tation was published by jMr. Teale, of Leeds, more than forty years ago ;' the next by the brothers Dr. and Mr. Griffin, of Limerick, about fifteen years later. ^ To Mr. Teale, indeed, belongs the credit of being the first to direct attention to this disorder, for, in reality, his claim either to priority or originality is scarcely, if at all, invalidated by the short commu- nications which were made previously to medical periodical literature by Mr. Player, of Malmsbury,'' by Dr. Brown, of Glasgow,* by Dr. Darwell, of Birming- ham,' and still less so by anything written about the commencement of the century by Franks, Nicod, Ludwig, and others. It would also seem to be difficult to find ■ A Treatise on Neuralgic Diseases depend- ent upon Irritation of the Spinal Marrow and Ganglia of the Sympathetic Nerve. By T. P. Teale, 8vo. London : Highley, 1829. ^ Observations on the Functional Affections of the Spinal Cord and Ganglionic System of Nerves, in which their Identity with sympa- thetic, nervous, and irritative Diseases is il- lustrated. By William Gtriffin, M.D., and David Griffin. 8vo. London : Burgess and Hill. 1844. ' Quarterly Journal of Science, January, 1822. * Glasgow Medical Journal, May, 1828. 5 Midland Medical and Surgical Reporter, May, 1820. any work of more recent date which de- serves to be mentioned as at all ecpial in merit and importance to that uf the brothers Grifliu. The name " spinal irri- tation" was first proposed by Dr. Brown, of Glasgow. _ 1. Symptoms.— The symptoms of spinal irritation at first sight appear to be as vague and various as those of hysteria. They are in reality so far hysterical as to be not readily distiuguishaljle. When further examined, however, one symptom stands out prominently, with which the others are obviously connected in a pecu- liar manner, namely, spinal tenderness ; and the upshot of the whole matter ap- pears to be that spinal irritation is a definite malady which must not be con- founded with hysteria or with any other disorder. For example : — Case.— In the early part of 18G3, an unmarried lady, aged twenty-three, con- sulted me for pains in the hea'elve months ago, after having been quite well for the year previously, this patient married and became pregnant. In the early months of pregnancy she had much headache, depression, weakness, and sickness ; but after a while these symptoms passed off, and everything went on smoothly and satisfactorily until two months after con- finement, when her baby died suddenly. And then began her present troubles. The fretting about her baby brought back the old headaches, the headaches produced great sleeplessness and irritability of the stomach, and then came on a state of un- controllable fidgetiness, which kept her SPINAL IRUITATION. 993 incessantly moving about until her leo-s one leg especially, failed altogether, ;uid obhged her to take to her bed. The very next morning her legs had become con- tracted, and she herself is convinced that this cliange for the worse, as she rei^ards it, >\as brought about by the pain and loss of blood produced by introducin"- a large speculum and by applying leeches to the OS uteri on the previous evenin"-. The treatment on this occasion consisted chiefly in a liberal allowance of food and wine, in repeated blisterings to the lum- bar region of the spine, and in the admin- istration of bromide of potassium and am- monia ; the result was the cessation of the contractions in about three weeks and the complete re-establishment of health in about two months and a half In commenting upon this case with the view of separating the general phenomena of spinal irritation from the particular, I take the following as the points which most deserve to be attended to, namely, these : Spinal tenderness, neuralgia, spas- modic cough and difficulty of breathin!?, palpitation and vascular throbbings, nau- sea, vomiting and eructations, and irrita- bility of the bladder, all in connection with spinal tenderness ; the connection of particular symptoms or groups of symp- toms with tenderness in particular parts of the spine ; prolonged muscular contrac- tion ; no paralysis of the limbs ; no pa- ralysis of the bladder or rectum; no numb- ness ; variability and inconstancy of the symptoms ; a nervous constitution. Spinal tenderness. — In the great majority of cases this symptom would seem to ])e present in spinal irritation and absent in spinal meningitis, myelitis, or spinal con- gestion, acute or chronic. It would seem, indeed, to deserve to be regarded as the pa- thognomonic symptom of spinal irritation; for in the few cases of spinal meniu'^itis, myelitis, or spinal congestion in which it is met with, there is reason to believe that its presence may be accounted for by the association of the phenomena of irri- tation with those of inflammation or con- gestion. At any rate, it is certainly tlie rule that spinal irritation without spinal inflammation or congestion is accompa- nied by spinal tenderness, and that spinal inflammation and congestion without sjsi- nal irritation is not accompanied by spinal tenderness. Spinal tenderness, however, can scarcely be spoken of as a prominent symptom in spinal irritation. It is often not complained of until it is specially in- quired after ; and now and then its exist- ence is not even suspected by the patient until he or she is made to wince under pressure applied to the spine. In a few cases which from their symptoms would seem to come under no other head than that of spinal irritation, there is no spinal VOL. I. — 63 tenderness— only Ave such cases are met with among the 148 cases brought together by the brothers Griffin, and these may without difficulty be in great measure ex- plained away ; but such cases are much too exceptional and doubtful to throw discredit on the rule in question, that spinal irritation and spinal tenderness o-o together. Spinal tenderness, however does not appear to be equally marked in all lorms of spinal irritation. It appears to be much less marked where the irrita- tion shows itself in spasm and prolonged muscular contraction than in the cases where it shows itself in pain ; and it is certainly absent in tetanus, which in one sense may be looked upon as the manifes- tation of spinal irritation in its most ag- gravated form. li'crvoits pains, often in connection with tenderness in a particular p)art of the spine. —Nervous pains, neuralgias, in one place or another, often intermittent and more or less regularly periodical, and often shifting suddenly from one place to an- other, are a very common, perhaps the most common, symptom in spinal irrita- tion. They are often brought on or exag- gerated by lifting any weight, by twisting or straining the back in any way, or by any effort, mental or physical: and as often they are relieved, to some extent at least, by lying down. Yery often, also, there is tenderness in the portion of the spine corresponding to the insertion of the affected nerves — in the upper cervical region, where the pains are in the scalp (clavus hystericus, megrim, and others), fixce, or neck ; in the lower cervical region, where they are in the upper extremities, shoulders, and upper part of the thorax ; in the dorsal region, where they are in the lower part of the thorax and upper part of the abdomen (pleurodynia, gastro- dynia, infra-mammary stitch, and others) ; in the lumbar and cervical regions, where they are on the lower part of the abdo- men, hips, loins, and lower extremities. In the majority of cases the pain would not seem to be in the part of the spine which is tender, or in any other part. In some cases there may be aching in some part of the spine, or else a sense of weight and heat ; but I am very much inclined to believe that these last mentioned symp- toms, and "back-ache" generally, have often to be referred to spinal congestion rather than to spinal irritation in its un- complicated form. When the spina' ten-- derness is very great, slight pressure will often cause pain to strike from the tender spot of the spine to the distant seat of pain, or will bring about or exaggerate this pain. This fact is illustrated in the case I have given, and better still in some of the cases related by the Griflin brothers. In one of these cases, for example, where the whole spinal column was found to be 994 DISEASES OF THE SPINAL CORD. acutely tender, "pressure of the first or second vertebra occasioned pain, which sliot forwards from the occiput to tlie brow ; a little lower, pain was excited at the larynx ; on pressing one of the lower cervical, it occurred at the point where it dips behind the sternum ; on pressing the upper dorsal, at the middle of the ster- num ; from the third or fourth dorsal to the eighth or ninth, it was excited at the ensiform cartilage ; yet lower, at the sides ; and in the lumbar vertebrte, pain was excited in the iliac and pubic regions" (p. 19). And in anotlier case, where there was some tenderness of the middle cervical vertebras, and acute tenderness from the fourth dorsal to the eighth or ninth, "pressure on any of those last, especially the seventh or eighth, brought on violent pain, whicli darted forwards to the ensiform cartilage. "When the last- mentioned vertebra was pressed upon, the patient said that she thought her ' heart •would break' " (p. 119). ' The pain is often curiously localized : sometimes it gives the idea of a nail being driven into the part, as in clavus hystericus ; some- times the feeling i^roduced by it is as if a walnut or other hard substance were pressed under a tight belt ; sometimes it is very severe, and neuralgic in its cha- racter rather than rheumatic : and not unfrequently, when it has existed some time, the painful part becomes tender on pressure. Most generally this morbid sensation is in the form of pain, but now and then it may take that of cold, ting- ling, itching, or some other feeHng which is disagreeable rather than painful. The amount of constitutional disturbance at- tending the pain varies very much, but it is usually comparatively trifling, and, as it would seem, quite out of proportion to the degree of suflfering. Nausea, retching, vomiting, eructation, &c. often in connection with tenderness in a par- ticular part of the spine. — These are com- mon symptoms in spinal irritation : next to pain, indeed, they are perhaps the most common. They are also intimately con- nected with certain forms of pain, espe- cially cephalalgia and gastrodynia, some- times preceding, sometimes accompany- ing, but more generally following, the pain. As regards the particular part of the spine wliich is likely to be tender when the stomach is the seat of irritation, the Griffin brothers say that " nausea and vomiting appear to bear more relation to tenderness of the cervical spine, pain of stomach to tenderness of the dorsal ; but that where there was soreness of both, nausea and vomiting was still more fre- quent, and pain of stomach scarcely ever absent. " The epigastric disorder in these ■^cases is generally accompanied with ten- derness on pressure, not merely in the spine but also in the epigastrium and in the left hypochondrium — with those three patches of tenderness which M. Briquet speaks of as the "trepied hysterique" — • as the tripod upon which the diagnosis of hysteria rests. Spasmodic cough, difficulty of breathing, &c., often in connection with tenderness in a particular part of the spine. — These again are symptoms which are common enougli in spinal irritation, and mostly so, asit would seem, when the tenderness in the spine is in the cervical and upper dorsal region. Palpitation, &c., often in connection with tenderness in a particular part of the spine. —Palpitation is another symptom of spinal irritation which seems to be often- est met with when there is tenderness in the upper half of the spine. It seems to be not unfrequently associated with a feeling of epigastric pulsation, and witli nausea, vomiting, and other signs of gas- tric disorder. vascular throbbings in other places, as in the temples, and "chills and flushes," and a disposition to syncope, and other signs of disturbed bal- ance in the circulation, may, and often do, go hand in hand with the palpita- tion, and seem to have to do with the same condition of the spine. Irritability of the bladder, often in connec- tion with tenderness in a particular part of the spine. — This was a marked symptom in the case which I have related when the seat of spinal tenderness shifted to the lumbar region, and it seems to be a very common, if not a constant symptom, in cases in which the tenderness is in this region. The connection of particular symptoms or groups of symptoms with tenderness in par- ticular regions of the spine. — The data best calculated to illustrate this connection are those supplied by the brothers Griffin. These consist of no less than 148 cases, of which 26 are in males, 49 in married women, and 73 in girls. In these 148 cases, the spinal tenderness was in the cervical region in 28, in the cervical and upper dorsal region in 46, in the dorsal region in 23, in the dorsal and lumbar region in 15, in the lumbar region in 13, and in the spine generally in 23. In the following table the prominent symptoms connected with each one of these forms of spinal tenderness are set forth in a way which requires no comment except this — that this grouping of symptoms with ten- derness in particular parts of the spine must only be looked upon as approximat- ing to the truth, and that now and then any symptom may appear out of the order in which it is sei down. SPINAL IRRITATION. 995 Begion of Spinal Tenderness. A. Cervical region. Cases 28 in number. B. Cervical and Dorsal region. Cases 46 iu number. C. Dorsal region. Cases 23 in number. D. Dorsal and Immhar region. Cases 15 in number. E. Limibar region. Cases 13 in number. r. All regions together. Cases 23 in number. Prominent Symptoms. somfwift?''' ''''f ^'''' 7°"»«ng' fece-ache, fits of in- |ensibility, cough, pams m tlie upper extremities, V Nausea and vomiting in 6 cases, pains of stom- acii in 2 only. In addition to the symptoms in group A, pain of stomach and sides, pyrosis, palpitation, oppression. ■ *• , ?"^ °' stomach in 34 cases, nausea and vomit- mg m 10. Pain in the stomach and sides, cough, oppression, "t| 01 syncope, hiccup, eructations. **'■ Pain in the stomach in almost all these cases, nausea or vomiting in only one. In addition to the symptoms in group C, pains in the abdomen, loins, liips, lower extremities, dvsurv, and isohury. "^ ' \* Nausea in only one case. Pains in the lower part of the abdomen, testes, or lower extremities, dysury, ischury, disposition to paralysis in lower extremities. %* Retching and spasm of the stomach in one case only. A combination of the foregoing groups of symp- toms, one group changing into another as the spinal tenderness becomes more marked in one region than in another. Prolonged muscular contraction. — This is a very conspicuous symptom in the case which serves as my text, and it is no uncommon symptom in other cases of spinal irritation. The lower extremities appear to be the parts most commonly affected, one or both of them ; but the up- per extremities can claim no exception, nor even the muscles of the jaws and neck, trismus or torticollis being among the re- sults in this latter case. " Occasional!}', " says Mr. Teale, " there is an inability to perform complete extension of the elbow, the arm appearing restrained by the ten- don of the biceps, pain and tightness be- ing produced in this part when extension is attempted beyond a certain point;" and to this fact I can testify. Moreover, I can testify as to the not unfrequent oc- currence of long-continued closing of the fingers and thumb upon the palm. The rule appears to be, for the extremities to be affected before the trunk or head. This contraction, which is generally pain- less, may be prolonged for weeks or even months continuously, even during sleep, or with occasional intermissions of uncer- tain duration ; and the attacks, primary or secondary, are usually found to begin and end suddenly and unexpectedly. The relations between this form of contraction and that which occurs in other cases, especially in tetanus and in that some- what vague disorder to which Dr. Trous- seau has given the name of tetany (teta- nic), are not very easily determined. In tetanus, with very rare exceptions, the contraction is painful, especially in the paroxysmal bouts, and the order in which it attacks the body is different — first, the jaws ; then the trunk ; and the extremi- ties only at a late period, if at all. In tetany, as in tetanus, the contraction is painful, but the order in which the body is attacked is different to that which is observed in tetanus, centripetal not cen- trifugal, — first the extremities, then the trunk or head ; the contraction, in fact, being confined to the extremities, except in cases of unusual severity. In the way in which it affects the extremities first, and often exclusively, the contraction of tetany agrees with the contraction under consideration, but in other respects it dif- fers. It differs, especially, in being ush- ered in and accompanied by symptoms which do not seem to form part and par- cel of simple spinal irritation ; namely, tingling and some degree of ancesthesia, and also (so it is said)ln the form of the contracted hand being peculiar — like that which the hand of the accoucheur takes in order to be introduced into the vagina — and in the possibility of bringing on the contraction by firm pressure upon the principal nerves or arteries of the affected muscles. It may be questioned, however, whether there are absolutely fixed lines of 996 DISEASES OF THE SPINAL CORD. division between these different forms of prolonged contraction, and wlietlier the difference wliicli exists may not be ac- counted for as tlie result of different de- grees of irritation, affecting, it may be, different parts of the spinal cord. It may be questioned, also, whether a sufficient case is made out for describing tetany as a definite disorder, and whether it is not rather a form of spinal irritation compli- cated with some graver spinal disease — spinal meningitis, myelitis, spinal conges- tion — in varying proportions. The asso- ciation of tingling and numbness with the prolonged contraction is, as it seems to me, a reason for an affirmative conclusion. At any rate, prolonged muscular contrac- tion, be its significancy in tetanus or teta- ny what it may, must be looked upon as a not unfrequent symptom in single spinal irritation — as a symptom, too, which is usually of no very grave import. Of this there need be no doubt. JSfo paralysis of the Umbs.^ln the case I have given in illustration there was great weakness of the legs, and one leg seemed to "drag" immediately before the contractions came on. There was a disposition to paralysis in the legs, but not more than this ; nor do I find paraly- sis of the limbs among the symptoms of spinal irritation strictly so called. There is, no doubt, a connection between pa- ralysis and spinal irritation which cannot be overlooked ; and under that form of paralysis which is known as "hysterical paralysis," and about which more will have to be said in due time, and under spinal irritation, there is a common basis. As it seems to me, however, it is patho- logically as well as physiologically incor- rect to speak of hysterical paralysis as a symptom of spinal irritation. Also, it seems to me, the right place of this pa- ralysis is after spinal irritation, not along with it, when the capability of morbid action which is implied in the term irri- tation is worn out ; and so in the other exceptional cases in which paralysis is connected with spinal irritation, it will, I believe, be found on careful examina- tion that the paralysis is not a symptom of actual spinal irritation, but of a state of vascular change into which this irrita- tion may issue and has issued — spinal congestion, it may be, or even myelitis. No paralysis of the hladder or bowel. — The remarks which have just been made apply equally to paralysis of the bladder or sphincter ani. Paralysis in either of these parts, or even a disposition to it, is rarely met with in any case which can be strictly brought under the head of spinal irritation ; and in the few exceptional in- stances which do occur, it is plain enough, when the matter is fairly inquired into, that the boundary has been passed which separates the state of irritation from the state of exhaustion, and that, in fact, the case is no longer one of simple spinal irri- tation. Wo numbness.' — iNumbness, again, is a symptom which is scarcely ever met with in cases to which the name of spinal irri- tation is strictly applicable, and, when it is met with, it is easily accounted for. In short, the relationship of numbness and paralysis to spinal irritation appears to be one and the same, the numbness and the paralysis being alike connected, not with the state of morbid action called irrita- tion, but with the after-state of morbid inaction for which exhaustion seems to be one of the appropriate names. Variability and inconstancy of symptoms. ■ — One most characteristic feature of spinal irritation is the way in which one symptom or group of symptoms may change, and change suddenly, into an- other symptom or group of symptoms. It is now this disease which is simulated, now that, there being scarcely any dis- ease whieh may not be copied : at one time the head is affected, at another the chest, at another the abdomen or the ex- tremities : and the only thing constant among these ever-shifting phenomena ap- pears to be this — that the spinal tender- ness changes from one part to another in a manner which is intelligible enough when the connection of the spinal nerves with the affected part is taken into con- sideration. A nervous constitution.— The subjects of spinal irritation, with few if any excep- tions, may be spoken of as hysterical, hypochondriacal, or nervous. They have, in fact, that nervous constitution which Whytt, following in the steps of Syden- ham, showed to be the common basis of hysteria and hypochondriasis. First in order among the signs of this constitution comes that sign which Sydenham regarded as pathognomonic of hysteria and hypo- chondriasis — namely, a proneness to pass, under or after strong emotion or excite- ment, large quantities of pale limpid urine. Then come other signs scarcely less characteristic : proneness to tender- ness, not only in some part of the spinal column, but also in the epigastrium and left hypochondrium — le trepied hystkique of Dr. Briquet already referred to ; prone- ness to sudden and distressing flatulent distension of the stomach and bowels, with loud rumbling and explosions, and with a feeling of a ball rolling about, first in the left flank, and then mounting, or tending to mount, into the throat, where it gives rise to a sense of choking and to repeated acts of swallowing ; proneness to bursts of crying and sobbing or of laughing ; proneness to sighing, yawning, and stretching the arms ; and proneness to fits of convulsive agitation and strug- gling. Then comes a promiscuous series SPINAL IRRITATION. 997 of signs : pronencss to erratic pains of a neuralgic cliaracter, breatlilessness, nerv- ous cough, palpitation, throbbing in the temples, epigastrium, and elsewhere ; "flushes and chills," syncope, hiccup, nausea, vomiting, aversion to food or un- natural craving for it, heartburn, oppres- sion at the preecordia, languor, debility, fidgetiness, tremulousness, "vertigo (espe- cially on rising hastily), ringing in the ears, fickleness, fancifulness and inability to discriminate between fact and fiction, undue lowness of spirits or the contrary, and other symptoms whose name is legion! JSTot only, indeed, is the name of these different symptoms legion, but there is ever going on a process of mutual meta- morphosis in the symptoms themselves ; and, in conclusion, it is this very hysteri- cal or hypochondriacal variability and mutability of the symptoms which must be looked upon as the great characteristic of the nervous constitution. 2. POST-MOETEMApPEARANdES.— The morbid structural changes strictly be- longing to spinal irritation are nil. The disease is nervous or functional in its cha- racter, and on this account it leaves no obvious traces after death. Still, as Dr. Copland wisely says, "an affection which may with justice be vieAved as functional to-day — as spinal irritation merely — may be inflammation on the morrow, and rap- idly followed by the consequences of inflammation. " Such a termination, how- ever, is altogether exceptional ; and when it does occur, the history during life will show very clearly that any traces of in- flammation which are met with after death are to be ascribed, not to'irritation, but to inflammation. How far irritation, which involves in its very essence, as I believe, capillary contraction and blood- lessness, not capillary paralysis and con- gestion, may involve changes which are opposed to inflammation — deficiency of blood and organic changes brought on by the part being starved for want of blood — remains to be seen. I take it that such changes would have been found if they had been looked for with the same amount of care which has been expended in the search for inflammatory changes; but the investigations have yet to be made which will verify or disprove this conjecture. 3. Causes. — ISTeglect of gymnastic training, insufficiency of wine or other alcoholic drinks, over-indulgence in sex- ual matters, onanism, would seem to de- serve a conspicuous place among _ the causes of spinal irritation. It is idle, however, to weigh the importance of par- ticular causes, or even to attempt to in- dividualize them, and it is enough to be content with the broad fact that every- thiiio- which tends to induce a nervous habit— that is, everything which exhausts vital power— must be reckoned as a cause. 1 believe that the starting-point of the disorder will very often be found in some strain or blow to the back, and I also be- lieve that a congenital predisposition may also be detected in very many cases. 4. Diagnosis.— The fundamental ques- tion for consideration in this place is how to distinguish between functional and or- ganic aflections of the spinal cord, and this question fortunately is one which is less difficult to answer than it might seem to be at first sight. In fact, the charac- teristics of spinal irritation indicated by the Griffin brothers are sufficient of them- selves to supply the ansiver to any one who has tolerably clear ideas respecting the principal diseases with which spinsil irritation may be confounded. These characteristics are:— "1st. The pain or disorder of any particular organ being altogether out of proportion to the consti- tutional disturbance. 2d. The complaints, whatever they may be, being usually re- lieved by the recumbent posture, and always increased by lifting weights, bend- ing, stooping, or twisting the spine. 3d. The existence of tenderness at that part of the spine which corresponds with the disordered organ, and the increase of pain in that organ by pressure on the corre- sponding region of the spine. 4th. The disposition to the sudden transference of the disordered action from one organ or part to another, or the occurrence of hys- terical symptoms in affections apparently acute ; and 5th. The occurrence of fits of yawning or sneezing, which, though not very common symptoms, yet, as rarely ever occurring in acute organic disease, may generally be considered as character- istics of nervous irritation." In the diseases of the spinal cord which have already been under consideration — spinal meningitis, myelitis, spinal conges- tion, and tetanus — it has been seen that it is the rule for the spine not to be tender on pressure, and in spinal irritation it has been seen that such tenderness is so con- stant as to deserve being reckoned as the distinctive feature. Here, then, is a point of difforence which will serve as a guide to a correct diagnosis in several important cases in which guidance is necessary— which will serve as a guide in almost all cases except in that with which spinal irritation is most readily confounded. This case, which is strumous disease of the vertebrae, is one in which spinal ten- derness is also present, as well as many other symptoms of spinal irritation— pain in the side, stomach, or bowels, cough, oppression, tightness around the waist, and so on— and in which relief is obtained by recHning. Nay, there may even be in spinal irritation a yielding and projectioa 998 DISEASES OF THE SPINAL COKD. of the tender vertebrfe, with some piiffiness of the overlying skin, which simulates in no imperfect manner the earlier stage of angular curvature. There are many re- semblances, in fact, but, as the brothers Griffin have pointed out, there are also certain differences which are so well marked as not to leave the diagnosis in doubt. Thus it is found :— " 1st. That strumous disease of the vertebrae attacks the young, and most frequently those under the age of puberty, who are least of all liable to be affected by spinal irritation. 2d. That disease of the vertebrae, when attacking young girls, is seldom accompa- nied by symptoms of a purely hysterical character, while any serious irritation of the cord can scarcely exist without them. 3d. That an apparent prominence of the tender portion of the spine, which some- times exists in cases of irritation, is never strictly angular ; for, if four or five of the vertebrae seem to project, the prominence is nearly equal in all, whereas in caries of the bones it is greatest in the middle, the prominence depending, in fact, on a slight puffing of the ligaments or investments of the spine, and not on displacement or curvature. 4th. That absolute paralysis of the lower limbs is a rare consequence of irritation, and a frequent one of caries of the bones. 5th. That the general health suffers less in the former com- plaint, and it is not attended with the look of serious organic disease which is indicative of the latter. 6th. That the constitution of the patient may also prove useful as a guide, the disposition to spinal irritation, as well as to scrofula, being hereditary." 5. Peogkosis.— However urgent the symptoms may be, the prognosis in spinal irritation is favorable rather than unfa- vorable. It must always be borne in mind, however, that spinal irritation is a state which may issue in inflammatory or other organic changes in the cord or in its membranes, and that a favorable prog- nosis must be qualified by this contingen- cy, especially in those "cases in which there is some obvious vice of the constitu- tion—scrofulous, gouty, rheumatic, syplii- litic, or other. 6. Treatmeitt. —" Local depletion by leeches or cupping," says Mr. Teale, "and counter-irritation by blisters to the affected portion of the spine, are the prin- cipal remedies. A great number of cases will frequently yield to the single appli- cation of any of these means. Some cases, which have even existed for several months, I have seen perfectly relieved by the single application of a blister to the spine, although the local pains have been ineffectually treated by a variety of reme- dies for a great length of time." Of the efficacy of blisters in these cases I have had abundant proof. As to the good ef- fects of local depletion I have had less experience, partly because I found that the blisters were sufficient of themselves, and partly because I believe that the state of irritation is associated with a state of capillary contraction and bloodlessness, and not with a state of capillary paralysis and congestion. Still, I can well believe that there are many mixed cases in which irritation has issued in some degree of capillary paralysis and congestion, espe- cially in the skin at the seat of spinal ten- derness, and in which this state will be greatly relieved by local depletion. As regards medicine, I should certainly be disposed to trust most in common tonics — quinine, steel, or cod-hver oil ; to the latter in conjunction with some prepa- ration of phosphorus most of all, perhaps. And certainly I should be disposed to fight against pain and spasm, as I have sufficiently explained elsewhere, by reme- dies which rouse the circulation to greater activity, and not by those which have a contrary action. Nay, I should even have more confidence, as a local applica- tion for pain, in some application which would produce a hyperaemic condition of the skin, than in any one which had a deadening effect upon the sensitiveness of the part. It is, no doubt, an indispensable part of the treatment to avoid standing or walk- ing to the extent of producing fatigue, but there would seem to be no necessity, except as a very temporary measure, per- haps, to insist upon a recumbent position being retained for any length of time. Upon this point Mr. Teale says (and he says all that need be said). When my attention was first directed to this sub- ject, I considered recumbency a necessary part of the treatment ; it is, for a mode- rate length of time, undoubtedly bene- ficial, and frequently very much accele- rates recovery ; but subsequent observation has convinced me that it is by no means essential. I have seen several instances of the most severe forms of these com- plaints, occurring in the poorer classes of society, where continued recumbency was impracticable, which have, nevertheless, yielded without difficulty to the other means of the treatment, whilst the indi- viduals were pursuing their laborious avo- cations." As regards diet I have only this to say — that I believe the great thing to be done is to supply wine or some other alcoholic drink as well as nutritious food in suffi- cient quantity. I believe that nutritious food in itself is not enough. In very many cases it is found that alcoholic drinks are either abstained from altogether or taken in very insignificant quantities from a fear that they will aggravate the pain or GENERAL SPINAL PARALYSIS. 999 spasm, or for some other reason : in ver3- many cases it is found also that relief is obtained only when this practice is aban- doned, and the diet made to include at least an average share of the drinks in question. Indeed, the result of my own experience is unequivo:al in this respect —that the somewhat bold use of alcoholic drinks is a cardinal point in the treatment of spinal irritation, and this indication must be fully acted upon if this treatment is to lead to anything like satisfactory re- sults. [Yet, fijr safety, this boldness must be regulated by the discretion of the phy- sician, not trusted to the mere inclination of uninstructed patients ; or else harm, instead of good, may be done by it. — H.] Of the spinal maladies remaining to be noticed the principal are these :— General spinal paralysis, hysterical paraplegia, reflex paraplegia, infantile paralysis, hemorrhage, non-inflammatory softening, induration, atrophy, hypertroph)% tumor, concussion, compression, caries of the ver- tebral column, spina bifida, &c. YII. General Spinal Paralysis. There is a form of general paralysis to which Dr. Calmiel gave the name of gen- eral paralysis of the insane, and with which all who know anything of insanity are sufficiently familiar. It may coexist with any form of insanity, but it is most commonly associated with the mono- mania in which the patient believes him- self to be possessed of unbounded opu- lence. The first signs are likely to be thickness of speech, quivering of the lips and tongue, fumbling and clumsy move- ments of the fingers, with an unsteady and sidehng gait. Then the urine escapes now and then involuntarily, or even the feces. Once begun, the downward course of the malady is headlong, and in a few months, in a few weeks it may be, withm two or three years at the most, the pa- tient is in bed, altogether without the power of supporting himself on his feet, unable to use his hands so as to help hmi- self in any way, incapable of sitting up or even of turning over in bed, requiring to be fed like a child, and, when fed, m no small danger of choking if left to masti- cate the morsels, with urine and feces escaping under him unheeded, and with every power of body and mind an utter wreck. With few exceptions the thick- ness of speech shows that the muscles ol the tongue and Mps are the first to tail, but in fact all parts of the muscular sys- tem show signs of weakness about the same time, and it is difiicult to fix upon any one part and say that it is affected before the rest. Sometimes the paralyzed muscles become considerably atrophied, but the rule appears to be that such atro- phy is less marked than in cases where the paralysis is the result of disease in tlie spinal cord : always, according to Dr. Ducheniie, the paralyzed muscles, whe- ther atrophied or not, retain their full share of electro-contractility. After death signs of disease are found in the brain, but not in the spinal cord ; these signs being increased vascularity, with serous or sero-fibrinous infiltration in the pia mater, in the cortical substance, and in the brain structure generally. General spinal paralysis is the name used by Dr. Duchenne to describe a form of paralysis which, until he pointed out the differences, was confounded with gen- eral paralysis of the insane. Looking hastily at the phenomena of paralysis when clearly developed, it is, indeed, not to be wondered at that these two dis- orders should have been confounded ; but in reality general spinal paralysis, as de- fined by Dr. Duchenne, possesses pecu- liarities which are sufiiciently character- istic. In general spinal paralysis the mental faculties are natural; in general paralysis of the insane they are funda- mentally deranged. In general spinal paralysis the electro-contractility of the paralyzed muscles is abolished or greatly impaired ; in general paralysis of the in- sane it is intact. In general spinal paral- ysis the paralysis usually begins in the legs and travels upwards, often remaining in°the lower parts of the body a long time before attacking the tongue, face, and up- per extremities; in general paralysis of the insane all parts of the muscular sys- tem would seem to be affected simulta- neously, or, if there be any diflerence as to time, it is the tongue and upper parts of the body which are the first to suffer. In general spinal paralysis there is a marked disposition to atrophy in the par- alyzed muscles and elsewhere, to bed- sores, and to other signs of defective nu- trition ; in general paralysis of the insane these evidences of wasting are, to say the least far less conspicuous. In general spinal paralysis the progress of the dis- ease is slow, often extending over several years ; in general paralysis of the insane the whole course of the disease is com- prised within three or four years at most. In general spinal paralysis the post-mor- tem si^ns of disease are in the spmal cord and not in the brain ; in general paralysis of the insane the reverse of this obtains, the cord being healthy and the bram the seat of the disease. Much, no doubt, remains to be done before it is possible to speak positively as to the character of the diseased changes in the cord which are met with in general spmal paralysis , and 1000 DISEASES OF THE SPINAL COKD. at present it must suffice to s&y, that in one case related by Dr. Duelienne there was softening and iujei lion of the anterior columns in the cervical region of the spinal cord, and that in one ca.'^e wliich I had the opportunity of examining there "was want of proper consistence, not ex- actly amounting to actual softening, and a perceptible degree of atrophy, in these columns, throughout the whole of their course from the middle of the neck down- wards. Whether general spinal paralysis will prove to have that relation to disease of the anterior columns of the cord which locomotor ataxy has to disease of the pos- terior columns, remains to be seen. General spinal paralysis blends, no doubt, with other spinal diseases, and its symptoms vary accordingly ; but still it occurs with sufficient frequency in the form described by Dr. Duchenne to de- serve the position which he assigns to it as an individual malady. There are also relations equally intimate between gen- eral spinal paralysis and cerebral mala- dies, and I am very much disposed to think that the cases in which the mental powers are obviously weakened will be found to be at least as numerous as those typical cases in which these faculties are natural. At the same time it must be borne in mind that in some cases of gen- eral spinal paralysis the mind may seem to be weakened, when in reality it is not so — that in some cases there may be an air of stupidity, or even fatuity, arising from the slow play of the features, the "thick- ness of the speech, the fumbling of the Angers, and like s3mptoms, which air has its origin in the paralyzed state of the muscles and not in the enfeebled state of "the man behind the mask." General spinal paralysis cannot be con- founded with local Cruveilhier's atrophy or lead palsy, and it must not be con- founded with the general forms of these maladies. In general Cruveilhier's ati'o- phy, as well as in local, the atrophy of the muscles is partial, certain muscles being, as it were, dissected out, and others left untouched, capriciously ; in general spinal paralysis the atrophy is en masse. In general Cruveilhier's atroph}^ what remains of muscle obeys the will and reacts with electricity properly — there is no paralysis ; in general spinal paralysis there is true paralysis, and the paralyzed muscles have lost much of their electro -contractility. In general lead palsy, also, the history will "be sufficient to prevent any confusion as to diagnosis — the paralysis at first electing the ex- tensor muscles of the forearm, the blue lino upon the gums, the colic, the consti- pation, the possibility of lead contamina- tion, and so on. As regards treatment there is nothing to be said except that it must be con- ducted upon the same principles as those which apply in analogous cases. VIII. Hysterical Paraplegia.' Paralysis is certainly entitled to a place among the sjinptonis of hysteria. Dr. Briquet met with it in 113 out of 430 hys- terical patients, its seat being in the four extremities and in the principal muscles of the trunk in 6, In the left arm and leg in 46, in the right arm and leg in 14, in both arms in 5, in the left arm only in 7, in the right arm only in 2, in both lowtr limbs in 18, in the left lower limb in 4, in the feet and hands in 2, in the face in 6, in the larynx in 3, in the diaphragm in 2 ; and my own experience is more in harmony with these statistics than with the statement of Todd, that the face and tongue escape in hysterical paralysis, that the heraiplegic form of paralysis is less common than the paraplegic, and that "hysterical aphonia" is the form which is most frequently met with. Hysterical paralysis, so called, is gene- rally met with in persons of a nervous habit of body, and in conjunction with symptoms of an unmistakably hysterical character. As a diagnostic feature, Todd laid stress on a peculiar expression of countenance, which he denominated fades hysterica — an expression charac- terized by a remarkable depth and promi- nent fulness, with more or less thickness of the upper lip, and by a peculiar droop- ing of the upper eyelids ; and, as it would seem, with good reason. Often, more- over, there is a definite history of symp- toms which clearly come within the cate- gory of hysterical phenomena — emotional excitability, globus, plentiful gushes of pale urine, and the rest. In diagnosing hysterical paralysis, however, it is not necessary to trust solely, or even chiefly, to evidence such as this, for the paralysis itself is found to have certain features which in themselves are sufficiently dis- tinctive. Hysterical paralysis is characterized by the paralysis being more or less incom- plete, by a marked degree of numbness being associated with it, and chiefly (ac- cording to Dr. Duchenne) by the paralyzed muscles, which are not wasted, havinij lost their electro-sensibility without losintj their electro-contractility — a loss which, by the way, does not support Sir Benjamin Brodie's opinion that it is the power to will contraction, and not the power of ex- ecuting the orders of the will, which is at fault in this form of paralysis. It would also seem to he a peculiarity of liysterical paralysis, as well as of hys- terical hypersesthesia, anaesthesia, and ' See also article on Hysteria, p. 630 et seq. REFLEX PARAPLEGIA. 1001 clonic convulsion, to affect the left side of the body rather than the right. Thus, M. Briquet found pleurodynia nineteen times, hyperasstliesia and anaesthesia five times, clonic convulsion twice, and pa- ralysis thrice as frequent on the left side as on the right side. He found, indeed, a state of tilings which presents a con- trast to what is met with in rheumatism, neuralgia, pleurisy, pneumonia, and otlier maladies, in all of which it is the right side of the body which is most prone to suffer. Very frequently, I believe, hysterical paralysis is preceded by symptoms which come under the head of spinal irritation, and not uufrequently, especially when the upper part of the body is affected, it is ushered in by emotional and other symptoms which may at times deserve to be spoken of as an attack of hysteria. Hysterical paraplegia agrees in its es- sential features with other forms of hys- terical paralysis. The paralysis is usually incomplete. Numbness of the paralyzed parts is a conspicuous phenomenon ; as conspicuous, it may be, as the paralysis. The paralyzed muscles have lost their electro-sensibility without losing their electro-contractility. The bladder and bowel (as much apparently for want of proper sensibility as from true paralysis) are little under control, if at all ; less so, as a rule, than in common paraplegia. The paralysis is often preceded by symp- toms of spinal irritation, in the lumbar region especially, — spinal tenderness, pains about the pelvis and in the legs, irritability of the bladder, and the rest ; and now and then it is ushered in by some ordinary hysterical disturbance of one kind or other. And where one leg only is affected, there would seem to be, as Todd pointed out, a gait which is not less characteristic than that which is seen in common hemiplegia. In common hemiplegia the trunk in walking is first of all inclined to the sound side, and the whole weight of the body made to rest upon the sound leg, and 'then the para- lyzed limb is raised from the ground and thrown forwards by swinging it out- wardly ; the whole series of movements being very like those which are necessary in walking with a wooden leg. In hys- terical paralysis, where one leg only is affected, the paralyzed limb, instead of being raised from the ground, as in com- mon hemiplegia, and thrown forward by an outward swing, is dragged directly forward, with the foot trailing on the ground. The prognosis in hysterical paralysis would always seem to be favorable. Sooner or later, in one way or another, a cure is brought about— most tardily, per- haps, in the paraplegic form of the dis- order. As regards treatment, all that need be said is, that general rules must be followed out, and that, if anything special luits to be done, most help" will probably be de- rived from sharp faradization with elec- trodes which allow the currents to act on the sentient nerves rather than on the muscles— that is, with metal ends rather than witli the moistened sponges com- monly used. At any rate, sharp practice of this kind has often served to bring about results as sudden and satisfactory as those which have now and then fol- lowed the exercise of faith in the power of St. Medard and other kindred agencies. IX. Eeflex Paeaplegia. Paraplegia is one of the consequences of primary disease in the spinal cord : of this there can be no doubt. Paraplegia may also be the result of disorder or dis- ease beginning at a distance and aftccting the cord secondarily — beginning in the urinary and genital organs more espe- cially: of this there can be but little doubt. In the former case the paraplegia is spoken of as centric ; in the latter as eccentric or reflex. The chief characteristics of that form of reflex paraplegia which is associated with disease of the urinary organs — urinary paraplegia, as it is often called — the com- monest and most important of all the forms of reflex paraplegia, as it certainly is, are these ; or at any rate these are those upon which Dr. Brown-Sequard, who has paid much attention to this sub- ject, insists. Usually the paralysis is in- complete both as to degree and extent, some muscles being obviously more af- fected by it than others ; usually the pa- ralysis is not associated either witli ting- ling or numbness, or anaesthesia ; usually the bladder and rectum are only slightly implicated in the paralysis ; usually there are changes for the better or worse in the degree of paralysis corresponding to changes for the better or worse in the dis- ease of the urinary organs ; usually there is no marked atrophy in the paralyzed muscles. Not unfrequently a cure or marked amelioration in the paralytic con- dition is brought about by the removal of the disease in the urinary organs. Dr. Brown-Sequard indicates these as the chief characteristics of reflex paraplegia con- nected with disease of the urinary organs, and of other forms of reflex paraplegia as well, the only difference in the description of these latter forms of disease being the substitution for the term "urinary" of the name which indicates the starting- point for the paralysis. Thus defined, reflex paraplegia differs diametrically from the paraplegia pro- duced by myelitis. In paraplegia from 1002 DISEASES OF THE SPINAL COKD. myelitis the paralysis is usually complete, and all the iimscles are attected equally ; not so in reflex paraplegia. In paraplegia from myelitis the paralysis is associated with tingling, numbness, or ansesthesia : not so in reflex paraplegia. In paraplegia from myelitis paralysis of the bladder and lower bowel is a marked phenomenon : not so in reflex paraplegia. In paraplegia from myelitis the paralyzed muscles are usually atrophied and degenerated : not so in reflex paraplegia. In paraplegia from myelitis cure, or even improvement, is the exception : in reflex paraplegia it is the rule. It is, indeed, easy enough to find marked differences between paraplegia from mye- litis and reflex paraplegia ; but the case is far otherwise ivhen a comparison is in- stituted between hemiplegia from spinal congestion and reflex paraplegia. In reflex paraplegia the paralysis is not associated with tingling, numbness, or auffisthesia : in paraplegia from spinal congestion it is the same, with the single exception, that th^re may be at one time or other a trifling degree of tingling at the extreme tips of the fingers or toes. In reflex paraplegia there are fluctuations in the degree of the paralj-sis ; so also in paraplegia from spinal congestion. In reflex para]ilegia there is no marked change in the "nutrition of the muscles : so also in paralysis from spinal congestion. And, lastly, in reflex paraplegia, as in paraplegia from spinal congestion, a cure is neither an impossible, nor even an im- probable, event. As to essential charac- teristics, indeed, I can find marked differ- ences when reflex paraplegia is compared with paraplegia from myelitis, but none when reflex paraplegia is put in comparison with hemiplegia from spinal congestion. Nor is reflex paraplegia always to be distinguished by being obviously preceded by eccentric disorder in the urinary organs or elsewhere. It is, indeed, as Sir W. Gull has well pointed out, "not always easy to determine at this point whether symptoms have a central or a peripheral origin. . . . There is, perhaps, no fact to be more insisted upon than the normal dependence of the sympathetic upon the integrity of the spinal system. As a result of this dependence, we learn that dyspepsia, vomiting, constipation, colic, vesical catarrh, prostatic irritation, pains in the joints, and many other peri- pheral disturbances, may seem to precede the central malady, and to be the cause of it, when in truth they are its effects." And again : "It is no new fact in medi- cine, that cerebral exhaustion may impair the functions of the cord (especially of the lower segments), and give rise to precisely those symptoms which have been set down as pathognomonic of urinary para- plegia." Dr. Brown-Sequard has taken a very different view of reflex paraplegia to that which is here taken. He regards this disorder as due, not to spinal congestion, but to a state of the circulation diametri- cally opposed to this. He believes that a state of irritation, commencing eccentri- cally, is propagated along the vaso-motor nerves, of which the result is, primarily, contraction of bloodvessels in, and, sec- ondarily, exclusion of the due amount of blood from, one or more of the three parts following — the spinal cord, the nerves proceeding to or coming from the cord, the muscles. He believes that the proper activity of the nervous tissue or muscle is starved into paralysis for want of blood ; and he founds this view on the fact that a state of iriitation in the vaso-motor nerves may proceed from a distant point and produce contraction of the vessels, and upon the fact that traces of organic dis- ease are wanting after death in many cases of reflex paraplegia. The argument, indeed, is all but as conclusive as it is masterly and original. The same evi- dence, however, admits of a very different construction, and that even without any- thing like special pleading. It is, no doubt, true enough that a state of irrita- tion in vaso-motor nerves may lead to contraction in bloodvessels, and thereby exclude a due amount of blood from the part to which these vessels belong ; but it is not less certain that the same state of irritation carried beyond a given degree, either in time or in intensity, may, by paralyzing the vaso-motor nerves, lead to relaxation of vessels, and, thereby, to the admission into them of an undue amount of blood. Moreover, it may also be assumed, as a thing by no means improbable, that the contraction of the coats of the relaxed and paralyzed vessels in rigor mortis may prevent any marked traces of such vascu- lar engorgement being met with after death ; at any rate it is impossible to infer, from the absence of such traces of conges- tion after death, that there was no such congestion during life. In itself, indeed, the evidence adduced by Dr. Brown- Sequard in favor of his theory of reflex paraplegia is insufficient to decide whether his view or that which I venture to put in opposition to it is the correct one, for in reality it may be used equally in sup- port of either view. And certainly it would seem to be a collateral objection to the view which connects reflex para- plegia with a state of capillary contraction and comparative bloodlessness brought about by irritation in vaso-motor nerves, in states where the whole nervous system is in a state of great irritation, as in tet- anus, and in the state specifically desig- nated spinal irritation, and where it may be assumed that the vaso-motor nerves REFLEX PARAPLEGIA. IOCS participate in tliis state of irritation, and produL-e vascular contraction and com- parative bloodlessness in tlie spinal cord and elsewhere, that paraplegia or any form of paralysis is precisely the symp- tom which is not present. Moreover, Sir W. Gull makes some remarks on urinary paraplegia which have an important col- lateral bearing on the subject in hand, as tending in no ordinary degree to support the conclusion to which all the previous considerations tend : "If,"'he says, "we regard the nature of the urinary disease which most commonly leads to paraplegia, we shall find that it is an inflammation, either in the prostate, bladder, or kid- neys ; and we shall also find, that it is only after chronic inflammation has lasted a long time that the paraplegic weakness supervenes. It is in just those cases where there is most irritation, and but little inflammation, that paraplegia does not occur. Uric acid and oxalate of lime calculi may cause hajmaturia and any amount of irritation, but unless suppura- tive inflammation set in, paraplegia is not produced. A review of all the recorded cases of urinary paraplegia will show that it is the inflammatory condition of the urinary organs which leads to paralysis, and not one of irritation." In speaking in this manner, however, I do not wish to confound reflex paraplegia with spinal congestion. On the contrary, the more I see of practice the more I am disposed to think that there is a reflex variety, not only in paraplegia from spinal congestion, but in every form of paraple- gia ; that, in fact, the causes at work in producing all spinal maladies are reflex in their character as well as centric, — reflex, it may be, rather than centric. [Dr. Brown-Sequard's theory upon this subject finds its only support in a supposition, in regard to vaso-motor excitation and its results, which is more purely hypothetical than almost anything else asserted in modern Physiology. For such cases of paraplegia as are, by exclusion, made out to be truly reflex in origin, the explana- tion proposed by Handfield Jones may be considered to be the best. This is, that a morbid impression conveyed from an organ (as the kidney) in a state of dis- order, to the nerve-centres, may be so overwhelming as to be inhibitory of the normal action of the parts innervated by those centres. "Paralysis without appa- rent lesion," in this sense, has been known since the time of Whytt. Morgagni re- corded the occurrence of amaurosis, im- mediately produced by a blow (from the spur of a cock) upon the eyebrow, wound- ing the supra-orbital nerve. Handfield Jones reports a case in which strabismus from paralysis of the rectus oculi externits disappeared after a piece of dead bone was removed from a whitlow on the thumb. Lawrence cured blindness (in one eye) in a case of thirteen months' standing, by the extraction of a carious tooth, into which a splinter of wood had been forced by an accident. Worms, other causes of intestinal disturbance, and uterine irritation, have also occasionally produced reflex paralysis (not nearly al- ways paraplegic), by a similar morbid in- hibitory action.— H.] If the true view of reflex paraplegia be the one which is here taken, it follows that the treatment of that forna of this disorder which is defined by Dr. Brown- Sequard will be substantially the same as the treatment of paraplegia from spinal congestion, and not that which has been recommended on the supposition that the spinal cord is starved for want of blood in consequence of its vessels being kept in a state of contraction by irritation of the vaso-motor nerves. Nay, even the neces- sity to treat eccentric disorder or disease in the urinary organs or elsewhere can scarcely be considered a peculiar feature in the treatment of reflex paraplegia ; for, in fact, it is always an essential part of any sound plan of treatment in any dis- ease of the spinal cord, whether originating in the cord or at a distance from the cord, to make a point of doing everything to remove or mitigate any eccentric malady. It is always necessary to do this, because an eccentric malady, whether primary or secondary to the spinal disorder, or whether having no other than a purely accidental relation to this disorder, inva- riably reacts prejudicially upon the cord. This eccentric malady must of course be dealt with on general principles, this thing or that being done according as irritation or inflammation may happen to be the predominating condition. In uri- nary paraplegia, for example, it is very possible that the local application of opium or belladonna to the urethra, as recommended by Dr. Brown-Sequard, may be of much use ; this is very possible on any hypothesis : but with respect to the frequent introduction of catheters, with a view to relieve irritation, I think it is difficult to come to a different con- clusion to that which Sir W. Gull has arrived at. "This course," says this able physician, "is not unattended with danger. There is no part of the treat- ment which calls for more discrimination. The diseased textures and veins about the neck of the bladder are so prone to suppuration, that the catheter is often a fatal weapon. The few scattered in- stances, such as that recorded by Dr. Graves, where immediate good effects have followed, have had undone influence towards promoting mechanical interfer- ence. Carefully considered, they do not warrant the inference drawn from them. If the urinary passages are so contracted 1004 DISEASES OF THE SPINAL CORD. that tlio bladder cannot empt}' itself, the catheter is obviously required ; but it mast be simply prescribed on tliese grounds. The rule for its use is the same as in the treatment of the aural passages, when the middle ear is diseased. If there be a free exit for the excretions, the less mechanical interference the better. As meddlesome midwifery is bad, so is the meddlesome employment of the catheter in urinary paraplegia. Cases might be quoted where a fatal issue has been in- duced by the meddlesome interference with a diseased bladder, under the hope of removing some hypothetical cause of reflex irritation." X. Infantile Paralysis. This disorder, to which attention seems to have been directed first of all by Un- derwood, Marshall Hall, and Kennedy, is the paralijsie [elite essentielle) de Venfance of several French writers. [Polio -myelitis Anterior Acuta, Kussmaul, Erb.' — II.] It attacks children indiscriminately, without any regard to sex, between the age of six months and two years, at the time of the first dentition more especially : and it is the grand source of shrivelled, half-dead limbs, club-feet, and other sad deformities. Mr. William Adams, who has had am- ple opportunities for becoming practically acquainted with the history of infantile paralysis, and whose account of this dis- order is more to the point than any other with which I am acquainted, indicates these as the most trustworthy character- istics : 1. The paralysis is usually partial, single muscles or groups of muscles only being affected. 2. The sensation in the paralyzed parts is usually perfect, or all but perfect. 3. The bladder and low^er bowel are usually not distinctly implicated in the paralysis. 4. The paralyzed mus- cles are at no time rigid. 5. Great im- provement or complete recovery is the rule, and not the exception. 6. The pa- ralysis is usually neither accompanied nor preceded by "head symptoms." The onset of the disorder is generally sudden and unexpected. The child is put to bed well, and in the morning it is found to be paralyzed. Or the paralysis may be grafted upon some marked febrile disor- der, as gastric or remittent fever, measles, or typhus ; or upon some other malady, as hooping-cough or pneumonia. In some cases there may be transitory and trifling feverishness at first, but fever is certainly no essential accompaniment at any time. Now and then, but only in exceptional cases, the disorder may be ushered in by convulsions or drowsiness. [' Ziemssen's Cyclopaedia of Practice of MediciuB, vol. xiii.] The paralysis has usually a wider range at first than that which it takes after- wards ; in other words^ the paralysis is more or less general at first, and more or less localized afterwards. Thus it is a common thing for all the limbs to be at- tacked and for only one leg to remain paralyzed, or, rather, to remain partially paralyzed, for there is a certain degree of recovery in certain nmscles, even in the worst cases. It is the constant rule, in- deed, for recovery to be slower in the legs than in the arms, and in certain muscles than in others. Usually the disease does not mount high enough to paralyze mus- cles whose nerves are given off above the true limits of the spinal cord. There is certainly no loss of sensation in infantile paralysis. On the contrary, as Dr. West remarks in his admirable treatise on the diseases of infancy and childhood, ''sensa- tion in the affected limb appears to be exalted when the paralysis is recent, the degree of hyperoesthesia in the early stage being in such cases proportionate to the loss of power which afterwards is appa- rent." Moreover Dr. West proceeds to say, "In some instances the exaggerated sensibility continues for several weeks, though this is unusual ; and when this is the case, the leg being the seat of the affection, and the paralysis incomplete, the existence of hip-joint disease may very likety be suspected. In such a case the child bears all its weight on the healthy limb, turns the foot of the affected side inwards when walking, and stands with the toes of that foot resting on the dorsum of the foot of the healthy side. Still it will usually be found that the ex- aggerated sensibility of the paralyzed limb varies greatly at different times, while that extreme increase of suffering produced in cases of hip-joint disease on striking the head of the femur against the acetabulum by a blow upon the heel, and the fixed pain in the knee of the affected side, so characteristic of diseases of the hip-joint, are absent ; and these points of difference will enable you to distinguish between the two affections. One other important means of diagnosis is furnished by the presence or absence of an increased temperature over the suspected joint, the value of which means in determining the presence or absence of inflammation about any particular spot is dwelt upon by Mr. Hilton in his lectures delivered recently at the College of Surgeons." The peculiarities of infantile paralj'sis, so thinks Mr. Adams, point to a special pathology which has yet to be made out satisfactorily. As it seems to me, how- ever, these peculiarities, instead of show- ing, as Mr. Adams beheves, that infantile paralysis is unlike paralysis in adults, only show a close analogy to, if not an actual identity with, the paralysis which has INFANTILE PARALYSIS. 1005 })een seen to result from spinal conges- ! found in the two cases examined after tion. In nifantile paralj^sis the paralysis ' death by M. Laborde, the writer of a very ' able treatise on infantile paralysis recently is partial : in paralysis from spinal con- gestion it is the same. In infantile paral- ysis sensation is exaggerated rather than dulled in paralyzed parts : in paralysis from spinal congestion it is the same. In infantile paralysis the bladder and lower bowel are obedient to the will : so also in paralysis from spinal congestion. In in published. In these two cases, without doubt, there were certain organic chan»-es in the spinal cord and in" some of Its nerves, but these changes are plainly not essential to infantile paralysis as defined alike by M. Laborde and Mr. Adams ; for the simple fact is, that the clinical history fantile paralysis the paralyzed muscles J of these cases is not clearly that of in are limber, not rigid : so also in paralysis fantile paralysis so defined. In a word from spinal congestion. In infantile pa- there is nothing in the scanty contribu- ralysis recovery more or less complete is tions of the dead-house to show that the the rule rather than the exception : so very closest relations may not exist be- also, and very much in the same order, in tween the disorder under consideration paralysis from spinal congestion. In in- and spinal congestion, fantile paralysis "head symptoms" are | [Accumulated observations by Prevost, exceptional phenomena at any time : so 1 Yulpian, L. Clarke, Charcot, Joftroy and also in the paralysis from spinal conges- ! others, have led to the conclusion, that tion. Neither do I know of anything to invalidate the conclusion which those re- semblances would seem almost to neces- sitate — that infantile paraly.sis, as defined by Mr. Adams, is notliing more than paralysis from spinal congestion. Moreover, this conclusion is not dis- credited by the disclosures of morbid anat- omy. There were no traces of organic disease either in the spinal cord or brain or nerves in the four cases of genuine in- fantile paralysis which were examined after death by MM. Barthez and Rilliet, Dr. Fliess, and Mr. Adams, all four most competent observers. The evidence sup- plied by these cases is indeed purely nega- tive. Nor is evidence more positive to be Fragment of a tran averse section of the Syiinal Cord taken from the lumbar region, in a case of Infantile Spinal Paralysis occupying the rK'ht inferior extremity. The right anterior cornu of gray matter Is represented. The lesions affect exclusively the antero-exterual group of nerve-cells; a cervix cornu posteHoritt ; b, postero-ex- ternal group of nerve cells : c,antero-external group. The cells of the latrer group have completely disappeared, whereas those of groups & and d are perfectly distincC ; ci, internal group ; e, the commissure. (Charcot. jj the most characteristic anatomical changes in this disorder affect the gray matter of the anterior cornua of the cord. While it is probable that congestion only has oc- curred in those cases whose duration is shortest, and whose progress is most favorable, Charcot and others regard the process as inflammatory in very many cases ; commencing in the nerve-cells, and aflecting afterwards the neuroglia ; later, with atrophic alteration, the motor nerves and muscles. In the anterior cor- nua, degeneration soon follows inflamma- tion. The large pyramidal cells undergo pigmental change, and shrink away, whole groups of them disappearing in time completely. This atrophy is not always symmetrical ; it may be either uniform or in patclies, for a con- siderable distance in the length of the cord. — H.] The duration of infantile paralysis is very variable. It may pass off" in a few days, or even a few hours : it is more likely to occupy several weeks or months in this process of im- provement. Improvement, to a greater or less degree, is in- deed the rule, and not the ex- ception ; and it may even be said that tlie cases which stop far short of recovery are by no means common. Mr. Adams savs, "It is generally supposed that, unless recovery takes place within a few months, the paralysis is persistent through life ; ' but I have seen many cases in which improvement has proceeded, to a very useful ex- tent, several years after the seizure ;" and to the truth ot this remark my own experience bears ample testimony. In- deed, I should say from what I have seen, that if the paralyzed muscles retain their electro- contractility and electro-sensi- 1008 DISEASES OF THE SPINAL CORD. bility, and so show that they have not passed into that state of fatty degeneration into which they always tend to pass even- tually, there appears to be scarcely any limit to the time in which improvement, and even complete recovery, is possible. The group of muscles most frequently affected" in infantile paralysis, according to Mr. Adams, are— 1. The muscles of the anterior part of the leg, forming the extensors of the toes and the flexors of the foot ; 2. The extensors and supinators of the hand, these muscles being always affected together ; and 3. The extensors of the leg, and with them generally the muscles of the foot, as in the first group. When single muscles are afl'ected, the most likely to suffer are these : 1. The extensor longus digitorum of the toes ; 2. The tibialis anticus ; 3. The deltoid ; and 4. The sterno-mastoid. The deformities produced by infantile paralysis are most frequently met with in the feet and legs, because these are the parts most frequently affected ; and the particular kind of deformity varies, of course, with the muscles involved in the paralj'sis. "The most frequent kind," says Mr. Adams, "is that of (1) talipes equinus ; and the other deformities occur in the following order — (2) equino-varus ; (3) equino-valgus ; (4) calcaneus, or calcaneo- valgus of one foot is generally found with equino-valgus of the other." Mr. Adams is of opinion that the great cause of the deformities which are met within infantile paralysis is the "adapted atrophy" of Sir .James Paget, this change taking place chiefly in the opponents of the muscles which have suft'ered from paralysis. If, for example, the anterior muscles of the leg are paralyzed, the ante- rior portion of the foot drops, and the heel is raised, not by active contraction of the posterior muscles — for the division or paralysis of one set of muscles does not excite active contraction in the opponent muscles — but in consequence of the posi- tion assumed by the foot from its me- chanical relations with the leg. Another cause of deformity is obviously atrophy and actual or comparative arrest of de- velopment in the paralyzed muscles ; for, unless the paralysis soon passes off, it is plain that the muscles will not only waste, but be left behind in the rapid process of development which is everywhere at work in a young and growing child. Mr. Adams is also of opinion that the early and late rigidity of Todd and true spasm have very little to do in causing the de- formities in question : and so it may be in the deformities connected with that form of paralysis to which he restricts the term infantile — that form which is un- doubtedly the common variety of infantile paralysis, and which, as it would seem, is dependent on spinal congestion. It is very certain, however, that infants and children are liable to more than one form of paralysis, and that there are deformi- ties associated with rigid as well as with flaccid muscles. It is very certain that this rigidit}' may be either "early or late," as distinuuished by Todd, or even still more decidedly spasmodic than that i form which is called "early rigidity." In a word, inlantile paralysis is a desig- nation as little to be defended as would be the term adult paralysis ; for on inquiry it is found that in children, as in adults, there is more than one form of paralysis, and that all the forms which may happen in adults may be repeated in children. The form of paralysis which has been de- scribed as infantile is unquestionably the commonest, and the other forms are so uncommon as to be little more than ex- ceptional ; and this, in fact, is all that can be said to justify the notion that infantile paralysis is a definite disorder of the spi- nal cord peculiar to infants. The treatment of the deformities, espe- cially of club-foot, resulting from the so- called infantile paralysis, is a subject of much , practical interest and difflculty. Mr. Adams says : " The probability of benefit in such cases by anj' surgical pro- cedure seems scarcely ever to be enter- tained. The existence of paralysis is sup- posed to contra-indicate any surgical in- terference ; but, from these apparently hopeless and essentially incurable cases some of the most striking and most valu- able results of surgery are obtained by a combination of surgical and mechanical treatment. Mechanical aid, alone, is fre- quently sought from the instrument- maker, but his art is powerless when any considerable amount of deformity exists ; and it is oul}' by a scientific combination of surgical and mechanical skill that much good can be effected. In all these cases the treatment essentially consists in the removal of existing deformities by te- notomy and mechanical means, and a sub- sequent compensation for the exii- ting pa- ralysis by mechanical support, varying in diflerent cases according to the extent of the paralysis." And no doubt very satis- factory results ai'e obtained by those means. At the same time it is certain that in manj^ cases very satisfactorjf re- sults may be obtained without tenotomy, and without apparatus, by means used I with the view of bringing back power into the paralyzed muscles — electricity,' ' There are certain forms of paralysis in which the paralyzed muscles do not react to the most powerful induced electric currents, but react energetically to a galvanic current of low tension, slowly interrupted (the labile current of Remak). The diagnostic and the- rapeutic bearings of this fact have yet to be SPINAL HEMORRHAGE. 1007 movements of various kinds, shanipoo- ings, and others ; and my own experience has convinced me that this fact is not yet sufficiently recognized and acted upon in practice. That in many cases neither tenotomy nor apparatus can be dispensed with, I fully believe : that in all cases the electrical and gymnastical parts of the treatment are of primary rather than of merely secondary importance 1 am every day more and more convinced, because every day I meet with instances of mus- cles which I should once have looked upon as hopelessly paralyzed being resuscitated by those means. Indeed, I cannot but think that so long as institutions espe- cially set apart for orthopfedic purposes are wanting in properly furnished electri- cal rooms and gymnasiums, there must be in some essential points a necessity for a great reformation in orthopaedic practice. [Acute SiJinal Paralysis of Adidts. — Since 1805, it has been shown by Meyer, Du- chenue, Frey, Seguin, Erb, and others, that an affection closely corresponding to Infantile Paralysis occurs sometimes later in life. Beginning rather abruptly, with febrile symptoms, violent headache, sometimes delirium, and vomiting, mus- cular paralysis soon follows ; generally in the lower limbs. Sensation is not im- paired ; nor is control lost over urination and defecation. In some cases improve- ment begins in a few weeks, and goes on to complete recovery. Much more fre- quently, the muscles very slowly, and some of them to the last imperfectly, re- gain motility. Contraction of the mus- cles of the limbs may become permanent; although deformities never result, to any- thing like the extent observed in children. This form of attack does not appear to be dangerous to life ; but its effects seldom entirely pass away. Cases which may be correctly called transitory or temporary are rare.'- — H.J worked out, but so far the therapeutic prom- ise is good. The phenomenon in question has been already observed in several very different oases — in facial palsy (first noted by Baierlacher), in certain cases of infantile pa- ralysis (discovered by J. Netten Radcliffe, of London, and Hammond, of New York, inde- pendently of each other), in certain cases of local palsy, e. g., palsy of the extensors of the forearm and of other muscles, from lead- poisoning (Bruckner and J. N. Radcliffe), in paralysis of the deltoid, not from lead (J. N. Radcliffe), in certain cases of muscular atro- phy (J. N. Radcliffe), and in paralysis from traumatic inj ury of a nerve (Bruckner) . [' Amongst the cases of this disease re- ported in America, may be mentioned those of Seguin, forty-five cases (Myelitis of the Ante- rior Horns, New York, 1877) ; two recorded hy Althaus (Amer. Journal of Med. Sciences, April, 1878) ; and five by W. Sinkler (Am. Journal of Med. Sciences, October, 1878).] XI. Spinal Hemokehage. Blood may be effused into the substance of the cord l)etween the arachnoid and pia matur, into the sac of the arachnoid, be- tween the dura mater and arachnoid, or between the dura mater and the osseous canal— anywhere in or about the spinal cord, in fact. Hemorrhage in the sub- stance of the cord, the haimatomyelie of Ollivier, may be a consequence of myeli- tis, the bloodvessels breaking up in the softening of the cord, and so allowing the blood to escape. It was so in the acute case which I took as my text when speaking of myelitis, for here the blood was collected at one point in the softened nerve matter to an extent which at first sight suggested the idea of hemorrhage into the cord rather than that of myeli- tis. Hemorrhage under or upon the spi- nal membranes, the hcematorachis of Olli- vier, may be a consequence of cerebral hemorrhage, the blood overflowing from the cranial into the spinal cavity, and perhaps mixing with the spinal fluid ; or it may result from spinal congestion, spi- nal meningitis, myelitis, tetanus, hydro- phobia, and certain other maladies. All these cases, however, are so uncommon as to be little more than exceptional. In fact, hemorrhage either into the substance of the cord, or under or above the spinal membranes — except as the result of some accidental injviry to the spine, as in death by hanging, or in (^ases of still-birth where it has been necessary to employ much force to bring about the delivery — is, to say the least, a very uncommon affection. The symptoms of spinal hemorrhage are by no means clearly marked. Sud- den and acute pain in the spine at the seat of the effusion, and sudden paralysis and loss of sensation, more or less com- plete, in the parts below this point, ap- pear to be the chief symptoms where ex- tensive hemorrhage has taken place into the substance of the cord. Sudden and acute pain in the spine would also seem to be a prominent symptom in hemor- rhage below or above the spinal mem- branes, but not sudden paralysis and anaesthesia. In this latter case, indeed, instead of paralysis there have been some convulsive or spasmodic symptoms, and instead of anaesthesia some hyperfesthe- sia. In some cases, as in one quoted by Dr. Copland, the pain may be not in the back, but at a distance from the back ; and in other cases, and this not unfre- quently, pain may be greatly masked by the shock of the accident which has caused the hemorrhage, or by the shock attendant upon the laceration of the spi- nal cord by the effused blood. When the hemorrhage is in the medulla oblongata, and high up in the cord, the symptoms may be rather like those of epilepsy than 1008 DISEASES OF THE SPINAL CORD. anything else — loss of consciousness, con- vulsion more or less general, choking noises, and the rest — and this equally whether the blood is effused into the sub- stance of the cord or around it : and this fact suggests the possibility, to say the least, that the convulsive or spasmodic symptoms, which have by some writers (on what to me seem to be insufficient grounds) been supposed to distinguish hemorrhage under or above the spinal membranes from hemorrhage into the substance of the cord, may in reality be due to irrita- tion transmitted to the medulla oblongata and upper part of the cord, and not to irritation acting upon the membrane or membranes. Moreover, when the hemor- rhage is high up in the cord, priapism and distress of breathing are found to ligure conspicuously among the symp- toms, as they do also in other cases where this part of the cord is damaged by dis- ease or injury. In a few instances, the (•ymptoms of spinal hemorrhage are pre- ceded by symptoms indicative of spinal congestion, or inflammation, or irritation. Remains of old apoplectic cysts, similar to those so often found in the brain, have been met with in the spinal cord, even in the medulla oblongata and upper part of the cervical region ; but these signs of partial recovery arc, to say the least, ex- ceedingly exceptional. Indeed the mis- chief done by the hemorrhage is generally not only irreparable, but very speedily fatal, and that too in spite of ever3'thing that can be done to promote recovery, XII. Noif-INFLASniATOIlT SOFTENING. Two well-marked varieties of softening of the spinal cord are detected by the naked eye — the red and the white. In both varieties the microscope brings to light broken down nerve-tissue mixed up with a number of bodies known as granule ■masses — large bodies, whose principal con- stituent is fat, black-looking, from not transmitting light, and somewhat like mulberries, from being built of a number of round bodies or granules. "It was once thought," said Dr. Wilks, "that these masses denoted inflammation. But you find them in any degenerating part, as a decaying strumous gland, or a can- cerous tumor, or a phthisical lung : and the question of their formation in the brain or cord is not yet answered ; whether they originate in inflammatory cells, or are the natural cells of the nerve- structure degenerated. In some you may still see a wall and a nucleus, which points ( to the former opinion as the more cor- rect." The red variety of softening is often in parts yellow rather than red : the redness being due to increased vascularity or effused blood-corpuscles, one or both ; the yellowness to the presence of fibrillat- ed tissue, nucleated fibre, pus-corpuscles, or some other form of distinctly intlanmia- tory product. In a word, there can be no doubt of the inflammatory origin of the red variety of softening. In the white variety of softening, on the other hand, there are generally an atheromatous state of the vessels and other signs of true de- generation, the vascularity is evidently diminished, and there is an absence of those distinctly inflammatory products which have just been enumerated. It would seem, indeed, that the white vari- ety of softening differs essentially from the red, in that, instead of being the re- sult of inflammation, it is brought about by the parts being starved and atrophied for want of blood. With respect to the reality of these diflerences between these two varieties of softening there ajjpears to be little or no reason for doubt : at the same time it must not be forgotten that it is not always easy to draw the line be- tween these two varieties, and that they both may exist together in the same cord. The symptoms of non-inflammatory softening would seem to be identical with those of the more chronic forms of myeli- tis. The more tardy the development of these symptoms, and the older the pa- tient in years or in constitution, the more likely is the case to be one of non-inflam- matory softening : and this is all that can be said in the matter of diagnosis. Prac- tically, however, this want of definiteness is of no moment ; for in the chronic form of myelitis the degenerative process has more to do in bringing about the diseased changes in the cord than the inflamma- tory, and more to do also in supplying the indications for treatment. Nay, it may even be held that the same remark applies to some extent to the more acute forms of myelitis as well as to the more chronic, for it is with the ruin rapidly produced by the inflammation rather than with the inflammation itself that the practitioner in medicine has to cope almost, if not altogether, from the very onset of the disease. XIII. Induration, Like the opposite condition of softening, induration (sclerosis) of the spinal cord is one of the consequences of myelitis, chro- nic or acute, of the chronic form more especially. Induration of the cord is gen- erally associated with atrophy — atrophy often more marked in the white matter than in the gray — and with a condition so curiously bloodless that a section is not unlike that of white of egg boiled hard. In its highest degree the cord may have a leather-like or fibro-cartilaginous hard- ness and consistency. Induration is a INDURATION. 1009 miicli less common change than softenhii;- : it has no .symptom:* by which it can be distinguisluid from softening: and it is often met with wlicn it was not expected and under very different circumstances^ as after acute myelitis on the one hand or after long-standing epileptic disease on the other. [In recent neuro-pathology, sclerosis has a much larger place than it had a few years ago. By the researches especially of Vulpian, Charcot, Ordenstein, Frerichs, Rindfleisch, Tiirck, rrommann,"\yestphal, Erb, Gull, Lockhart Clarke, Moxon, Se- guin, and Hamilton, it has now been more exhaustively studied than almost any other morbid affection of the nervous ap- paratus. From the nature of the diseases in con- nection with wliich it has been observed, whose progress is ordinarily slow and protracted, the actual primary character of the process of which it is the result is known, almost alone, by inference and analogy. While very many autopsies of sclerosis have been made at the end of maladies of several years' duration, it has been only cases in which life has been shortened by intercurrent attacks of other kinds that have given opportunities for examining the morbid changes going on in the same maladies in their earlier stages. It is, however, the common opin- ion of pathologists, that inflammation has generally to do with the beginnings of sclerosis of the brain or spinal marrow, very much as it has with the commence- ment of cirrhosis of the liver, lung, or other organs. Some writers make the term sclerosis synonymous with chronic inflammation (Bristowe). At all events, the later and more im- portant alterations are atrophic and degen- erative. The nervous elements, cells, or fibres, according to the part involved, waste away, and in their place the con- nective tissue (neuroglia) in eml^ryonic form undergoes increase ; with fibroid, amyloid, and pigmentary degeneration, in various degrees, proportions, and extent. In progressive muscular atrophy and general spinal paralysis, sclerosis has been found in the anterior horns of the gray matter of the cord. In unfavorable cases of infantile paralysis, and the similar spinal paralysis of adults, the same morbid change is believed, upon good evidence, to occur. Locomotor ataxy is now known to have for its characteristic lesion sclerosis of the posterior white columns of the cord. Lateral sclerosis of the cord gives rise to the symptoms of progressive spasmodic paralysis ; a like affection of the motor nuclei in the medulla oblongata, is con nected with glosso-labio-laryngeal paral- ysis ; and multiple or disseminated scle- rosis is the name now given, on an anatomical basis, to a disease whose clini- VOL. I.— 64 cal phenomena vary according to the seats of the disease in dittereut parts of the brain, medulla oblongata, and spinal marrow. It seems appropriate, in this place, to give some attention to such of these disorders as are not otherwise treated of in this work, viz., lateral spinal sclerosis ; sclerosis of the medulla oblon- gata ; and multiple or disseminated scle- rosis. Lateral Spinal Sclerosis.— This has been found anatomically associated with at least two affections : one primary, in the cord, and the other secondary, following cerebral hemorrhage, or softening ; or a similar lesion of the crura cerebri, medulla oblongata, pons, or of the spinal marrow itself. The latter of these forms (secondary) is apt to be unilateral (like the lesion which it follows), as a descending sclerosis. It occurs on the side opposite to the primary lesion, and can be traced upwards through the decussation to its site. In its descent, the sclerosis becomes more and more limited, so as, in the lumbar part of the cord, to include often but a small portion of the lateral column. The gray sclerotic patches in this form are rounded when seen in transverse section, and do not reach the pia mater exteriorly. This is the case in "Tiirck's degeneration," fol- lowing cerebral hemorrhage, and also, generally, in sclerosis descending from in- fiaramation or hemorrhage of the cord. In the latter instance, particularly, the sclerotic change stops short of the poste- rior cornu, being separated therefrom by a thin layer of healthy white nervous tissue. In idiopathic or primary lateral scle- rosis, the characteristic lesion is symme- trical upon the two sides of the cord. It occurs at first and chiefly in the crossed pyramidal columns of Flechsig ; posterior to the lateral columns proper, but anterior to the direct cerebellar columns. Exten- sion may take place, however, horizon- tally, so as to include the whole of the posterior half of the lateral column, reach- ing to the posterior cornua. The form of the sclerotic patches is then wedge-like or triangular in transverse section. The ap- pearance of these patches is much the same as that observed in disseminated or multiple sclerosis, of which a more mmute account will be given presently. Primary lateral sclerosis (O. Berger) corresponds most nearly with the tabes dorsalis spasmodka of Charcot, or spiastic spinal pamhjsis of Erb; tetanoid paraplegia of Seguin. When the disease extends so far as to involve the anterior cornua, and is attended by wasting of some of the muscles, it meets the description of Char- cot's "sclerose laterale amyotrophique.' Both forms usually commence between the thirtieth and the fiftieth years of hfe. 1010 DISEASES OF THE SPINAL CORD. Symptoms of the early stage of lateral sclerosis are mainly those of muscular weakness and paresis ; that is, diminution of motor power short of actual paralysis. Gradually, however, a truly paralytic con- dition is developed. The limbs at first drag heavily ; but before becoming para- ; lyzed, signs of irritation of the motor j centres occur, in spasmodic symptoms. | These are, twitchings of the legs, when at i rest, especially after exertion ; trembling of the limbs when, in sitting, the toes are made to touch the floor ; and an increas- ing tension of the muscles, producing a peculiar gait in walking. The legs are held close together, the knees bend for- ward, the patient rises at each step on his toes, with a sort of hopping motion, so that he is constantly in danger of falling forward. Fig. 62. A B A. Antero-Iateral Sclerosis. B. Posterior Spinal Sclerosis. {After Charcot.) At this stage, there is a marked in- crease in the tendon-reflex (see Locomo- tor Ataxy, in this volume) of the knee and other parts. This phenomenon can, in patients having lateral sclerosis, be readily shown with the triceps and biceps muscles of the arm, the biceps flexor fem- oris, and other muscles. The foot-clonus also, induced by tapping the tendo Achil- lis while the foot is held in a flexed po- sition, is exaggerated in the same cases. No disturbance of sensibility or intelli- gence exists, nor muscular atrophy ; and no troubles affecting the bladder, rectum, or sexual organs. There is not, as in the subiects of locomotor ataxy, a disposition to throw out the limbs in walking, nor any inability to stand erect with the eyes shut or in the dark. Slowly the disease advances, to com- plete paralysis ; first of the lower and then of the upper limbs ; with, also, rigid con- tractions of their muscles. At last the patient is unable to walk or stand ; yet the vegetative functions of the body are commonly unimpaired. In such a con- dition he may continue to live for many years, death finally resulting from some other disease. As already said, should the sclerotic change extend as far as the anterior cor- nua of the cord, muscular atrophy is added to the above symptoms ; giving the fea- tures of the " sclerose laterale amyotro- phique"of Charcot. Recovery from spasmodic spinal paral- ysis is not to be expected . Charcot doubts its possibility in any case. Westphal has reported one instance of the disappearance of the disease, after all its symptoms had been progressively developed. Dr. E. von der Velden has recorded' the particulars of a case occurring in Kussmaul's Clinic at Strasburg, in which, after a rather acute onset, entire recovery finally re- sulted. Sclerosis of the Medulla Oblongata is the anatomical designation of what was first described by Duchenne as muscular paral- ysis of the tongue, soft palate, and lips ; the glosso-labio-laryngeal paralysis of Trousseau ; the progressive bulbar paral- ysis of ISTachsmuth ; or, more descriptively yet, progressive bulbo-nuclear paralysis of Kussmaul.^ It has been most generally referred to in medical works by the name proposed by Trousseau, upon clinical grounds ; glosso-labio-laryngeal paralysis. If the anatomical basis of nomenclature continues to obtain the preference of pa- thologists for the group of diseases now under consideration, hidho-nuclear sclerosis would seem to be most consistent with the other titles which have been named. Amongst chronic diseases, there is none more terrible in its course than this. Be- ginning mostly after the age of forty, gen- erally in males, its first symptoms are those of pain and oppression in the neck and back of the head, with dizziness and hesi- tation in speech. The tongue becomes more and more clumsy in its action, both in articulation and in mastication. Weak- ness of the lips soon increases the difficulty felt in speaking. The mouth falls, giving [' Berliner Klinische Wochenschrift. Sept. 23, 1878.] [2 Erb, in Ziemssen's Cyolopsedia, vol. xiii.] INDUKATION. 1011 a lugubrious expression to the face. Swal- lowing also is impeded, by enfeeblement of tlio muscles of the soft palate; and, later, those of the pharynx and epiglottis. In the act of deglutition, food, and especially liquids, at times may escape into the larynx, producing suftbcation. The voice is altered, growing more and more indis- tinct, and attacks of dyspnoea are fre- quent. At the same time sensibility and intelligence are unaffected. Month after month, the disability of speech, mastica- tion, swallowing, and respiration grows worse, until it becomes almost impossible for any nourishment or drink to be swal- lowed. At last, unless anticipated by some intercurrent attack, as, for exam- ple, of pneumonia, death will ensue from starvation. Not unfrequently, coincident with the above symptoms, progressive atrophy may be observed in a number of the muscles ; it is first, and especially, noticeable, in the smaller muscles of the hand. After death, sometimes the unaided eye can perceive no morbid change in the me- dulla oblongata. In many cases, how- ever, diminution in bulk and alteration of consistence, with gray discoloration in spots or patches, may be seen. Micro- scopic examination has shown the charac- teristic change to be a yellow pigmentary degeneration of the nuclei of the hypo- glossal, spinal accessory, vagus, and fa- cial nerves. The nerves and nerve-roots themselves partake of this atrophy and degeneration. AUiod changes, especially fatty atrophy, are found to have taken place in the muscles supplied by these nerves ; those especially of the tongue, lips, palate, and lower portion of the face. It appears to be at the origin of those fila- ments of the facial nerve which are dis- tributed in its inferior branches only, that the lesion affecting that nerve occurs. Dribblinsr of the saliva is an almost con- stant symptom at a late stage of the disorder, from paralysis of the lips, tongue, palate, and pharj-nx ;_ with- out any ascertained increase in the salivary secretion itself. The marked atrophy of many mus- cles in this affection has led several pathologists ( Kussmaul, Hallopeau, Charcot, Erb) to assert its essential identity with progressive muscular atrophy. Others (Duchenne, Fried- reich, Hammond) oppose this view. At all events, while the anatomical appearances observed after death do not greatly difler from those of scle- rosis of other parts of the cerebro- nervoua axis, the evidence that in- flammation has any important share in its pathology is very imperfect. Atrophic degeneration of the motor nuclei of the medulla is its charac- teristic lesion ; as a similar change of other motor nuclei coincides with ordi- nary progressive muscular atrophy. From one to five years is the common period of duration of this disease ; from which, when clearly established, there ap- pears to be no prospect of recovery. Multiple Cerebrospinal Sclerosis. — This is. the "sclerose en plaques disseminecs" of Charcot; the insular sclerosis of Moxon. Although disseminated sclerosis may oc- cur in the brain alone, or in the spinal cord only, yet such a limitation is excep- tional ; and the typical history of the disease can be best studied by gi\in^ attention to cases in which both brain and spinal cord are affected. Charcot (to whom is accorded the credit of having made the most valuable contri- butions to our knowledge of this affection) asserts that the first mention of it occurs in Cruveilhier's "Atlas d'Anatomie Pa- thologique, ' ' 1835-1842. Carswell, Turck, Eokitansky, Frerichs, and others subse- quently added similar observations. But the systematic attachment of definite scle- rotic lesions of the cerebro-spinal axis to the clinical symptoms now understood to belong to them, dates from the records and studies of Yulpian, Charcot, and Bouchard of cases at La Salpetriere, from 1862. Multiple sclerosis is most frequent in women, between the ages of twenty and thirty ; it is not unknown, however, in quite young persons. Hereditary predis- position appears to be more marked in connection with it than with either of the other sclerotic affections of the nervous apparatus. Like them, it is obscure in its immediate causation. Exposure to cold and wet, and powerfuUy disturbing mental or moral influences, are belie\-ed to have the most to do with its produc- tion. Excessive exertion, of mind or body, injuries of the head, or shock from concussion of the whole body, pregnancy, Fig. 63. ection taken from the nppermost .,5,.jii,in Disseminatod Scl terior columns are invaded throuKhout their 1 Lesions observed on a secuuu 1,0..^..... ..■,■- • _•,• rpj^g the lesion predominates in their middle region. (Charcot.) 1012 DISEASES OF THE SPINAL CORD. and acute diseases, as t3'phus, cholera, smallpox, have all been supposed to pro- mote or determine its occurrence. When the brain and spinal cord of a patient who has died from multiple scle- rosis are examined with the naked eye, numerous grayish, or yellowish - gray, spots or patches are seen, irregularly dis- tributed (plaques disseminees). They are almost translucent, somewhat of the ap- pearance, in this respect, of cartilage ; clearly defined from the surrounding healthy tissue. Sometimes they are slight- ly elevated above the surface ; in other instances level with it, or sunken a little below it. They are roundish, but irregu- lar and various in form and mode of dis- semination ; not symmetrical upon the two sides of the body. When exposed to the air, they become somewhat rose- or salmon-colored. In consistency, these plaques are firm enough to be felt distinctly by the finger. To the knife they present much more resistance than the normal nervous tissue of the brain and cord. On division, they show a clean smooth sur- face, giving out a small quantity of trans- parent liquid. In a few instances, in which death from other causes allowed examination at an early stage, they have been found (Zenker) soft, gelatinous, semi- fluid in consistence. In number they vary indefinitely in different cases. Their size also varies from microscopic minuteness up to the magnitude of a hazel-nut. In the cord they naay extend longitudinally, in the same column, to a distance of from one to three or four inches. The cortical part of the cerebrum sel- dom contains any sclerotic pfitches. Its white substance, the walls of the ventri- cles, the corpus callosum, pons, medulla oblongata, and cerebral peduncles, all may have numerous spots of sclerosis. In the cerebellum they are commonly fewer, and absent from its exterior sur- face. In regard to the appearances observed after death from this aflection, with the aid of tlie microscope, similar as they are to those of other forms or types of sclero- sis (varying chiefly in location), our read- ers will profit most by the description given by Charcot.' ' ' Microscopical examination, even when a low power is used, enables us to state that the apparently healthy region border- ing the sclerosed patch really presents, to a certain width, very plain traces of alter- ation. When you pass the apparent limit of the sound parts the lesions be- come more marked, and they augment gradually in intensity as you approach the centre of the patch, wliere they acquire their highest degree of development. [i Lectiiros on Diseases of the Nervous Sys- tem, Lect. VI.] Whilst proceeding thus, from the circum- ference to the centre, we are led to recog- nize the existence of several concentric zoneSjWhich answer to the principal phases of the alteration. ' Fig:. 64. Eepresenta a fresh preparation, taten from the cen- tre of a patch of Sclefosis, colored with carmine, and dilacerated. In the centre is Been a capillary vessel, supporting seyoral nuclei. To the right and left of this are axis-cylinders, some voluminons, others of very small diameter, and all deprived of their medul- lary sheaths. The capillary vessel and the axis- cylinders were vividly colored by the carmine ; the axis-cylinders present perfectly smooth herders, with- out ramification. Between them are seen slender iibrillse of recent formation, which form on the left and in the centre a sort of network resulting from the entanglement or anastomosis of the fibrils. These are distinguished from the ax s-cylinders, 1st, by their diameter, which is much smaller ; 2d, by the raroifica- tions which they present in their course ; 3d, by taking no coloration from carmine. Nuclei are seen scat- tered about; some of tbom appear to be in connection with the connective fibrils ; others have assumed au irregular form, owing to the action of the ammoniacal solution of carmine. a. "In the peripheral zone the follow- ing appearances are observed : The trabe- culfe of the reticulum are markedly thick- ened ; sometimes they have acquired a diameter twice as great as that possessed in the normal state. At the same time, the nuclei which occupy the nodes of the reticulum have become more voluminous ; they are occasional^ found to have multi- plied, and you may count two or three nuclei, rarely more, in each node f the cellular form becomes more distinct, owing to the thickening of the trabecule ; the nerve-tubes appear to be further apart each from each — in reality, they have chiefly diminished in volume, and this kind of atrophy goes on at the expense of [' Charcot, " Socigte de Biologie," 1868.] [2 Occasionally some of these nuclei present towards their middle region an indentation vrhich seems to indicate the beginning of scis- sion.] INDURATION. 1013 the medullary sheath, for the axis-cylinder has preserved its iiornial diameter, or it may even be hypertrophied. The amor- phous matter which surromids the fibres of the reticulum, ou all sides, appears to be more abundant than in the healthv state.' ^ Fig. 65. Patch of sclerosis in tlie fresU state: a, lymrhatie sheath of a vessel distended by volumiaous fatty globules ; b, a vessel divided transversely. The adventitious coat is sepa- rated from the lymphatic sheath by a free spacn, the fatty globules which distended the sheath having disappeared'; cc, fatty globules, gathered into small groups, dispersed here and there over the preparation. 6. "The nerve-tubes in the second zone, which may also be called the transUkm zone, have become still more slender. Many of them seem to have disappeared ; in reality, they have been merely deprived of their medullary sheaths, and are now only represented by their axis cylinders, which, ^indeed, sometimes acquire com- paratively colossal dimensions.^ As to the trabeculse of the reticulum, these offer not less remarkable alterations. They have become more transparent, their out- lines are less distinct ; tinallj^, in certain pai'ts, and this is a really fundamental fact, they are replaced by bundles of long and slender fibrils, closely analogous to those which characterize common connec- tive tissue (laminous tissue). These fibrils are disposed in a direction parallel to the greater axis of the nerve-tubes ; hence but little of them is seen in trans- verse sections, except their extremities, which present the appearance of a multi- tude of very fine dots. They tend, we have said, to usurp the place of the fibres or trabeculae of the reticulum ; but they, also, invade the meshes which contain the fi Fromraann, passim. ] [2 Frommann, 2 Theil, PI. ii. figs. 1, and Charcot.] uerve-tubes, according as these diminish i" f ^;? "y loss of medullary matter, so that the reticulated or alveolar appear- ance which the connective gano-ue or matrix shows so distinctly in the healthy state, tends to become more and more eflaced. ' c. "The central region of the scle- rosed patch, you are aware, is that in which the most marked alterations are observed. Here all vestige of fibroid reticulum has disappeared ; we no longer meet with distinct tra- bcculfe or cell-forms ; the nuclei are less numerous and less voluminous than in the external zones ; they are shrunken in every direction, appear shrivelled, and do not take so deep a tint as usual under the action of car- mine.^ They may be observed form- ing little groups here and there in the interspaces between the bundles of fibrilte. The latter, however, have invaded every part. They now fill up the alveolar spaces, from which the medullary matter has completely disappeared. Nevertheless, a certain number of axis-cylinders, those last vestiges of the nerve-tubes, still per- sist in the midst of the fibrils ; but they, in general, no longer retain that comparatively large volume they ac- casioually possessed in the early phases of the alteration ; most of them, in- deed, have even diminished to such a degree that they might be mistaken, so close is the resemblance, for the fibril filaments of new formation, from which, however, we shall soon learn how to dis- criminate them." "I cannot pass over in silence the dif- ferent alterations which those bloodvessels undergo that traverse the nodules of scle- rosis. These changes may be well studied in the longitudinal sections of the cord, hardened by chromic acid. At the com- mencement, that is to say, in the peri- pheral zone, the parietes of these vessels, even of the finest capillaries, appear much thickened, and contain a larger number of nuclei than in the normal state. Xearer the centre of the nodule the nuclei are still more abundant, and, besides, the adventitious coat is replaced by several layers of fibrils quite similar to those which are simultaneously developed in the substance of the reticulum. ^ Lastly, at the final term of alteration, the walls of the vessels have become so thickened that their calibre suffers a notable diminution.* "I should notice, in passing, the habit- [' Frommann, 2 Theil, loc. cit., P. iv. 1, 2, and 3.] [2 Frommann, Charcot.] [3 Vulpian, " Cours de la FaoultS."] [^ Frommann, loc. cit.] figs. 1014 DISEASES OF THE SPINAL CORD. ual presence of a certain number of amy- loid corpuscles in the midst of the fibrillary tissue. But I should at the same time mention the singular fact that these bodies are always less abundant in disseminated sclerosis than in the other varieties of gray induration." The symptomatology of multiple sclero- sis is a variable composite, so to speak, of that belonging to sclerosis of the different portions of the cercbro-nervous appara- tus. Generally, the first signs of the dis- order are obscure. Weakness and drag- ging of the lower limbs, difficulty in using the hands, in writing or otherwise, pains in various parts of the body, muscular rigidity, and sometimes giddiness and headache, are among the earlier indica- tions of cerebro-nervous disorder. There are cases in which, later, genuine ataxia is present, with all the characters of loco- motor ataxy. In such instances, the posterior white columns of the cord have been invaded. Other examples exist in which the features of spasmodic spinal paralysis are equally well marked ; with a corresponding localization of the lesion ; and the same is true of bulbo-nuclear paralysis, as it has been above described. These associations of S3fmptoms with special localities of morbid change having been anticipated in cases of multiple cerebro-spinal sclerosis on the ground of clinical indications, have been repeatedly confirmed by post-mortem examination. The disease is truly polymorphous. Yet, since in most cases the dissemination of the morbid process involves several cen- tres of innervation, a combination of re- sulting symptoms is observed in typical cases. Of such, the following features are most prominent : — Tremor accompanying all voluntary movements ; impairment of speech, with monotony of voice and a "scanning" ar- ticulation ; nystagmus (movement of the eyeballs from side to side) ; amblyopia (feebleness or indistinctness, without total loss, of vision) ; diplopia (double vision) ; vertigo ; and apoiilectiform at- tacks. The last named, however (attacks resembling apoplexy), according to Char- cot, are met with only in about one-fifth of tlie cases observed. Of the volitional tremor, it is to be noticed that it differs in a marked man- ner from that of paral3-sis agitans. In the latter, trembling exists while the pa- tient is at rest, even when lying upon his back ; while in multiple sclerosis, it is absent except when an effort is made with some of the muscles ; it then at once begins. The head is usually in- volved in the shaking of multiple sclero- sis ; almost never in that of shaking palsy. The tremor is smaller, finer, in its vibrations in the latter than in the former complaint. In chorea, again, the erratic movements are more irregular and excursive, having less relation to the in- tended direction of movement, than in multiple sclerosis. The explanation of the tremor in this disease has been cousiderablj' debated. Charcot refers it to the persistence of many of the axis-cylinders of the spinal nerve-fibres, giving rise to an imperfect and jerking conduction of the impulses of the will to the muscles. Erb and Orden- stein object to this view ; and urge tlie greater probability of the tremor being due to the localization of the sclerotic le- sion in some part of the brain. Orden- stein asserts the pons, and the portion of the brain anterior to it, to be the seat of this lesion. Hammond reports that tre- mor is absent in cases of spinal, without cerebral, disseminated sclerosis. Ebstein, Vulpian, and Engesse have observed spinal cases without trembling ; and Kelp, one case entirely cerebral, in which tre- mor was present. Erb' examined twenty- two cases after death with a view to determining this question. In all of them which had presented tremor during life, the pons, medulla oblongata, and pedun- culi, besides other portions of the brain, were particularly involved ; while in the few cases which had been without tremor, although there were nodules elsewhere in the brain, there were none, or those of small size only, in the pons, medulla ob- longata, cerebellum, &c. Apoplectiform attacks, occurring in cases of multiple sclerosis, may be diag- nosticated from true apoplexy, by the high temperature (104°-105t° F.) they present ; by the gradual approach and deepening of the coma ; and by the tran- sitory nature of the hemiplegia which follows them. The patient may remain unconscious for a day or two ; after the return of consciousness he falls asleep, and awakens in his usual condition of health, except the persistence of hemi- plegia for a few days longer. Such at- tacks may be repeated at variable inter- vals, usually of a few or several months. Kot unfrequently, however, the patient dies in the comatose state. Ordinarily, the duration of cases of multiple sclerosis is from five to ten years. Remissions of many of the symptoms arc not uncommon ; but they seldom last long. Vulpian has given an account of one case, in which an attack of varioloid was followed by the disappearance of all the symptoms ; but they returned after an interval of three years. Upon the treatment of this and all other forms of sclerosis of the brain and spinal marrow, nothing satisfactory can as yet be said. Many remedies have been exten- [' Ziemsseu's Cyclopaedia, vol. xiii.] ATROPHY AND HYPERTROPHY. 1015 sively tried, with only occasional, doubtful or transitory benefit. Formerly, muntcr-irritutlon was much rehed on ; by bhsters, issues, setons, and moxas applied to the back. Under the reaction caused by their frequent failure to produce cures, such measures are now too much neglected. If it be true that the pathological state preceding or inau- gurating sclerosis is one of inflammaUon, powerful derivants applied to the spine ought to be serviceable at that period. For milder effect, nothing is more conve- nient tlian croton oil, rubbed (a few drops) over a limited surface, to produce an arti- ficial eruption. Painting with pure tinc- ture of iodine will also produce moderate irritation. For the most vigorous action of this kind, the moxa may be employed. Among the medicines used in treatment of sclerosis, have been nitrate of silver, arsenic, chloride of gold, ergot, phospho- rus (or phosphide of zinc), strychnia, belladonna, iodide and bromide of potas- sium, and chloride of barium. Charcot, Erb, and Schiile have reported temporary improvement after the use of cold water (hydropathic) treatment. Nitrate of sil- ver, and hypodermic arsenical injections, have eacli had like transient influence only. Dr. Da Costa recommends, and in early stages of the disease has seen marked benefit from, the use of corrosive subli- mate ; given internally, for months to- gether. ' Electricity continues to be the last re- sort of therapeutics in such cases. The continuous galvanic current affords, in them, the greatest hope of possible ad- vantage. Massage, or systematic kneading of the muscles of the trunk and limbs, may be useful, especially if coml^ined with inunc- tion of olive or cocoa oil.^ Palliative remedial treatment, accord- ing to the symptoms, may often be of much importance to the patient. In lateral spinal sclerosis (spastic spinal pa- rah'sis), for example. Dr. S. Weir Mitchell' recommends, for the relief of suffering, hypodermic in.iections of morphia, alone or with atropi'a. The same or similar anodyne treatment is also often appro- priate for the mitigation of the distress of those affected with the severe pains of locomotor ataxy; or, most of ah, the horrors of glosso-labio-laryngeal paralysis [' N. Y. Medical Record, April 5, 1879, p. 314.] [2 Unfortunately, professional rubbers are apt to lack discretion in their performance, and to weary their patients by too violent or long-continued manipulation. Such excess should be prevented, if possible, by the medi- cal attendant. — H.] [3 N. Y. Med. Record, June 28, 1879, p. 605.] (bulbo-nuclear sclerosis). Erb, in regard to the late stages of this last allectlon, remarks that " to close the tragic course, the physician might well think of eutha- nasia.'" Hygienic measures will, in all such cases, afford means of valuable aid on the part of the medical adviser, especially in the earlier and middle stages. Proper regulation of the diet ; sutBcient warmth of clothing, and protection otherwise from exposure ; choice of climate for residence ; avoidance of, or extreme moderation in, sexual indulgence ; occupation, rest, men- tal and moral surroundings and influ- ences : all these may not only make a difference of months or years in the dura- tion of prolonged attacks, but may lessen very greatly the sufferings of those to whom recovery is made impossible by the nature of their disease. — II.] Xiy. Atrophy and Hypbeteophy. Atrophy of the spinal cord, like atrophy of the brain, is one of the changes which must be looked upon as natural to old age. In elderly persons, indeed, the cord becomes shorter and narrower and firmer, the spinal fluid increases in quantity, so as to fill the space left vacant by the shrunken cord, and the spinal nerves are sensibly wasted at both their roots. All this has been abundantly proved by Chaussard, OUivier, and others. Atro- phy, more or less general, is also asso- ciated with many forms of paralysis in which the cord has been long left in a state of comparative functional inactivity ; and local atrophy is one of the conse- quences of tumor, displaced vertebrfe, or anything which exercises pressure upon the cord. Of partial forms of atrophy re- sulting from disease, the only one about which there is any certain knowledge is that which is associated with the disease called locomotor ataxy-— namely, atrophy of the posterior columns ; and about this form enough has already been said in a separate article. In a few instances the spinal cord has been found to be so much enlarged, appa- rently by a true hypertrophy of its natu- ral tissues, as to occupy the whole space of the vertebral canal ; but most generally what seems to be hypertrophy at first sight is due, chiefly at least, to congestive sweUing and ffidema. True hypertrophy has been met with in the foetus : it occurs mostly in children : and it presents, so far as is known, no symptoms by which it can be recognized. Hypertrophy of the brain is a very uncommon affection, but it is common as compared with hypertro- phy of the spinal cord. [' Ziemssen, loc. citat.] lOlG DISEASES OF THE SPINAL CORD. XY. Tumor, etc. "Tubercle and cancer," says Eokitan- sky, ''are frequent in the brain, unfre- quent in tlie spinal cord. Tubercle I have observed only in combination vfith other advanced tuberculoses. Its principal seat is the cervical or lumbar portion of the cord, where it sometimes occupies the white fibres, sometimes the gray sub- stance. As in the brain, it leads to in- flammation (red softening) and to yellow softening. I have never seen a tubercu- lous cavity in the cord. Sometimes sev- eral tubercles are grouped' together, none exceeding the size of millet or hempseed ; at other times only one exists, which is of large dimensions, equalling a pea or a bean. Exclusively of several cases of cir- cumscribed callous induration of the white columns, as to the cancerous nature of which I am still in doubt, I have iBCt with but one case of cancer of the cord. It was a solitary nodule of medullary cancer. Ollivier mentions several exam- ples of ditfused carcinomatous growths, as well as of the so-called colloid cancer. Among the entozoa I have repeatedly seen the cysticercus in the cervical por- tion of the spinal marrow. The acepha- locyst sacs, as far as has been observed, have no connection with the cord ; their nidus is even outside the dura mater. In one case the cyst forced its way into the cavity of the arachnoid." Norare exostoses, cartilaginous growths, or aneurisms frequently met with in posi- tions which can exercise pressure upon the spinal cord. Cartilaginous growths, or rather bony plates, it is true, are not unfrequently met with in the visceral arachnoid of the cord — a condition which appears to be rarely met with in the brain ; but these growths or plates can scarcely be brought under the head of tumors. Except, perhaps, in connection with scrofulous disease of the vertebrse, the pia mater of the cord is not the seat of tuberculous deposits ; and here again is another point of difference between the pathological history of the spinal cord and the brain, for it is a well-known fact that the pia mater of the brain is a favorite seat of these deposits. The symptoms produced by tumor vary greatly. Neuralgic pain in the back, over the seat of the tumor, appears to be an almost constant symptom. ' ' Pain, ' ' says Dr. Eeynolds, "is more marked in cases of carcinoma than of tubercle. " If a par- ticular nerve be irritated by the tumor, there maybe pain, tingling, or some other anomalous sensation in the part or parts supplied by its sentient fibres, or some morbid form of contraction in the muscles supplied by its motor fibres. If a par- ticular nerve be pressed upon more de- cidedly by the tumor, there may be local anaesthesia, or paralj'^sis instead of morbid sensations or muscular contractions. It is but seldom, however, that these s} inp- toms of irritation or pressure are so strictly localized ; and, in fact, the presence of the tumor is made known usually only by more general symptoms of irritation, or compression, or inflammation, which, in- stead of being in any way pathognomonic 1 of tumor, may arise from many other I causes. "There is, indeed," as Sir W. Gull says, "no symptom, or single group of symptoms, which, taken alone, can serve as a secure basis for diagnosis." Tuberculous or carcinomatous deposits elsewhere, with signs of the peculiar dys- crasia of tubercle or cancer, aneurism else- where, nodes elsewhere, may help to a diagnosis by showing that symptoms which appear to point to a tumor may have such a cause, and at the same time may supply some information as to the special character of, the tumor; but this possibility of help in diagnosis is too re- mote to be of much practical value, if any. It may be supposed that any scrofulous deposit in the cord is more likely to occur in children, and any cancerous growth in older persons ; but even this rule has too many exceptions to make it of much use. XVI. Concussion. Concussion of the spinal cord, like con- cussion of the brain, is the result of a fall from a height, a blow on the back, or some other accident, and its symptoms vary with the intensity of the shock. Sudden paralysis and loss of sensation, more or less complete, with some inability to pass water or to prevent the escape of flatus or feces, are the more special symptoms. Sudden and marked failure in the circu- lation and respiration, as shown by pallor, feebleness of the pulse, diminished tem- perature, slow and shallow breathing, and other signs of common shock, are also associated with the more special symp- toms. Great pain along the spine or in some part of the spine has been consid- ered as one of the symptoms of spinal concussion ; but neither pain nor spasm is met with in the cases which I have examined ; and Dr. Eeynolds comes to the same conclusion, for speaking of these cases, he says, " There is in them neither marked pain nor spasm." Indeed, in the majority of cases the patient is obviously rendered incapable of experiencing pain by the fact of lieing stunned. The symptoms of spinal concussion not unfrequently issue in those of spinal con- gestion, or myelitis, or spinal meningitis, or else death without any signs of reaction may be the result. Often, without pass- ing into any definite disease, the cord, even after what might at first seem to be CARIES OF THE VERTEBRAL COLUMN. lOlT only a slight degree of concussion, may not recover its former power perfectly the patient ever afterwards being weak in many respects, especially in his leo-s and bladder. Indeed, concussion of the spine suflaciently severe to produce at the time any marked degree of paralysis in the limbs and bladder and lower bowel witk loss of sensation, is certainly a very grave matter, and it may be questioned whether in such a case recovery is ever more than partial. The appearances after death may pre- sent nothhig unnatural, or they may be those of hemorrhage more or less exten- sive. It is very po'ssible that the cases in which severe pain in the back was a symptom would prove, if all the facts were fully known, to be cases in which the symptoms of concussion were mixed up ■with those of hemorrhage : at any rate there was hemorrhage "in one case of spinal concussion in which pain in the spine was a conspicuous symptom, which case came under my own notice not long a^o. In fatal cases, in which the reaction atter the concussion has issued in inflam- matory and other changes in the cord, these changes will be met with after death ; and if fracture or dislocation of the vertebriB was produced at the time of the concussion, the evidence of such injury win of course not be wanting. XVII. COMPRESSIOK. When the spinal cord is compressed by a dislocated or fractured vertebra, by a tumor, by a bullet, or in any other way, the symptoms will of course vary with the seat and degree of compression. The symptoms will, in fact, be as variable — for they will be the same — as those which are produced by experimental division of the parts compressed, and about which more than is convenient had to be said in the preliminary remarks. All, therefore, that is necessary here is to refer to those preliminary remarks for the information which may help to make the symptoms of compression intelligible, and, in passing, to express a hope that trephining or other operative procedures which have been recommended and practised in certain cases of spinal compression may not be altogether unjustifiable. XVIII. Caries of the VEETBBBAii Column. This disease is usually limited to the bodies of the vertebrse and to the inter- vertebral substances, but sometimes it extends backwards to the arches and pro- cesses of the vertebrse as well. It com- mences, very generally, in the middle dorsal region, and, as generally, it does not extend beyond this region ; but there IS no part of the spinal column in which It may not begin, or to which it may not extend: it nivariably, when sufliciently advanced, gives rise to "angular curva- ture," or projection directly backwards of the diseased part of the spine, this de- formity being due to the way in which the thinned and diseased bodies of the vertebne become crushed in under the weight of the upper part of the body. In the great majority of cases caries of the vertebrse is an unmistakably strumous affection, being neither more nor less than tuberculous infiltration of the bodies of the vertebrse ; and the changes in the bone are due to the melting down of this deposit rather than to any strictly inflam- matory process. The earlier symptoms of caries of the vertebrse are not at all well marked. Of these the most conspicuous are — weakness in the back, generally in the dorsal re- gion, with aching or pain, more or less severe, in the weak part, causing a dispo- sition to lean forward and to use" the arms as props ; some prominence of the spinous processes of the weak and painful part of the spine, with some pufliness of the over- lying skin ; a feeling of undue heat, or even burning, in the weak and painful and prominent part, which is not felt iu other parts of the spine, ■\\-hen a sponge soaked in moderately warm water "is passed down the spine ; and a state of tenderness on pressure or percussion, which is equally restricted to the same weak and painful and prominent part. Afterwards, when the disease is more advanced, there are more marked S3-mp- toms, namely these : — unmistakable "an- gular curvature," the formation of ab- scess, slight hectic in the evening, a feel- ing of constriction around the waist, it may be, and still later, more or loss paral- ysis of the legs, more or less loss of con- trol over the bladder and bowel, and other symptoms indicative of secondary mye- litis or spinal meningitis. Abscess may be one of the earlier symptoms preceding any obvious deformity, or it may not occur at all. In fact, abscess appears to be a symptom of strumous disease of the ver- tebrse exclusively, and not of the non- strumous variety of caries. When it does occur, which is certainly in the great ma- jority of cases, there is usually some dim- inution of pain and other evidences of irritation. When it does occur, as is well known, it generally makes its appearance at a distance from the diseased vertebrse, most commonly as "psoas abscess" in the groin, but by no means exclusively in this form and locality. It is seldom that the spinal cord becomes comiwessed by the giving way of the bodies of the vertebrse in the progress of the disease : but sooner 1018 DISEASES OF THE SPINAL CORD. or later it almost constantly happens that the cord or its membranes opposite the diseased vertebrse become the seat of inflammatory changes, which changes, rather than the drain from an abscess, are indeed the reason why, in so many cases, sooner or later, caries of the vertebrse proves to be destructive to life. The diagnosis between " angular curva- ture" from caries of the spine, and the curvatures forward, backward, and side- ways, without other structural changes in the vertebral column than those of simple adaptation to the altered position, is not very diflicult. These latter curva- tures, in fact, want all the special and grave features which have been indicated as characterizing the former. Nor yet is the diagnosis ditlicult between "angular curvature" in its earliest stage and spinal irritation, with which it is sure to be as- sociated, and with which there is cer- tainly no small danger of its being con- founded. This topic has been already touched upon when speaking of spinal irritation, and here it is enough to say that the occurrence of tlio symptoms which are jiresent in the beginning of caries of the vertebrse (which are no other than those which may belong to simple spinal irritation), in children or youths of a manifestly scrofulous habit — at an age, that is to say, and in a habit, in which symptoms of simple spinal irritation are not likely to be mot with — are sufficient to do more than create a bald suspicion of the existence of disease of the vertebral column. The prognosis of caries of vertebrse is always bad enough. A hump-back is the best result to be hoped for. The end to be aimed at in treatment is, of course, to promote anchylosis of the diseased bones of the vertebrse by allowing them to fall together — by favoring, that is to say, the deformity which is inevitable by letting the back bend and not by trying to pre- vent it by keeping the back straight, — and to keep up the strength in every way. But these are matters which I cannot touch upon without trespassing upon the domains of surgery, and I therefore leave them to those who are better able, and whose right it is, to deal with them. XIX. Spis-a Bifida, &c. The commonest congenital affection to which the spinal cord is liable is dropsy, or hydrorachis, and of this dropsy spina hificla is the variety most frequently met with, and of most practical interest. The spine is bifid in this disorder from the non-development or separation of the spinal processes and laminse, and the con- sequence of this malformation is that an opening is left through which, very often. the dropsical fluid presses outwards, and distends in so doing the integuments and subjacent tissues into an hernial tumor. Very generally congenital hydrocephalus is associated with congenital hydrorachis. The fluid in hydrorachis is precisely of the same constitution and character as that which is met with in hydrocephalus : it varies in quantity from a few ounces to several pints : it accumulates between the arachnoid and pia mater, in the arachnoid sac, in the central canal of the cord, and even outside the dura mater, sometimes in one place, sometimes in another, some- times in more places than one. The her- nial tumor into which this dropsical fluid bulges outwardly varies greatly both in position and size, and in the condition of its coverings : it is .almost invariably met with in the lumbar region, but it may be in any region : it is usually of the size of a walnut or orange, but it may be as large as a child's head, or even larger : it may be single or multiple : its bulk may vary considerably under different circum- stances, or not at all, becoming, if it vary, fuller and more tense if the position of the child be made such as to cause the fluid to flow into it, emptier and flaccid if this position be altered so that this fluid may run out of it, or if pressure be made upon it so as to bring about the same re- sult : it may swell during expiration and fall during inspiration : it may present distinct fluctuation or none at all ; and the skin over it may be sound, thickened, inflamed, ulcerated, gangrenous, covered with tufts of hair, and so on. The dura mater and its lining of arachnoid mem- brane always enter into the composition of the coverings of the tumor, and these are the only constant elements in these cover- ings. In the lumbar region, the cord and its nerves, which are generally rudimentary, are out of the tumor altogether : in the cervical and upper dorsal region, on the contrary, it is no uncommon thing for the cord and its nerves to be adherent to the walls of the tumor. In spina bifida the lower limbs are gen- erally paralyzed as well as the bladder and lower bowel, and not unfrequently there is, in addition to the spinal deform- ity, deficiency of the abdominal walls, hernia of the bladder, imperforate anus, &c. But few cases recover, or even im- prove, death happening generally at an early period either in convulsions or from spinal inflammation, the immediate cause often being the bursting of the tumor: still there are cases on record in which life has been prolonged — and this too with tumors of no small size — not only for a few months, but for 17, 18, 19, 21, and even 50 years. There is little to be done for the relief of spina bifida. Pressure on the tumor by means of an air-pad and suitable ban- SPINA BIFIDA, ETC. 1019 dages can do no harm ; and occasional punctures with a grooved needle, as recom- mended by Sir Astley Cooper, may be a justitiable measure. Even cures have re- sulted from a combination of these punc- tures with pressure. "All the plans of treatment," says Mr. Erichsen, "by which the tumor is opened and air allowed to enter it, are fraught with danger, and will, I believe, inevitably be followed by the death of the child from inflammation of the meninges of the cord and convul- ' sious. " There are several other congenital affec- tions of the cord, of which the best account is still to be found in the classical pages of Ollivier. The cord may be entirely absent {amyelie) ; or it may be imperfect (atelomyelie). Of the imperfect forms of cord there are several varieties. The up- per part may be wanting, as in anencepha- lous and acephalous monsters. The cord may be bifurcated at one extremity or the other, at the upper extremity in monsters with two heads and one body, at the lower extremity in monsters with one head and two bodies. It may be double. It may vary greatly in dimensions, being larger or smaller, longer or shorter than natural — longer, for example, in monsters with tails, shorter in monsters of a contrary sort. It may, as in one form of hydro- rachis, be little more than a long bag in consequence of the distension of the cen- tral canal of the cord with the dropsical fluid. Or it may be discolored, as it is in the state Avhich Ollivier designates lir- ronese or coloration irterique. These mal- formations or morbid conditions, how- ever, are of theoretical rather than of practical interest : and therefore they do not form fit subjects for further notice in an article like the present, which has solely a practical end in view. B.-PARTIAL DISEASES OF THE NERVOUS SYSTEM.- GONTINUED. 3. Diseases of the I^ekves. KErRITIS AND KeUROMA. Neuralgia. Local Paralysis, Local Spasms. Torticollis. Local Ax^esthesia. l^EUEITIS AI^D :N^EUE0MA. By J. Warburton Begbie, M.D., F.E.C.P.E. Morbid appearances, the results of in- flammatory action, are occasionally met with in nerves. Such are the conse- quences usually of injury; the nerves have been divided by a sharp instrument ; or if independent of wounds, they are in all probability connected with rheumatism or gout. There seems no reason to doubt that inflammatory action may likewise extend to nerves from the contiguous tis- sues. In its general characters Neuritis re- sembles the inflammation of fibrous tissue. The fibrous investing sheath of nerves, or neurilemma, is indeed its usual seat ; the appearance of inflammatory action being for the most part limited to it, and only seen in the form of red softening of the nervous tissue itself when the inflamma- tion has been of an intense description. A doubt as to the spontaneous occur- rence of jSTeuritis has been entertained and expressed by several authorities. Boerhaave, for example, writes : "Nemo forte unquam vidit inflammationem in nervo ; hsec vero si contingat, in sola tunica vaginali hseret."' Others, again, with even greater inaccuracy, have main- tained the frequent existence of Neuritis. ^ Pathologically the inflammation of nerves may be acute or chronic ; and these two conditions are described by Rokitansky as ■ De Morbis Nervorum. 2 See on this point Animadversiones de Neu- ritide : Praxeos Medics Universse Prsecepta, auctore Josepho Frank ; Partis secundse, vol- umen primum, Sectio secunda, p. 131. Also Elements of General and Pathological Anato- my, by David Craigie, M.D., p. S79. ( 1020 ) follows : The marks of the former facute) are — (a) Injection and redness. The in- jection presents a linear arrangement, and the redness is partly caused by injection, and partly by small extravasations. (6) Looseness, succulence, and swelling of the nervous cord, due to infiltration of serum into the tissue of the neurilemma, and into the sheaths between the primi- tive nervous filaments. The nerve has lost its smooth, white, glistening appear- ance ; its neurilemma is opaque, and has a rough and wrinkled look, (c) Exuda- tion. This is generally a grayish or yel- lowish-red gelatinous product, which sooner or later becomes firm. It occupies the sheath and tissue of the neurilemma, and is likewise effiised between the primi- tive filaments themselves, (d) The cellu- lar tissue around the nervous cord always participates in these changes ; it becomes injected, re^ilened, and infiltrated with a sero-fibrinous' fluid. Not only the neigh- boring cellular tissue, but the sheaths of the muscles, the fascia, the subcutaneous cellular tissue, and the general integu- ments, become involved. Such a degree of inflammation as that now described may terminate in resolution, occurring quickly or slowly in different cases, or in induration of the nerve, and a permanent loss of its function in whole or in part. If the latter be the result, the nerve continues thickened, and more or less misshapen, forming a grayish cord, which is sometimes marked with black pigment and crossed by varicose vessels. The nerve filaments diminish in size and finally disappear, this result being in part due to the pressure to which they are ex- NEURITIS. 1021 posed by the inflammatory product, and in part to tlic interrupted nutrition, for tlie vessels are obliterated by the inflam- matory process, (e) In a more intense in- flammation the primitive nervous fila- ments are destroyed. They are found in a state of red or grayish or yellowish-red soft- ening, while the neurilemma is easily torn. {/) The fluid product of the inflammation may be purulent ; and if so, the nerve ap- pears highly discolored, and infiltrated with purulent fluid tinged with blood. The neurilemma is then much altered, and readily gives way, while the nerve is converted into a yellowish-red, brownish- red, or chocolate-colored pulp. The cel- lular tissue surrounding the nerves be- comes infiltrated with yellow fibrinous exudation, and abscesses are formed in its course, (g) Ulcerative destruction of the nerve is the next step. But if the pro- gress of inflammation be stayed before that point is reached, granulations ap- pear, which become progressively changed into cicatricial tissue, as is observed in the stump of a nerve after amputation. Nerves, however, resist for a lengthened period the suppurative and sanious de- struction which may be going on around them. Clironie Inflammation is characterized by the varicose state of the vessels of the aflected nerve, by products which become indurated, and gradually increase in quan- tity, and by a change of the nerve to a slate or lead-gray color. Sometimes the products are not deposited uniformly throughout the nerve, and then nodular swellings are formed on it.' Romberg, when directing attention to the anatomi- cal knowledge we possess of sciatica, speaks of Neuritis being found, but of its rare occurrence.^ The same writer, how- ever, refers to the possible production of Neuritis, by the sciatic plexus being dragged and irritated by the head of the child in a diflicult labor. Valliex and Beau have descriljed inflammation of nerves more systematically than other authors. The latter has at consideralile length, in his interesting memoir on the subject, directed attention to " Intercos- tal Neuritis. " ' Eeference has been made * to the occurrence of a rheumatic or gouty Neuritis. Dr. G. B. Wood considers it to be highly probable that in a large propor- tion of cases rheumatism lies at the founda- ' A Manual of Pathological Anatomy, by Carl Rokitansky. Sydenham Society's Trans- lation, vol. iii. p. 462. 2 Lehrbuch der Nervenkrankheiten des Menschen : Neuralgie des Huftnerven. ^ Valleix Guide du M^decin Praticien, t. Iv. p. 299; also Traitg des N^vralgies. Beau, Archives Generates de M^decine, 4e serie, t. xiii. 1847. tion of the disease.' And Dr. Garrod, while admitting, according to the usually received notion, that the nervous aftec- tions occurring in connection with gout are generally functional, believes them sometimes to be dependent on inflamma- tory action, which, he adds, appears, so far as can be ascertained, to have the character of true gouty inflammation. ^ The most characteristic symptom of Neuritis is pain, not hmited to the precise seat of the inflammation, but felt in the course of the nerve, and sometimes to its minutest branches. Besides its severity, the pain in Neuritis possesses other dis- tinctive features : it is darting, and ting- ling, and there often accompanies it a feeling of numbness. The pain has been further described as intermittent, but is more probably remittent, being, as long as the disease continues, never entirely absent. Tenderness over the affected nerve invariably exists. It is possible that in some forms of local palsies [see Local Paralysis from Nerve Disease) the loss of power, partial or complete, as well as the existence of various morbid sensa- tions, of which formication is one, and perhaps the most common, is due to dis- organization or other permanent change in the trunk of a nerve, resulting from in- flammatory action. It seems to be generally admitted, that the nerve most liable to such change is the sciatic ; but the various branches of the brachial plexus, and especially the ulnar nerves, likewise suffer ; and so in all probability do at times the other nerves in both lower extremities and trunk. That inflammation may also attack the nerves of special sense, as Dr. Wood has conjectured, seems not improbable, par- ticularly the nerves of hearing and of sight. Most assuredly a true gouty in- flammation, apparently commencing, in some cases, in the nerves themselves, not unfrequently either damages or entirely destroys one or other of the delicate organs connected with these most impor- tant functions. In the treatment of Neuritis the proba- ble alliance of the affection with some peculiar diathetic condition, the gouty or rheumatic, or possibly with the syphilitic cachexia, must not be lost sight of. Local abstraction of blood, and the ap- plication of emollient and anodyne poul- tices, rest, low diet, and the use of laxa- tives, are the chief remedies in cases of the acute Neuritis. When th(? disease is chronic, the use of bhsters, issues, and even the cautery, has been recommended. 1 A Treatise on the Practice of Medicine, vol. ii. p. 843. . r^ i J 2 The Nature and Treatment of Gout ana Rheumatic Gout, p. 517. 1022 NEURITIS AND NEUROMA. Internally, besides opium or other nar- cotic for the relief of pain, it will be pru- dent to give a fair trial in both the acute and chronic Neuritis to quinine, and col- chicum, the iodide and the bromide of potassium. Netjrosia (Tumor of Nerve). — Growths of various sizes and natures occurring in the course of nerves had been described before the term Neuroma came to be ap- plied to such. Dr. Robert Smith, in his valuable and elaborate memoir, makes a brief reference to the early history of the subject ;' and so likewise does ilr. Wil- liam Wood, in his important papers enti- tled, " Observations on Painful Subcuta- neous Tuljercle," and "On Neuroma."^ The famous English surgeon, AVilliam Cheselden, is specially mentioned, as hav- ing given the first accurate account of the nervous tubercle, which has become famil- iar chiefly through the writings of ilr. Wood. "Immediately under the skin, upon the shin bone, I have twice seen little tumors, less than a pea, round and exceeding hard, and so painful that both cases were judged to be cancerous : they were cured by extirpating the tumor. But what was more extraordinary was a tumor of this kind, under the skin of the buttock, small as a pin's head, yet so painful that the least touch was insup- portable, and the skin for half an inch round was emaciated ; this, too, I extir- pated, with so much of the skin as was emaciated, and some fat. The patient, who before the operation could not endure to set his leg on the ground, nor turn in his bed without exquisite pain, grew im- mediately easy, walked to his bed without any complaint, and was soon cured." The same writer describes and figures the cystic neuroma. "A tumor formed in tlic centre of the cubital (ulnar) nerve, a little above the bend of the arm ; it was of the cystic kind, but contained a trans- parent jelly ; the filaments of the nerve were divided and ran over its surface. This tumor occasioned a great numbness in all the parts that nerve leads to, and excessive pain upon the least touch or motion. Tliis operation (for the removal of the tumor) was done but a few weeks since ; the pain is entirely ceased, the numbness a little increased, and the limbs as yet not wasted. '" The term Neuroma, or rather Neii- romes, was first employed by M. Odier of Geneva. "Enfin," writes Odier, "on ' A Treatise on the Pathology, Diagnosis, and Treatment of Neuroma. Dublin, 1849. 2 Transactions of the Medico-Chirurgical Society of Edinburgh, vol. iii. pp. 317 and 367. = The Anatomy of the Human Body, 12th edit., London, 1784, pp. 136 and 256. pent donner le nom de Neuromes a ces tumeurs mobiles, circouscrites et pro- fondes, qui sont produites par le goutte- ment accidentel d'un nerf, a I'extremitfi duquel la compression de la tumeur fait eprouver des crampes tres-penibles. '" There have been various classifications of neuromatous tumors attempted by pa- thologists, such as local and general — that is, as atfecting one nerve, or several nerves ; and, again, those which are the direct consequence of a morbid process, and those resulting from an original vice of conformation. Dr. Smith, rejecting these divisions, has suggested, as sufficient for practical purposes, that Neuromata should be considered as of two kinds : 1st, of spontaneous origin, or Idiopathic; 2d, as the result of wounds or other injuries of the nerves, and therefore Traumatic. Before offering a brief description of these varieties, it may be well to direct attention a little more fully to the jminfid subcutaneous tubercle, which we have the authority of Dr. Hughes Bennett and other pathologists for stating "must be referred to this class of tumors,"^ that is, neuromatous fibrous tumors. "Although," remarks Dr. Smith, "pa- thologists have hitherto failed to discover anything like nervous structure in these tumors, I still incline to the opinion that they are connected with the minute fila- ments and ultimate ramifications of the nerves. Upon any other supposition it is, I conceive, impossible to offer a rational explanation to account for the dreadful severity of the suffering which they in- duce. " Sir J. Paget, who has carefully examined the "painful subcutaneous tu- mors " describes them as being formed of " either fibro-cellular or fibrous tissue, in either a rudimental or a perfect state." Alluding to a case described by the late Professor Miller, in his "Principles of Surgery," and by Professor Bennett, the same pathologist admits that tlieir struc- ture may sometimes be fibro-cartilaginous.' Of this affection the first detailed ac- count was given by the late Mr. William Wood of Edinburgh. After the publica- tion of Mr. Wood's earlier papers,'' cases were recorded by different observers, and in 1829 an instructive resume of the whole subject was laid by him before the Medico- ' Manuel de Medecine pratique, ou Som- maire d'un Cours gratuit, donng en 1800, 1801, et 1804, aux Officiers de Sant^ du d&- partement du L^man, par Louis Odier. Paris, 1811, p. 362. 2 Clinical Lectures on the Principles and Practice of Medicine. 3d edit. p. 171. 2 Lectures ou Surgical Pathology, vol. ii. p. 123. * The Edinburgh Medical and Surgical Journal, 1812. Two articles, pp. 285 and 429. NEUROMA. 1023 Cliirurgical Society of Edinburgh, and appeared, as already mentioned, in its "Transactions." Tliis disease consists in the formation of a small lump or tubercle seated in the sub- cutaneous cellular tissue, immediately under the integuments, which retain their natural appearance. The tubercle is met with in different parts of the body, but most frequently in the extremities. It is extremely small, pisiform in shape, of firm consistence, and apparently quite circumscribed. The characteristic feature of the disease is the occurrence of violent pain coming on paroxysmally. The paroxysms vary in duration from ten minutes to upwards of two hours, their frequency as well as intensity appearing to increase in precise relation to the length of time the disease has existed. Some patients enjoy inter- vals of relief from pain for days or even weeks, while others have repeated attacks in the course of a single day. The parox- ysms of pain frequently occur when the patient has fallen asleep. They are also apt to be excited by various external causes, such as pressure and blows; while in rarer instances mental disquietude and atmospheric changes have been their only apparent occasion. Females are more frequently the sub- jects of this disease than males. Wood, referring to thirty-five cases collected by him, mentions that twenty-eight were fe- males, five males ; and in the account of two the sex was not stated. Of thirteen cases quoted by Descot, ten occurred in females, and three in males. Eomberg has met with three instances, all in fe- males. The situation of the tubercle in the thirty-five cases referred to by Wood was as follows : in the lower extremities in twenty-two, in the upper extremities in eleven, in the chest in one, and in one in the scrotum. In only two of these cases was there more than one tubercle present. This disease does not seem to be inti- mately connected with any particular period of life, as it has been noticed at all ages from thirteen to above seventy. "It is a happy circumstance that this very painful affection is capable of being remedied by a very simple operation. The tubercle is easily removed by a single in- cision, and it is unnecessary to take away any portion of the integuments, or of the surrounding cellular tissue. No bad effect can follow the removal of the little body. " (Wood.) Although this subcutaneous tubercle has been considered as a variety of Neu- roma, it must be held in remembrance that, its distinct connection with branches of nervous trunks never having been deter- mined, this is more a matter of inference than of demonstration. OUivier and Ray er together carefully dissected the tumor in a case to which reference is made in his latest paper by Wood, and the result is thus expressed : " Exterieurement 11 etait enveloppe de tissu cellulaire, dans lequel nous ue pumes distinguer aucun filet ner- veux, meme a I'aide d'une forte loupe " ' 1 aget remarks that the general opinion is agamst the supposition of the intimate connection of these painful tumors with nerves. ' ' Dupuy tren, ' ' he writes, ' ' says that he dissected several of these tumors with minute care, and never saw the slightest nervous filament adherino- to their surface. I have sought them with as little success with the niicroscope. Of course I may have overlooked nerve-fibres that really existed. It is very hard to prove a negative in such cases ; and cases of genuine Neuroma, i. e. of a fibrous tu- mor within the sheath of a nerve, do sometimes occur, which exactly imitate the cases of painful sul)Cutaneous tumor." We have now to consider the first of the two forms of Neuroma, as distinguished by Smith, and now generally recognized —namely, the Idiopathic Kcuroma. Tu- mors of this nature are of an oval or ob- long form, their long axis corresponding with the direction of the nerve to which they are attached. They vary consider- ably in size. One figured in his work by Smith is as small as a grain of wheat, while another is as large as a good-sized melon. Between these two extremes every variety of size occurs. There may be only one, or several may be found on the same nerve ; occasionally they are found existing simultaneously upon all the spinal nerves. "In number," says Kokitauskj', " they vary from one until they are almost countless." A remark- able general disease is thus constituted, of which three cases have been observed in the Vienna Hospital. Neuromata are comparatively rare in the ganglionic sys- tem. But although occurring most fre- quently on the spinal nerves. Neuroma is not hiiiited to them; the cerebral nerves, motor as well as sensory, particularly those most closely resembling the nerves of the cord, present at times the same tumors. In general. Neuromata are solid throughout their entire structure, but in some 'instances are of cystic formation, as in the case recorded by Cheselden, and already referred to. These tumors are of slow growth, but continue to undergo a steady increase in size, although many years may elapse before they attain such dimensions as to prove a source of serious inconvenience. They are movable in tlie transverse direction, but not in the ' Traits th^oraique et pratique des Mala- dies de la Peau, seconde edit., t. it. p. 290. Paris, 1835. 1024 NEURITIS AND NEUROMA. course of the nerve upon which they are seated. There may be difficulty in dis- tinguishiug tumors which are merely con- tiguous to nerves from the true Neuroma, having its origin within the neurilemma. "Wood has specially alluded to this diffi- culty in diagnosis, and Smith has pointed out that the non-nervous tumors, unlike Keuromata, are generally movable in all directions, and, when drawn away from the nerve, cease to be painful on pressure. Nerve tumors are described by Roki- tansky as lying between the fasciculi of the nerves, and interwoven with their neurilemmatous sheath. Neuroma, the same pathologist observes, is never de- posited in the centre of a nerve, but at its side, so that only a small part of its fasciculi is displaced ; the displaced fasci- culi are spread abroad and stretched over the tumor, while the greater mass of the nerve remains on the other side unin- jured, and with its fibres in connection with one another. The solid neuromatous swellings are of a tough elastic consistence, of grayish or pale yellowish-red color, and are invested with a distinct fibrous sheath. Dr. Hughes Bennett thus describes them : " On being minutely examined, they are found to consist of fibrous texture more or less dense, the filaments often arranged in wavy bundles running parallel to each other, but occasionally assuming a looped form, or intercrossing with each other. I have also found them to contain groups of cells. Not unfrequently they arc fibro- cartilaginous ; sometimes with the cells closely aggregated together, at others widely scattered. In some of the neuro- matous swellings described by Dr. Smith I found the fibrous tissue to present wavy bundles, among which a few granule and cartilage cells were scattered and shri- velled, apparently from the action of spirit.'" Neuromata seldom contract adhesion to the investing integuments, unless they have been subjected to continued pres- sure. Smith has never known them to suppurate, or to be removed by absorp- tion. Pain has been generally considered to be a characteristic feature of neuroma- tous swellings. In this respect, however, there is infinite variety. When a single Neuroma exists, there is almost invari- ably much suffering. The pain, more- over, occurs suddenly and paroxysraally, darting along the nerve with the violence and instantaneousness of an electric shock. On the other hand, in those ex- amples of Neuroma which are distin- guished by the number of the tumors, it is not uncommon to find these occasioning little or no inconvenience to the patient. ' Loo. cit. p. 171. It is exceedingly difficult to determine with anj'thing like exactness the real cause of the paroxysmal attacks and sud- den aggravation of severe pain which occur in this as well as in many other forms of disease of the nervous system. Mental emotions and the ordinary atmos- pherical vicissitudes have been generally assigned as the occasion of these occur- rences in Neuroma. Paget has some very interesting obser- vations on the cause of pain in Neuroma, as well as on the nearly entire absence of all suffering which has been noticed in some cases ; and founding on the obser- vations of Smith and others, including himself, this excellent writer is no doubt correct when he states "that we cannot assign the pain in these cases entirely to an altered mechanical condition of nerve- fibres in or near the tumor. AVe must admit, though it be a vague expression, that the pain is of the nature of that morbid state of nerve force which we call neuralgic. Of the exact nature of this neuralgic state indeed, we know nothing ; but of its existence as a morbid state of nerve-force, or nervous action, we are aware in many cases in which we can as yet trace no organic change, and in many more in which the sensible organic change of the nerves is inadequate to the expla- nation of the pain felt through them." In short, Paget argues for the pain being functional, and not necessarily dependent at least on an organic disorder. If such a pain is found to be influenced by the remedies chiefly available for the relief of ordinary neuralgia — quinine, iron, ar- senic, belladonna, stramonium, the bro- mide of potassium — this suggestion will receive corroboration. We know that such Neuromata as are the seat of severe pain and of continual irritation may give rise to attacks of the so-called sympathetic epilepsy. Instances of this nature are to be found in the writings of several authors, and it is sufficient here to refer to the well-known views of Brown-Sequard respecting the exciting causes of the epileptic convulsion, and of many other nervous aft'ections.' In the idiopathic form of Neuroma the pain is generally limited to the parts be- low the tumor ; and the sign of the true Neuroma, signalized by Aransoohn, has been accepted by others — namely, that when the trunk of the nerve is compressed above the tumor the pain ceases, and then the Neuroma previously acutely sen- sitive can be touched without any uneasi- ness being caused. The remark already ' Researches on Epilepsy, p. 35; also Course of Lectures on the Pliysiology and Pathology of the Central Nervous System, p. 181. Ar- ticle Neuroma, by same Author, in Holmes's System of Surgery, vol. iii. p. 896. TRAUMATIC NEUROMA. 1025 made as to the solid variety of Neuroma not being necessarily painful applies like- wise to the fluid or cystic tumor. Our knowledge of the determining causes of Neuroma cannot be said to have advanced since the period when the im- portant treatise of Dr. Smith first ap- peared, and we are still compelled to adopt his expression, " I feel it must be confessed that we know nothing with certainty regarding the causes of Neu- roma.'" Neuromatous tumors have been fre- quently removed along with the corre- sponding portion of the nerve on which they were situated ; and such operations, while entirely relieving the patients from suffering, have not been succeeded by any considerable loss of sensibility, or of the power of voluntary movement, in the parts supplied by even large nerves. The sciatic nerve may be divided, as in a case of severe neuralgia of that nerve, by M. Malagodi, and a portion of it ex- cised, without permanently destroying the functions of the limb. The magnitude of the nervous trunk, which is the seat of the disease, will of course largely determine the period at which complete or partial restoration of the function in the limb is established. In some cases a few months, in others a year and upwards, have elapsed ; but sooner or later, in all recorded instances, the banished sensibility and motor power have been regained. The interference with the caloi-ific func- tion of the nervous system is strikingly exhibited in cases of operation for Neu- roma. Mr. Adams and Dr. Smith have drawn attention to tlie diminution of tem- perature in the limb after tlie removal of the tumor, and with it a portion of nerve —a diminution readily noticed both by patients and operator, and which has lasted for a lengthened period, even after tlio restoration of the other functions. It may then be concluded that when idiopathic Neuroma is seated in the hand, forearm, or upper arm (the positions in which it has most commonly been found), the operation of removal may be safely practised. It is possible that a similar plan might be adopted in the case of Neu- roma in the lower extremity ; but it is on record that amputation of the limb has been had recourse to by Chelius, in a case of nervous tumor occupying the popliteal space and stretching to nearly the centre of tlie back of the thigh. This was an illustration, and there are others which teach a similar lesson, of the disease hav- ing been permitted to attain a very large size — so large as to prevent any attempt being made for its simple removal. ' Loc. cit. p. 5. VOL. I. — 65 Traumatic Neuroma.— Under this division are to be included tumors of nerves resulting from any form of me- chanical injury, such as wounds, blows, pressure, or following amputation. Traumatic Neuroma is almost invaria- bly single. The tumor is the seat of in- tense pain, which, unlike the suffering in the idiopathic form of the disease, is°not confined to the growth itself, or felt merely m the parts below it, but is frequently found extending along the nerve towards its origin. Wlien Neuroma occurs as a consequence of a wound of nerve, it usu- ally consists of a solid tumor, not invested by neurilemma, and destitute of any dis- tinct capsule.' It is most likely to form, when the nervous cord has been cut, but not entirely divided ; and cases of this nature are even more than ordinarily painfuh The following case is published by Mr. Wood in his "Memoir on Neuroma ;" it occurred in the practice of Mr. Syme :— "James Muir, aged 43. 80th June, 1828.— On the inner side of the left knee, about a hand-breadth above the joint, tliere is a narrow depressed cicatrix, two inches long. Between this cicatrix and the sartorius there is a small tumor, about the size of an almond, and of very firm consistence. When the limb is ex- tended, this tumor can hardly be per- ceived, being then overlapped by the sartorius ; but when the knee is bent, it can be felt very distinctly. It is most movable in a lateral direction, but seems pretty firmly connected to the subjacent parts by condensed cellular substance. "The patient states that the tumor is always painful when pressed, but is more so at one time than another. The pain is not confined to the part, but shoots all over the knee, and sometimes extends from the groin to the toes. He observes that the pain is more severe during cold and damp weather. It frequently, for days together, prevents him from walk- ing, or even resting on the limb. His story is, that when a boy, about eleven years old, he strained his knee by jump- ing into a saw-pit, which led to the forma- tion of a large abscess that opened on both sides of the knee, namely, at the part where the cicatrix above mentioned still remains, and exactly opposite, where also there is a similar cicatrix. Several small bits of bone were discharged, and at the end of two years he got quite well. For the following twenty-seven years he led an active hfe ; ten of them were spent in a militia regiment. About eight years ago he strained his knee while walking in hfs garden, and thereafter became subject to flying pains about the joints. These Smith, loo. cit. p. 20. 1026 NEURALGIA. pains induced him to rub the knee fre- quently ; and in doing so, about two years ago, lie noticed the tumor. It was tiien the size of a pea, and has gradually enlarged. The disagreeable symptom^ also have become greatly aggravated ; and, as he refers them all to the tumor, he is desirous of having it removed. " l'2th July.— Mr. "Wood (continues Mr. Synie), who was kind enough to examine the patient, having agreed with me that the tumor was seated on or in the nervus saplionus, and that it ought to be removed, I performed the operation, with his assist- ance, on the 1st of July. "The tumor being divided showed a firm fibrous capsule, containing a soft, brownish-white pulpy matter. The nerve was traced into the tumor, but not through it. The patient made a good recovery, and remains free from his complaint.'" The foregoing case illustrates the pro- per treatment of Traumatic Neuroma, which is to excise the tumor with the corresponding portion of nerve, in every case when its situation will permit of this being done." The last form of Neuroma which re- quires any separate consideration is that succeeding to amputations. Smith re- marks in regard to such, that "their ex- istence is so constant that we may, per- haps, consider them as representing the normal condition of the ends of the nerves in stumps." Generally they cause no uneasiness whatever : but, on the other hand, they have occasionally been the source of severe neuralgia, occurring in paroxysms of great length. The Neuroma of stumps varies in size, being in some instances not larger than a garden-pea, in others as large as^ a grape, or even plum. Such Neuromata are gen- erally of an oval or oblong form, of gray- ish-white color, and of a firm dense tex- ture. The situation of the Neuroma in the stump is not always the same ; it may be several inches above the surface of the latter, and be connected with the cica- trix by means only of a fibrous cord, itself destitute of any nervous structure. It is the opinion of some pathologists, that the Neuromata succeeding amputa- tion are produced by the pressure which is exerted upon the surface of the stump. An objection fatal to this explanation, however, has been advanced — namely, that in many stumps which have never been subjected to pressure these little tu- mors are found. Dr. Smith believes their formation to be for the protection of the extremity of the nerve. ' NEURALGIA. By Francis Edmund Anstib, M.D., F.R.C.P. Definition. — A disease of the nervous system manifesting itself by pains, nearly always unilateral, which appear to follow the course of particular sensory nerves. The pains are usually sudden in their commencement, and of a darting, stab- bing, boring, or burnin^^ character ; they are at first unattended with any local change which can be recognized, or by any constitutional pyrexia. They are al- ways markedly intermittent; sometimes regularly and sometimes irregularly so. The periods of intermission are distin- guished by complete freedom from acute sufiering, and in recent cases the patient appears quite well at these times. In old standing cases, however, persistent ten- derness and other signs of local mischief are apt to be developed in the tissues ' Loo. cit. p. 426. ' Smith, p. 22. which surround the distribution of the nerves which are the seat of acute pains. Severe attacks of Neuralgia are usually complicated with secondary affections of other nerves which are intimately con- nected with that which is the original seat of pain ; and in this way congestion of bloodvessels, hypersecretion, or arrest- ed secretion from glands, inflammation and ulceration of tissues, &c., are some- times brought about. Synonyms. — The word Neuralgia has a generally recognized force, and there is no equivalent to it (except foreign varia- tions in mere terminology) which repre- sents the whole group of disorders to which it applies, though there are nu- [' See Wounds and Injuries of Nerves, by Drs. Mitchell, Morehouse, and Keen. Phila. 18134.— H.] CLINICAL HISTORY AND SYMPTOMS — VARIETIES. 1027 merous phrases for particular forms of the disorder. Clinical Histobt and Sysiptoms — These vary so greatly in different cases' of Neuralgia that it will be necessary to dis- cuss tlie greater part of this subject under the headings of the special varieties of the disease. There are certain features, however, which are observed in all true Neuralgias. In the first place, it is universally the case that the existing condition of the pa- tient at the time of the first onset of the disease is one of debility, either general or special. I make this statement with great confidence, notwithstanding the contrary assertion advanced by so high an authority as Valleix, whose able' treli- tise really laid the foundation for all our accurate knowledge of the Neural"-ias. la the first place, it is certainly the "caso that the larger half of the total number of patients coming under my care with va- rious forms of Neuralgia are either deci- dedly anaemic or have recently undergone some exhausting illness or fatigue : and the reason why Valleix did not find so many cases of this type among his neu- ralgic patients appears certainly to be, that he limited the neuralgic class of dis- eases by an artificial definition, which we shall have to reject as untenable. On the other hand, although a considerable num- ber of neuralgic p.xtients are so far healthy in appearance, that they have a fairly ruddy complexion and a good amount of muscular strength, it is impossible to ad- mit that these facts disprove the existence of debility, either structural or functional, in the nervous system, for the commonest experience teaches that such debility does frequently coexist with great robustness and development of the apparatus of veg- etation and the lowest forms of animal function. And it will invariably be found, on carefully examining these ap- parently robust neuralgic patients, that the nervous system has given warnings of its weakness : thus, the patient who, after an exhausting confinement, attended with great loss of blood, is attacked with obstinate davits hystericus, will inform us that whenever in earlier life she had suf- fered from headache, the pain was always chiefly, if not altogether, confined to the narves which are now the seat of decided Neuralgia. In a large number of cases I hive also found that the attack of acute pain was immediately ushered in by a remarkably anesthetic condition of the parts about to become painful ; and a slighter degree of blunted sensation may often be observed in the intervals between the earlier attacks in cases of Neuralgia. In short, I have never seen a case of ' Traits des N^vralgies. Paris, 1841. neuralgic pain in which there were not marked evidences of nervous debilitv, either local or general. Another circumstance is common to all Neuralgias of superficial nerves ; and as a large majority of neuralgic aflections are superficial in situation, this is, for practi- cal purposes, a general characteristic of the disease. I refer to the formation of tender spots at various points where the aft'ected nerves pass from a deeper to a more superficial level, and particularly where they emerge from bony canals, or pierce fibrous fascia;. So general is this characteristic of inveterate cases, that Valleix founded his diagnosis of the genu- ine Neuralgias on the presence of these painful points, in which assumption I think there can be little doubt, that he committed an error. ' The third general characteristic of neu- ralgic affections is, that the pain is inter- mittent, or at the least remittent, in every stage of the disease. The fourth general characteristic is, that fatigue and every other temporary depressing influence directly predisposes to an attack of acute pain, aiid aggravates it when already existent. Varieties. — It is possible to classify the Neuralgias upon either of two sys- tems : first (A), according to the consti- tutional condition of the patient ; and, secondly (B), according to the situation of the affected nerves. It will be necessary to follow both these lines of classification, avoiding repetition as much as possible. (A) In considering the influence of con- stitutional states upon the typical devel- opment of Neuralgia, it will be convenient to commence with (I. ) the group of cases in which the general state of the organism exerts the least amount of effect. This is the case where the pain is the result of direct injury to a nerve-trunk, whether by external violence, by the mechanical pressure of a tumor, or by the involve- ment of a nerve in inflammatory or ulcer- ative processes, spreading to it from neighboring tissues. As regards the de- velopment of symptoms, the important matters are, that the pain in these cases commences comparatively gradually, that the intermissions are usually much less complete, and that the pain is far less amenable to relief from remedies than in ' Trousseau insists with mneli energy that a still more important "point douloureux" is constantly present in Neuralgia, viz., over the spinous processes of one or more vertebra, corresponding to tlie origin of the painful nerve. It is true (as the Brothers Griffin had long before pointed out) that there is tenderness in this situation. But this "point apophysaire" is not always, nor frequently, the seat of spontaneous pain. 1028 NEUKALGIA. other varieties of Neuralgia. Tlie little that can be said about the form which is dependent upon progressively increasing pressure, or involvement of a nerve in malignant ulcerations, caries of bones, or teeth, &c., falls under the heads of Diag- nosis or Treatment, and need not detain us here. The clinical history of Neural- gia from external violence, however, re- quires separate discussion. 1. Neuralgia from external violence may be produced by a shock (as of a fall, a railway collision, &c.), which gives a jar to the central nervous system, or by severe mental emotion, operating upon the same part of the organism. Upon either of these circumstances the develop- ment of the affection seldom occurs at once, but ensues after a variable interval, during which the patient exhibit symp- toms of a general depression, with loss of appetite and strength. Sometimes vomit- ing, and even, in other instances, actual paralysis of a partial and temporary kind occur. When once developed, the neural- gic attacks are undistinguishable from those which occur from causes internal to the organism. The affection is usually very obstinate. In a large number of cases the nerve or nerves affected have previously shown signs of weakness, by a tendency to painful affection in depressed states of the organism. In the greater number of instances, as far as my expe- rience goes, it is the fifth cranial nerve which becomes neuralgic from the effects of central shock. Illustrative cases will be given in the sections on local classifica- tion. 2. Neuralgia from direct violence to superficial nerves is produced either by cutting, or, more rarely, by bruising wounds. Cutting wounds may divide a nerve- trunk, (a) partiallj'', or (13) completely. (a) AVhen a nerve-trunk is partially cut through, neuralgic pain commonly occurs, if at all, immediately on the receipt of the injury. One such example only lias come under my own care, but many others are recorded.' In this case the ulnar nerve was partly cut through with a tolerably sharp bread-knife, at a point not far above the wrist ; partial ansssthesia of the little and ring fingers was induced, but at the same time violent neuralgic pains in the little finger came on, in fits recurring sev- eral times daily, and lasting for about half a minute. Treatment was of little apparent effect in promoting cure, though opiates gave temporary relief, as did the local use of chloroform. The attacks re- curred for more than a month, long after the original wound had healed soundly ; and for a long time after this pressure on the cicatrix would reproduce the attacks. Vide Lancet, 1866. A slight amount of anaesthesia still re- mained when I last saw the patient, more than a year after the injury. (|3) Complete severance of a nerve-trunk is a sutticiently common accident, far more common than is the production of Neuralgia from such a cause ; indeed so marked is this disproportion between the injury and the special result, that I have been led to the conclusion that a neces- sary factor in the chain of morbid events must be the existence of some antecedent peculiarity of organization in the central origin of the injured nerve. This opinion is rendered more probable by the fact that the consecutive Neuralgia is not unfre- quently situated not in the injured nerve itself, but in some other nerve with which it has intimate central connections. Two such examples are recorded in my Lett- somian Lectures,' in which the ulnar nei've, and one in which the eervico- occipital, respectively, were completely divided : in all three instances the Neu- ralgia was developed in the branches of the trigeminus. In all the cases which have come under my notice the Neuralgia, whether direct or reflex, set in at a par- ticular period, viz., after complete cica- trization of the wound, and while the functions of the branches on the peripheral side were partty, but not completely, re- stored. The same obstinacy and rebel- liousness to treatment was noticed as in other instances of Neuralgia from injury. A few words must be given, before quitting the subject of Neuralgia from wounds of nerves, to the cas-es in which a foreign body lodges, with more or less laceration, in the substance of a nerve trunk. I have never seen such a case ; hut many instances are recorded in which most violent and painful Neuralgia has been set up in this way. Not unfre- quently the irritation produces no notice- able effect on the nerve actually pressed upon, but sets up Neuralgia in a nerve so distant that no connection is suspected between the neuralgic pain and the origi- nal accident. The removal of a small piece of glass, or such other irritating body from the cicatrix of an old wound, has in several recorded instances put an end to neuralgic pains in quite another situation, for which all manner of reme- dies had long been tried. Sometimes the neuralgic pain has been accompanied by tissue degeneration of an alarming char- acter, and these have likewise ceased at once upon the removal of the peccant body which had been the unsuspected source of the evil. Neuralgias which result from some local injuries of so peculiar a character as gunshot wounds scarcely fall properly within the province of this article. The Vide Lancet, 1866. VARIETIES. 1029 reader who desires to know all that can be said witli regard to this particular class of affections is recommended to study the able and carefully compiled " Eeport" of Messrs. Mitchell, Morehouse, and Keen.' The case of Neuralgia from injury, pressure, and local disease of nerve's has been mentioned first, because this form of the disease is less influenced than others by general constitutional states. But it is an erroneous opinion, however com- mon, that the general condition of the body is here without any influence on the development of the nerve-pain. It has been forcibly urged, by Dr. Brinton and Dr. Handfield Jones more especially, that a condition of general bodily vigor miti- gates, and that constitutional debility decidedly aggravates, these forms of Neu- ralgia ; and my own experience gives most practical proof of the justice of this argument. (11.) Neuralgias of intra-nervous origin. —As regjards the constitutional conditions with which the several varieties of Neu- ralgia that arise independently of external violence, or disease of extra-nervous tis- sues, are respectively allied, the following preliminary subdivision may be made : — 1. Neuralgias of malarious origin. 2. Neuralgias of tne period of bodily development. 3. Neuralgias of the middle period of life. 4. Neuralgias of the period of bodily decay. 5. Neuralgias associated with anaemia and mal-nutritiou. 1. Neuralgias of malarious origin were formerly far more prevalent than they are at present, within the sphere of the English practitioner of medicine ; with the general decline of malarial fevers, conse- quent on improved drainage and cultiva- tion of lands, they have become constantly more scarce. In former times, on the contrary, they were so common, that they forced themselves on the notice of every physician. The term "brow-ague," to this day applied by many medical men to every variety of supra-orbital Neuralgia, is a relic of the older experience on this point ; as is also the very common mis- take of expecting all neuralgic affections to present a distinctly rhythmic recurrence of symptoms. My own experience of malarial Neural- gia has been very limited, and I may as well say all that I know of its symptoms at once. In fact, though the out-patient practice of the Chelsea Dispensary and ' Report on Gunshot Injuries to Nerves, observed in the late American War. Phila- delphia, 18e4. Westminster Hospital has afforded me a considerable number of examples of a"ue in past years, I have only seen two un- doubted and one doubtful case of malarial Neuralgia, in all of which the fifth nerve was attected. The periodicity in one of the genuine cases was regular tertian ; in the other regular quotidian. An al^ide condiUon always ushered in the attacks : but this was gradually exchanged, as the pam continued, for a condition in which the pulse was rapid, soft, and bounding, and the strength was further depressed. In both of these cases there were uni- lateral flushing of the face, and congestion of the conjunctiva, to a slight degree, during the attack of pain. The pain be- came duller and more diffused contempo- raneously with the lowering of arterial pressure (as estimated by Marey's Spln-g- mograph) ; and after the disappearance of active pain, moderate tenderness over a considerable tract around the course of painful nerves remained for some time. But there was no distinct development of the painful points of Valleix (to be here- after described), a circumstance which I attribute to the rapid cure of the com- plaint, in each instance, by quinine. 2. Neuralgias of tlie jxriocl of bodily de- velojmwnt.— By the "period of bodily de- velopment" is here understood the whole time from birth up to the twenty-fifth year, or thereabouts. This is the period during which the organs of vegetative and of the lower animal life are consoli- dating. The central nervous system is more slow in reaching its fullest develop- ment, and the brain more especially is many years later in acquiring its maxi- mum of organic consistency and func- tional power. That portion of the period of bodily de- velopment which is antecedent to puberty is but little obnoxious to neuralgic affec- tions. From the moment when puberty arrives, however, all is changed. In the stir and tumult which pervade the or- ganism, and especially in the enormous diversion of its nutritive and formative nisus to the evolution of the generative organs and the correlative sexual in- stincts, the delicate apparatus of the nerv- ous sj'Stem is apt to be overwhelmed, as well as left behind, in the race of develop- ment. Under these circumstances the tendency to neuralgic affections rapidly increases. It will, however, be seen later that there is a great preponderance of particular varieties of the disease among the cases occurring during this period. 3. Neicralgias of the middle period of life. —By this period is meant the time in- cluded between the twenty-flftli and about the fortieth or the forty-fifth year. It is the time of life during which the indi- vidual is subjected to the most serious pressure from external influences. The 1030 NEURALGIA. men, if poor, are engaged in the absorb- ing struggle for existence and for the maintenance of their families ; or, if rich and idle, are immersed in dissipation, or haunted by the mental disgust which is generated by ennui. The women are going through the exhausting process of child- bearing, and supporting the numerous cares of a poor household in some cases, or are devoured with anxiety for a certain position in fashionable society for them- selves and their children, or again they are idle and heart-weary, or condemned to an unnatural celibacy. Very often they are both idle and anxious. It must not be supposed that there is a sharp line of demarcation between this period and the last : nevertheless it will be seen, when we come to discuss the local varieties of Neuralgia, that there are cer- tain broad differences in the general ten- dencies of the two epochs. It must be noted that particular Neuralgias, which are first manifested in the development period, frequently recur, under special provocation, in the period of middle life. 4. JSffAiraJgias of declining hodily riyor. — The period here referred to is that which commences with the first indications of distinct physical decay, of which the ear- liest that we can recognize (in persons who are not cut off by special diseases) is perhaps the tendency to atheromatous change in the arteries. The earliest de- velopment of this symptom varies very con- siderably in date ; but whenever it occurs it is a plain warning that a new set of vital conditions has arisen ; and especially notable is its connection with the charac- ters of the neuralgic affections which take their rise after its commencement. The period of declining life is pre-eminently the time for severe and intractable Neural- gias. Very few patients indeed are ever permanently cured, who are first attacked with Neuralgia after they have entered upon what may be called the " degenera- tive" period of existence. Perhaps a separate heading should be reserved for those Neuralgias which are the heralds of locomotor ataxy. But they seem naturally to fall under the present class, although the nervous degeneration which produces them is chiefly in the direction of sclerosis. The character of these pains is fully described in the article on Locomotor Ataxy. 5. Neuralgias which are immediately ex- cited by anmmia or mal-nutrition. — Of the neuralgic affections which can be ranked within this group, the sole characteristic worthy of note here is the circumstances in which they arise. It would seem that conditions of anasmia and mal-nutrition simply aggravate the tendencies of exist- ing weak portions of the nervous system to be affected with pain ; just as they notorioasly do aggravate lurking ten- dencies to convulsion and spasms. (B) We come now to the consideration of local varieties of Neuralgia. The pri- mary subdivision of these may be made as follows : — (I.) Superficial Neuralgias. (II.) Vis- ceral Neuralgias. The superficial Neu- ralgias may be subdivided thus : — (a) Neuralgia of the fifth (trifacial or trigeminal) nerve. (6) Cervico-occipital Neuralgia. (c) Cervico-brachial Neuralgia. id) Intercostal Neuralgia. (e) Lumbo-abdominal Neuralgia. (/) Crural Neuralgia. (g) Sciatic Neuralgia. This classification is taken from Val- leix, and appears to me substantially correct. (a) The most important group of Neu- ralgias are those of the fifth cranial nerve. Neuralgia of the fifth nerve always ex- hibits itself with especial violence in cer- tain foci, which Valleix was the first to define with accuracy. These foci are always in points where the nerve becomes more superficial, either in turning out of a bony canal, or in penetrating fasciae. In the ophthalmic division of the nerve the following possible foci are noticeable : (1) the svpra-m'bital, at the notch of that name, or a little higher in the course of the frontal nerve ; (2) the jjalpebral, in the upper eyelid ; (3) the nasal, at the point of emergence of the long nasal branch, at the junction of the nasal bone with the cartilage ; (4) the ocular, a somewhat in- definite focus within the globe of the eye ; (5) the trochlear, at the inner angle of the orbit. In the superior maxillary division the following foci may be found: (1) the infra- orbital, corresponding to the emergence of the nerve of that name from its bony canal ; (2) the malar, on the most promi- nent portion of the malar bone ; ( 3) a vague and indeterminate focus, some- where on the line of the gums of the upper jaw ; (4) the superior labial point, a vague and not often an important focus ; (5) the patome point, rarely observed, but in some recorded cases the seat of intoler- able pain. In the inferior maxillary division the foci are : — (1) the temporal, a point on the auriculo-temporal branch, a little in front of the ear ; (2) the inferior dental point, opposite the emergence of the nerve of that name ; (3 1 the lingual point ( not a common one) on the side of the tongue ; (4) an inferior labial point, one rarely met with. Besides these foci in relation with dis- tinct branches of the trigeminus, there is VARIETIES. 1031 one of especial frequency, wliich corre- sponds to the innscuUUivn of various branches. This is tlie parietal point, situ- ated a little above the parietal eminence. It is small in size ; the point of the little finger would cover it. It is the com- monest focus of all. Neuralgia of tlie fifth nerve may attack any one, or all three of the divisions ; the latter event is comparatively rare.' The most common is tlie case of its limitation to the ophthalmic division, and incompa- rably tlie most frequent foci of the pain arj the supra-orbital and parietal points. The most common of all the varieties of trigeminal Neuralgia is Migraine, or sick-headache. This is an affection wliich is entirely independent of digestive dis- turbances, in its primary origin, though it may be aggravated by their occurrence. It almost always first attacks individuals at some time during tiie period of bodily development. Under the influences pro- per to this vital epoch, and often of a further debility induced by precocious straining of the mental powers, the pa- tient begins to suffer headache after any unusual fatigue or excitement, scmietimes without any distinct cause of this kind. The unilateral character of this pain is not always detected at first ; but as the attacks increase in frequency and severity, it becomes obvious that the pain is limited to the supra-orbital, and sometimes to the ocular branches of the ophthalmic division of the fifth nerve of one side. In very rare cases, however, as in all forms of Neuralgia, the nerves of both sides may be affec'ted. If the pain lasts for any con- sideral)le time, nausea, and at length vomiting, are induced. This is followed at the moment by the increase of the severity of the pain ; but from t'lis point the violence of the affection begins to sub- side, and the patient usually falls asleep. The history of the attacks negatives the idea that the vomiting is ordinarily re- medial. Tills symptom merely indicates tlie lowest point of nervous depression ; but it may happen that a quantity of food which has been incautiously taken, lynig, as it does, undigested in the stomach, may of itself greatly aggravate the Neuralgia, by irritation transmitted to the medulla oblongata. In such a case vomiting may directly reheve the nerve-pain. When the patient awakes from sleep, the active pain is gone. But it is a common occur- rence, indeed it always happens when the Neuralgia has lasted a certain length ot 1 It is with much difSdence that I make this statement, as it is opposed to the opinion of Valleix. But my own experience is very positive on the matter ; and, besides, it ap- pears to me that Valleix's definition of Neu- ralgia which I cannot accept as suiKciently expansive, accounts for his views. time, that a tender condition of the super- ficial parts remains for some hours, per- haps for a day or two. Tliis tenderness is usually somewhat diffused, and not Hmited with accuracy to the foci of great- est pains during tlie attacks. Sick-lieadache is not uncommonly ush- ered in Ijy aigliiug, yawning, and shudder- ing—symptoms which remind us of the prodromata of some graver neuroses, to wliicli it is probably related by hereditary descent. Another variety of trigeminal Neuralgia which infests the period of bodily develop- ment is that known as clavus hystericus ; davits from the fact that the pain is at once severe, and limited to one or two small definite points, as if a nail or nails had been driven into the skull. These points correspond either to the su^jra- orhital or the parietal; sometimes both these are the seat of the pain. But for the greater limitation of the painful area in clavus, that affection would scarcely differ from migraine, for the former is also accompanied, when the pain continues long enough, witli nausea and vomiting. Tlie adjective hystericus is an improper and inadequate definition of tlie circum- stances under which clavus arises. The truth is that the subjects of it are usually females who are passing through the try- ing period of bodily development ; but there is no evidence to show that uterine disorders give any special bias towards this complaint. Both migraine and clavus are often met with in persons who have long passed the period of bodily develop- ment. But their first attacks have nearly always occurred during that period of life. The adult or middle period of life is not, according to my experience, fruitful in first attacks of trigeminal Neuralgia. But when the neuralgic tendency has once been set up, there are many circumstances of middle-adult life which tend to recall it. Over-exertion of the mind is one of the most frequent ; more especially when this is accompanied by anxiety and worry; indeed the latter is a more powerful cause than the former. In women, the exhaus- tion of hemorrhage at parturition, or of menorrhagia, and also the depression pro- duced by over-lactation, are frequent causes of the recurrence of a migraine or a clavus to which they had been subject when young. The middle period of life is also most obnoxious, on the whole, to severe mental shocks, and also to severe bodily accident, of a kind to produce dam- age to the central nervous system. Spe- cial mention ought to be made in the ease of women, of the disturbing influences of the titution among the most numerous group of sciatic patients — those between thirty and fifty vears of age; unless, indeed, we suppose tfiat many of their "robust" patients were so fresh in color and possessed such good muscular Strength as to lead the phj'sician to ignore the far more significant vital indications which are given by the above-mentioned appearances. A prominent feature in this variety of sciatica is its great obstinacy and intrac- tability. Another equally marked is the development, around one or more foci of severest pain, of spots which are perma- nently and intensely tender, and tlie slightest pressure on which is sufficient to renew the agony of acute pain : this de- velopment of tender points is far less marked in the preceding form of the dis- ease. The places which are specially apt to present this phenomenon are as fol- lows : — (1) A series or line of points, representing the cutaneous emergence of the posterior branches, which reaches from the lower end of the sacrum up to the crista ihi. (2) A point opposite the emergence of the great and small sciatic nerves from the pelvis. (3) A point oppo- site the cutaneous emergence of the as- cending branches from the small sciatic which runs up towards the crista ilii. (4) Several points at the posterior aspect of the thigh, corresponding with the cuta- neous emergence of the filets of the crural branch. (5) Aflhular point, at the head of the fibula, corresponding to the division of the external popliteal. (6) An external malleolar, behind the outer ankle. (7) An internal malleolar. Another circumstance which distin- guishes the form of sciatica which we are considering, is the degree in which (above all other forms of Neuralgia) it involves paralysis. Bj' far the largest part of the whole »Hotor-nervous supply for the limbs passes through the trunk of the great sciatic; it might therefore be naturally expected that a strong affection of the sensory portion of the nerve would in a reflex manner, produce some powerful effect on the motor element. This effect is the most frequently in the direction of paralysis. Complete palsy is rare, but in a large number of eases which have lasted some time there can be no doubt that there is a positive and very considerable loss of motor power, independently of any eftect which may be produced by wasting of muscles. It is of course necessary to avoid the fallacy which might be produced by neglecting to observe whether move- ment was merely restricted in consequence of its painfulness. AruBsthesia is also a common complica- tion of sciatica, far commoner, as I ven- ture to think, than it has been represented either by Valleix or Xotta. It is neces- sary, however, to be explicit on this point. In the early stages both of this form of sciatica and of the milder varieties pre- viously described, there is almost always partial numbness of the skin previous to the first outbreak of neuralgic pain, ami during the intervals between the attacks. COMPLICATIONS. 1037 By degrees this is exchanged, in the milder form, for a generally dittused hy- persesthesia around the foci of neurah'ic pain, while other portions of tlie limb may still remain anajsthetic. In tlie severer forms it sometimes happens that, besides an intense liyperaesthesia of the skin over the painful foci, there is diffused hyperfcs- thesia over a greater part or the whole of tlie surface of the limb. But it is impor- tant to remark that both in the ana3stlietic and the hypertesthctic conditions (so- called), the tactile sensibiHty is very much diminished. I have made a great many examinations of painful limbs in sciatica, and have never failed to find (with the compass points) that the power of dis- tinctive perception was very decidedly lowered. Convulsive movements of muscles are met with in a moderate proportion of the cases of severe sciatica of middle and advanced life, in which affection they are entirely involuntary. They differ from certain spasmodic movements not unfrequently observed in the milder form (and especi- ally in hysteric women) , for these are more connected with defective volition, and are, in truth, not perfectly involuntary. In several cases of inveterate sciatica I have seen violent spasmodic flexures of the leg upon the thigh. Cramps of particular muscles are occasionally met with. I have seen the flexors of all the toes of the af- fected limb violently cramped; and in one case the patient was troubled with severe cramps of the gastrocnemius. It is chiefly at night, and especially when the patient is just falling asleep, that this kind of affection is apt to occur. A third variety of sciatica is the rather uncommon one (so far as my experience goes) in which inflammation of the tissues around the nerve is the primary affection, and the iN'euralgia is a mere secondary effect, from mechanical pressure on the nerve, which however is, apparently, not itself inflamed. I believe that tliese cases are sometimes caused by syphilis, and sometimes by rheumatism. It need hardly be said that this affection is essentially different, and requires a difterent treat- ment from Neuralgias in which the dis- turbances originate in the nervous system. (II. ) Visceral HSfeurcdgias. — This most important class of diseases still remains very much unknown ; but it is constantly assuming a greater consequence. The Neuralgias of viscera, of which anything can with confidence be said, are the fol- lowing:— (1) Cardiac, (2) Hepatic, (3) Gastric, (4) Peri-uterine (including ova- rian), (5) Testicular, (6) Renal. It is, however, unnecessary to describe the chnical history of these disorders here, since they will be treated of under the headino-s of the morbid affections of the particular organs which they infest. _ Complications.— This part of our sub- ject IS ol tlie greatest interest, and the tacts regarding it are, to a considerable extent, of recent discovery. If we turn to the excellent treatises of Valleix and Romberg, which appeared about a quar- ter of a century ago, we And a very inade- quate importance assigned to the secon- dary aflectious which occur in Neuralgia. The convulsive movements of the facial muscles which occur in the severer forms of tic douloureux could not fail, of course, to attract attention even from the earlier times. Of the functions of special sense Valleix only mentioned hearing as liable to be aflected. Injection of the conjunc- tiva he spoke of as if it were a rare phe- nomenon in trigeminal Neuralgia. He did not mention modifications of nutrition at all, except those of the hair ; and of modifications of secretion he only enume- rated lachrymation, mucous flux from the nostril, and sahvation as occasional phe- nomena. Of disturbances of the stomach he took a more appreciative view ; and he mentioned, as a remarkable fact, that he never knew facial Neuralgia caused by gastric disturbance, but had frequently observed the latter affection to occur in the course of a neuralgic attack, and ap- parently as the consequence of it. He gives no pathological explanation of the connection between them. It is to M. Notta' that we owe the first scientific treatment of this subject of the complications of Neuralgia. The import- ance of these secondary affections is par- ticularly brought out by this author in his remarks on trigeminal Neuralgia, of which he analyzes V2S cases. As regards special senses, he states that the retina was completely, or almott completely, paralyzed in ten cases, and in nine others vision was interfered with ; partly, prob- ably, from impaired function of the re- tina, but partly, also, from dilatation of the pupil, or other functional derange- ment independent of the optic nerve. The sense of hearing was impaired in four cases. The sense of taste was per- verted in one case, and aboUshed in an- other. As regards secretion : Lachry- mation was observed in sixty-one cases, or nearly half the total number. Nasal secretion was repressed in one case ; in ten others it was increased on the affected side. Unilateral sweating is spoken of more doubtfully, but is said to be prob- ably present in a considerable number of cases. In eia;bt instances there was de- cided unilateral redness of the face, and five times this was attended with notice- able tumefaction. In one case the unila- teral redness and tumefaction persisted, and were, in fact, accompanied by a general hypertrophy of the tissues. Bila- ' Archives Gciierales de Mgdecine, 1854. 1038 NEURALGIA. tation of the conjunctival vessels was observ- ed ill thirt3--four cases. Nutrition was affected as follows : In four cases there was unilateral hypertrophy of the tissues ; in two, the hair was hypertropliied at the ends, and in several other cases it was ob- served to fall off or to turn gray. The tongue was greatly tumefled in one case. Muscular contractions, on the affected side, were noted in fifty-two cases : of these, in thirteen, the contractions were m the muscles of the lip and nostril ; in ten, there was tremor of the eyelid ; in a great number many muscles were simul- taneously affected. Permanent tonic spasm (not due to photophobia) was observed in the eyelid in four cases ; in the muscles of mastication, four times ; in the mus- cles of the external ear, once. Paralysis affected the motor oculi, causing prolapse of the upper eyelid, in six cases ; in half of these, there was also outward squint. In two instances, the facial muscles were paralyzed in a purely reflex manner. The pupil was dilated in three cases, and con- tracted in two others, without an^ im- pairment of sight ; in three others it was dilated, with considerable diminution of visual power. Finally, with regard to common sensibilit\', — M. Notta reports three cases in which ancesthesia was ob- served, liypercesthesia of the surface only occurred in the latter stages of the disease. Various other observers have added to this list of the secondary affections which may occur in facial Neuralgia the follow- ing : Iritis, glaucoma, corneal clouding, and even ulceration ; periostitis, uni- lateral furring of the tongue, herpes uni- lateralis, &c. All the above complications of facial Neuralgia, excepting glaucoma, have been under my own observation, and most of them I have seen in a great many cases. Moreover, my own attention had been called independently to the subject by my own unlucky personal experience. I began, at the age of about fourteen, to suffer from attacks of unilateral facial Neuralgia in the right side (chiefly supra- orbital), which very soon assumed the type of severe migraine, such as it has already been described. A year or two later, the pains being at this time severe and frequent, there occurred a painful thickening and tumefaction of the perios- teum round the brow, and also the forma- tion of one or two dense white patches on the cornea, in the centre of which small phlyctenular ulcers appeared. About the same time, probably, there occurred a great thickening of the fibrous tissue, surrounding the upper end of the nasal duct, which caused a dense stricture of that canal. Some years later, when the attacks had become much less frequent, they recurred with great severity during the prostration brought on by choleraic diarrhoea. I then first noticed that the hair of the eyebrow was whitened oppo- site the supra-orbital notch, and that gray hairs were thickly strewn over the right side of the head for some time after the attack ; and this phenomenon has occurred after every severe attack since that time. It only lasts in intensity for a few days, and the color soon becomes partially restored to its original tint, but without any falling off of the hair. The latter fact seems at first difficult of be- lief; but I have most closely observed the phenomenon, and have since wit- nessed the same thing in several patients, both of my own and other practitioners. Another nutritive modification which I have seen in my own case is the forma- tion of a dense epithelial fur on one-half of the tongue. There is another complication which, so far as I am aware, was first identified by myself as having a definite relation to facial Neuralgia : viz. erysipelatoid in- flammation of the tissues to which the painful nerve is distributed. Some years ago I was much surprised at observing, in a woman aged thirty -two, a patient of the Chelsea Dispensary, a most acute at- tack of unilateral erysipelas of the face and head, supervening on some severe and frequently recurring attacks of Neu- ralgia, which affected all three divisions of the trigeminus, but was most violent in the branches of the ophthalmic divi- sion. On the recurrence of the erysipe- las, the acute pain subsided, but the most intense tenderne.-s remained for some da}-s, and pressure anywhere in the track of the nerves would re-excite a mo- mentary spasm of pain. Since that time I have been constantly on the look-out for similar cases, and have observed a good many either in my own practice or that of others. In several instances I have seen Neuralgia of the fifth actually terminate in an affection undistinguish- able from ordinary erysipelas, limited to the painful parts : in four of these cases it was limited to the side of the nose, the infra-orbital and frontal regions. But the facts bearing on a connection between facial neuralgia and erysipelas are by no means limited to this. In twenty-two cases which have come under my care, of patients suffering either from typical facial tic, from migraine, or from clavus hystericus, I have discovered, by inquiry, the existence of a strong tendency to erysipelatoid inflammation of the parts then affected with Neuralgia. An attack of erysipelas would be brought about in these patients, by the most trivial causes, by a slight exposure to cold winds, or, on the other hand, by unusu- ally depressing fatigue or emotion. The majority of these patients give me a COMPLICATIONS. 1039 lamily history which showed a marked Inherited dibposition to neurotic affec- tions, a circumstance which, as we shall hereafter see, is of importance. Perhaps the most striking of all the cases which have come under my notice is one which was obligingly sent to me by Mr. Ernest Hart, and which I have al- ready published' in detail. The exciting cause of the whole train of phenomena was apparently fright from an accident which there was no reason to suppose in- tlictcd any direct physical injury. The sequence of events was : (1) abrupt cessa- tion of menses, with hysteric depression ; (2) severe neuralgia of the first and second divisions of the fifth, quickly producing iritis, with effusion of lymph ; (3) erysipe- las, exactly limited to the skin of the pain- ful parts, and as it were supplying the Neuralgia. Tlie concurrence of iritis with the ery- sipelas, in this case, is a most interesting fact, as showing a general tendency to paralj'sis of the vessels in the affected dis- trict, which will be much dwelt on in the section on pathology. The connection of iritis with ifeuralgia is a subject which, though only quite recently mooted, already assumes an extraordinary magnitude, and may yet lead to pathological and thera- peutical discoveries of first-rate import- ance. For my own part I do not hesitate to express the belief that the very vague and ill-definod disease known, in common phrase, as "Rheumatic iritis," is destined to be almost, if not quite, banished to limbo ; for, that careful observation will prove the cases so denominated to be nearly all capable of classification as "Neuralgic iritis." The symptoms which characterize this malady are as follows. The patient first of all complains (usually after exposure to cold wind, or damp, or both.) of pain round the orbit, which gradually increases to a pitch of great severity, but which ex- hibits marked intermissions or at least remissions. The vessels of the conjunc- tiva, but more particularly of the sclero- tic, tlien become injected. Last of all the iris itself becomes cloudy, and, in se- vere cases, actual deposits of lymph take place. 1 cannot hesitate to say, from careful inquiries into the past history of such patients, that this kind of affection occurs quite as frequently in persons who have never shown any distinctive rheu- matic tendencies as in those who have. On the otiier hand, there is nearly always a recognizable history of tendencies to- wards neuralgic affections of one sort or another. And indeed with regard to the whole series of so-called chronic rheu- matic affections of fibrous membranes, it must be remembered that there is reason 1 Lancet, 1866, vol. ii. p. 548. to doubt whether, on careful analysis, their local symptoms can be grouped into any intelligible unity. It seems far more likely that, as the consequences of spinal irritation become more perfectly known, the whole group of such aftections will be resolved into particular cases of centric nervous irritation. And finally it may be noted that this variety of iritis is greatly more amenable to the influence of quinine than to that of any other remedy ; in fact, beyond the use of belladonna to prevent pupillary adhesion, no other treatment is required. Herpes, as a complication of dorso- intercostal Neuralgia, has been already referred to. Although not so connnonly, it may probably attend Neuralgia of any superficial nerve. For instance, the oc- currence of a regular facial herpes zoster has been considered by many authors not so much a rarity as an impossibility. But various single cases have been recorded by individual observers of late years ; and in a very valuable paper on unilateral herpes in the London Hospital Reports for 1866, Mr. Jonathan Hutchinson reck- ons up fourteen cases, including several which came under his own observation : some of them are mentioned to have been accompanied by Neuralgia of the fifth. In one of these cases, in which the Neu- ralgia was particularly severe, the her- petic vesicles were followed by ulcers, which left considerable scars on the fore- head. I have myself seen herpes the attendant of two cases of cervico-brachial Neuralgia, in one of which the ulcerations following the vesicles were a cause of severe suffering; and in one instance of sciatica in my practice there occurred enormous vesicles, or rather bullae, on the back of the calf, which formed most trou- blesome and exquisitely painful ulcers. I3arensprung' records a similar case, in which the irritation of the sciatic was secondary to psoas abscess. The tendency of deeper tissues to be affected in an inflammatory manner as a consequence of Neuralgia, which is spe- cially shown in the cases of neuralgic iritis, receives every-day illustration. In fact, the painful points so universally observed in severe or inveterate cases are probably produced by a subacute inflam- mation, first of the fibrous membranes (periosteum or fascia) in contact with the nerve at points where it comes out from a deeper to a more superficial position, and further (in some cases) to all the subcuta- neous tissues for an inch or two round. In one of the cases of cervico-brachial Neuralo-ia already referred to, a bright red painful spot, as large as half-a-crown, appeared on the outer side of the arm ; there was dense thickenin g of tissues in I Loc. oit. 1040 NEURALGIA. this situation, and the resemblance to an inflamed syphilitic node was remarkable. The neuralgic origin was, however, un- mistakable. Among the cases of facial herpes collected by Ilutchinson, there are several in which serious or even irreme- diable damage was inflicted on the eye by general inflammation of its tissues. Diagnosis. — The diagnosis of neural- gic atfections from others which may in- volve pain is, on the whole, not difficult, if we are able to extract from the patient a full account of his history. The essen- tial points for observation are : — 1. The situation and direction of the pain, wheth- er this is unilateral, whether it corre- sponds to the course of a recognizable nerve branch or branches. 2. AVhether it ^s intermittent or markedly remittent. The points of history which are most im- portant are :— 1. Whether the patient has suffered Neuralgia before, and if not, whether Neuralgias, or neurotic diseases of any kind, have prevailed in his family. 2. Wliether the attack was preceded by- nervous disposition, or was ushered in by distinct numbness or tingling. 3. Wliether the immediate excitant appeared to be cold or damp or both, or a severe nervous shock, or a direct physical injury. 4. (If the affection has lasted some time) whether there has occurred anj^ development of secondary tender points in the situations where, as above described, they might be expected. 5. Whether the patient has suffered from secondary affections of glands (e. g. lachrymation, in the case of facial pain) during the attacks, or of tem- porary congestion of surfaces (e. g. of the conjunctiva) in the same case, or from alterations of epithelium or hair, or her- petic eruptions, or erysipelatoid inflam- mation of the skin corresponding lo the distribution of the affected nerve's. The affirmative answer to any of these questions is, pro tanto, in favor of the genuinely neuralgic character of the dis- order ; and, indeed, the union of features 1 and 2, under the heading of "observa- tion," with one, or still more with two or three, of the "historical" facts, would be pretty well decisive in this sense. The main source of embarrassment, in difficult cases of diagnosis, is the impossi- biUty which we sometimes encounter of getting a clear history. This is especially apt to occur when we are called to the pa- tient not so much on account of the pri- mary neuralgic affection as because of severe secondary consequences that hap- pen to have arisen. For instance, in a case of severe Keuralgia of the fifth, attended with periosteal inflammation round the orbit, or with intense conjunc- tivitis, and, it may be, corncitis, or 'even iritis, the history related is likely enough to lack explicit details of the primary aflection. It is necessary to inquire very strictly whether the pain, when it first occurred, was, or was not, accompanied by tenderness on pressure ; and whether this simple pain markedly preceded the organic lesions. Another serious difficulty arises, not unfrequently, in distinguishing between true Neuralgia, and that form of pain which is vaguely called hysteric ; and also between the former, and Myalgia not associated with the hysteric diathesis. The great characteristic of true Neuralgia is the limitation of the pain to the course of recognizable branches of nerves, as op- posed to the diffused character both of hysteric and neuralgic pains. A history of intense hysteric predisposition may help the diagnosis in some cases, and a histoi'y of overwork done by under-nour- ished muscles may clear it up in others. But hysterical persons may, and some- times do, suffer from true Neuralgia. And again, it is very common for hysteric patients to develop tender points in cer- tain situations (esijecially beneath the left mamma, in the epigastrium, and at various situations along the vertebral fossse which lodge the great muscles of the back), which bear a superficial similarity to the tender points developed in long- standing Neuralgia. The more general- ized hyperffisthesla of the skin which usu- ally accompanies these symptoms, when they are due to hysteria, will seldom be observed, however, in true Neuralgia ; and the remarkable affections of volition which mostly accompany the hysteric diathesis rarely occur in Neuralgia pure and simple. A means of diagnosis be- tween hysteric hypersesthesia and the true Neuralgia which I have found most useful is the use of Faradization. It has a strikingly inactive effect in the former, but acts much more slowly, or not at all, in true Neuralgia. It is almost impossible to lay down rules of diagnosis, in this place, between Neuralgia pure and simple, and that which accidentally occurs from a nerve becoming squeezed, or otherwise dam- aged, in the progress of tumors or other organic diseases external to it. The reader must be referred to the diagnostic characters mentioned in the treatises on such diseases for the means of distinction. The neuralgic pains which usher in locomotor ataxy, are highly peculiar, and their diagnosis from ordinary Neuralgia must be learned by studying the article on the former disease. Prognosis.— The prognosis of Neural- gia is nearly always an uncertain matter. The simplest case is when a clearly mala- rial history can be made out, and when the blood infection has not lasted too long : here we may expect a speedy cure PATHOLOGY AND ETIOLOGY, 1041 by appropriate treatment. The least complicated varieties of traumatic Neu- ralgia—those in which tlie irritation is only kept up by some mechanical irrita- tion (e.g., a foreign body lodged, or a tight cicatrix making pressure)— of course offer a good chance of cure by surgical interference. Among the Neuralgias which are more purely'of internal origin, those are chiefly to be regarded as benign which occur in young subjects : and next to youth in favorable influence on the prognosis comes the fact of otherwise un- broken health. Neuralgia becomes pro- gressively less curable in each successive decade of life, and more especially after the commencement (at whatever nominal age) of the symptoms of organic degenera- tion. Very formidable, in all cases, is the fact that the patient's family have been liable either to severe Neuralgias, or to other grave neuroses. And when a patient with such a family history is first attacked with a Neuralgia after he has already entered on the period of organic degeneration, his chances of complete re- covery must be reckoned very small. Moreover, such a Neuralgia is not unfre- quently the first warning of degeneration of the centres, which will end with soft- ening of the brain. These are the fundamental points in prognosis. A less essential, but still im- portant, class of momenta are the circum- stances of the patient's life ; how far, for instance, he is likely to be exposed to the hostile influences of cold, damp, and pri- vation, with the disorders which they tend to engender ; and how far there may be unavoidable exposure to the influences of mental distress, or of "the weariness of an objectless life." Pathology and Etiology. — These two subjects, in the case of Neuralgia, are inextricably mixed ; nor is it possible to discuss the one without constant refer- ence to the other. They are so mixed, firstly, because there is no suflftcient basis of anatomical fact to support a "pathol- ogy, "in the ordinary sense ; and secondly, because, in addition to tlie philosophical diificulties which always beset the con- struction of an etiological system, there are, in the case of Neuralgia, special obstacles to the decision as to what is "cause" and what "effect," arising from the necessity of regarding a neuralgic per- son as a mere offshoot of a certain family beset with peculiar tendencies, rather than as an individual who forms his own phys- ical destiny by the manner and circum- stances of his life. Of facts tending to elucidate the mor- bid anatomy of Neuralgia there are very few. This necessarily follows from the raritj' with which neuralgic patients die under circumstances which lead to any VOL. I.— tJb careful examination of the nerves and nerve-centres. Among the very lew re- corded cases which show anything posi- tive is the remarkable one related by Komberg.' The patient was a victim to the severest form of facial Neuralgia, " of the period of bodily degeneration," such as I have described it. The Gasserian ganglion of the painful nerve was almost destroyed by the pressure of an internal carotid aneurism, the trunk and posterior root of the nerve were completely degen- erated, and the atrophic process had ex- tended, in less degree, to the nerve of the opposite side. This case, alone, of course proves no- thing as to the general question of the pathology of Neuralgia. But it teaches a notable fact, that the extremity of pain can be suffered in a nerve in M'hich sen- sation would soon have become extinct by dissolution of the connection between centre and periphery. It is imaginable that a not less real, but less advanced and less coarsely obvious atrophic change may have been present in every case of Neu- ralgia, even where dissection has failed to reveal anything amiss. It must be re- membered that the microscopic study of morbid changes in nerve tissues is even now only in its infancy. It would be vain to occupy a large space in a prac- tical treatise, with disquisitions on a sub- ject at present so obscure as the pathol- ogy of Neuralgia ; I shall therefore content myself with stating the hypothesis which appears most probable to me, and the mere outline of the reasons which incline me to adopt it. I think it most probable that in all cases of Neuralgia there is either atrophy, or a tendency to it, in the posterior or sensory root of the painful nerve, or in the central gray matter with which it comes in closest connection. The follow- ing are the heads of the argument :— 1. Neuralgia is eminently hereditary. It is constantly observed to prevail in par- ticular families, breaking out in succes- sive generations and various individuals. But what is even more important to notice is the fact that these neuralgic families are almost invariably also dis- tinguished by a tendency to the severer neuroses— -insanity, cerebral softening, pa- ralysis, epilepsy, hypochondriasis, or an uncontroflable tendency to alcoholic ex- cess ; and very often in the various mem- bers of the same family we may observe the alternation of all these affections with Neuralgia. [The importance of the hereA- itury gouty diathesis is quite great in some instances. — H.] 2. Such hereditary tendencies m a race seem strongly to suggest a tendency to J Diseases of Nervous System, Syd. Soe. Trans, vol. i. 1042 NEURALGIA. imperfection in the congenital construc- tion of the central nervous system ; so that we may imagine tliat certain cells and fibres of this system are, in a large proportion of that race, built, as it were, only to live with perfect life for a short term. The weak spot may be in one place in this person, in another place in that. 3. Given such a weak spot, congenitally present, all hostile influences will tell more heavily on it than on the rest of the organs. The depressing influence of cold applied to the periphery, of a wound of the trunk or branches of a nerve, of a severe shock (mental or physical) to the nervous centres generally, or of continued alcoholic excesses, will suffice to throw the imperfectly constructed cells into a state of positive disease, which may end in de- cided atrophy. Even in the absence of any special external cause, the depressing influence on the nervous centres produced by the great crisis of puberty, child-bear- ing, the involution of the female organs at the grand climacteric, and still more the partial failure of nutrition which the arterial degeneration of advanced life would cause — any of these may suffice to start the local morbid process. 4. A very weighty argument in favor of the idea that central mischief is a factor in all cases of Neuralgia is the great fre- quency of complications, such as have been described, in which various nerve- fibres, quite distinct from those which are the seat of pain, and connected with these only through the centre, are secondarily affected. 5. Those cases in which a localized peri- pheral lesion is the immediate excitant also require for their explanation the as- sumption of a peculiarity in the indi- vidual, as one factor, and that the most important, in the production of the Neu- ralgia. For of hundreds of persons to whom exactly similar lesions happen every year, not more than two or three, perhaps, experience any Neuralgia ; and these two or three will, I believe, be in- variably found to belong to neurotic families. 6. The only cases in which the theory of congenital central imperfection appears neither applicable nor necessary are those in which a pressure, ulceration, or other lesion extending from neighboring tissues towards the nerve, maintains a constant depressing centripetal influence which it is not difficult to suppose might impair the vitality of the posterior root, or of the central gray matter. 7. Certain influences, especially that of excessive drinking, which notoriously tends to produce degeneration of the nervous centres, are powerful predisposers to the production of Neuralgia of the in- veterate type. Moreover, the descendants of drunkards, among other evidences of an enfeebled nervous organization, arc decidedly prone to Neuralgia. So fre- quently have I made the discovery that neuralgic patients have had drunken parents, that I cannot suppose the coinci- dence to be accidental. Treatment. — The treatment of Neu- ralgia may be classified under three heads. The first division includes all remedial measures which are intended to improve the general nutrition, including tliat of the nervous system, or to remove any vicious condition of the blood which may impair nervous function. The second division includes the narcotic stimulant remedies. The third division comprises all the remedies which are destined to exert a direct influence upon the aflfected nerve. 1. Constitutional treatment. (a) Under the head of nutritive remedies for Neuralgia, by far the most important sub-class is the series of animalfats. There is a theoretical basis for the use of these substances which it is impossible to ignore, although I have no desire, in the present state of our knowledge, to insist too ab- solutely upon it. In some way or other, fat must undoubtedly be applied to the nutrition of the nervous system, if this is to be maintained in its organic integrity ; since fat is one of the most important, if not the most important, of its organic in- gredients. But if our theoretical ideas on this point be as yet deficient in the exact- ness which is to be desired, there can be no doubt, I think, that the practical les- sons which they would teach are abun- dantly verified in experience. If we take, for instance, the class of Neuralgias which are most plainly and indubitably connected with impaired nutrition — those of ad- vanced life, and particularly the invete- rate forms of facial tic douloureux — there is the strongest ground, in the results of experience, for insisting upon the value of this class of remedies. To Dr. Ead- cliiTe belongs the merit of having been chiefly instrumental in bringing forward this therapeutical fact in this country, and it is one which I liave had repeated occa- sions to verify. It is a very singular cir- cumstance, which also was first pointed out by Dr. Eadcliffe, that neuralgic pa- tients are, in the majority of instances, found to have clierished a dislike to fatty food of all kinds, and to have systemati- cally neglected its use. I have also ob- tained strong evidence tliat this is the general rule, and the reverse a rare excep- tion. And it has several times occurred to me to see patients entirely lose neu- ralgic pains, which had troubled them for a considerable time, after the adoption of a simple alteration in their diet, by which the proportion of fatty ingredients in it was considerably increased. TREATMENT. 1043 Cod-liver oil occupies the highest rank among fatty remedies ; where it does not mimediately disagree with the stomach this oil is the best fat to employ. But in other cases butter, and especially cream may be employed with great advantage ; and m fact one of the most successful ex- amples of the treatment of ISTeuralo-ia which I record was treated solely by The administration of Devonshire cream in increasing, and finally in very large quan- tities. Even the vegetable olive oil, though far inferior to animal fats as a general rule, may occasionally be used with good effect. It is necessaiy in many cases to make a series of trials, before we arrive at the particular form of fatty food which is best suited to the particular patient. (6) The various preparations of iron are of use, so far as I know, only in cases which are marked by the existence of actual antemia. For patients who possess well-globulated blood (as indicated not merely by the color of the face, but by that of the mouth and tongue, especially by the freedom of the latter from teeth- markings, and by the absence of the drowsiness, muscm volitantes, &c., which indicate defective blood-nutrition of the brain) I do not believe that iron treat- ment has any value. The carbonate, in large doses, is the best form, when iron is needed at all. [Obstinate neuralgia is one of the signs of anaemia, itself so gene- rally positive, that, when nothing contra- indicates iron, the carbonate may be used with confidence. Its effects are not un- frequently admirable. — H.l (c) The employment of the so-called special nerve tonics is of great use in some cases, of none at all in others. Quinine, arsenic, and zinc (in various preparations) are the only medical substances of this class which possess any solid claims to efficacy. With regard to the efficacy of quinine there are the most conflicting opinions, except in one respect. oSTo one doubts that in the IS'euralgias which are of mala- rious origin this medicine, though not infallible, is extremely eflScacious. It should be administered, in all eases which from their regular intermittence leave room for a suspicion that this may be their nature, in full doses (five to twenty grains) shortly before the time at which the attack of pain is expected; in fact just in the way which proves most effective in the treatment of regular agvie. If after three or four doses a decided improvement is not effected, the probability is great that the Neuralgia is not malarial. Never- theless, arsenic may subsequently be tried if other means (to be presently described) prove ineffectual. In a certain number of non-malarial cases, also, quinine produces good effects ; but there is no need, nor is it advisable, to employ it in such large doses. From two to three grains, three times a day, is the largest quantity which is likely to be of any use, if my own experience is worth anything. I know of no circumstances which indicate beforehand that quinine will be useful in non-malarial cases, except that it seems always riiuch more effective in Neuralgia of the ophthalmic branches of the ffth,than in other non-malarial Neuralgias. With regard to other non-malarial Neu- ralgias I share Valleix's opinion, that it is far from being frequently useful. Arsenic is a more widely applicable remedy : for it is useful in many cases both of the malarial and of the non- malarial type. In the former it should be given, probably, in full doses, of ten minims, increasing to thirty, of Fowler's solution, three times a day. In the non- malarial forms, the ordinary tonic dose of five miuims of liq. arsenicalis, three times a day, or ,\ grain of arseniate of soda in pill, with extract of hop,' will effect all the good which this medicine can produce. The ordinary precautions must of course be observed, as in anj^ other case where we employ arsenic. There is one form of Neuralgia, however, which merits special mention in relation to arsenical treatment ; I mean the specially neurotic form of angina pectoris. In France this remedy is extensively used for cardiac Neuralgia. I have myself seen most re- markable relief afforded by arsenic in this complaint, and an extraordinary tolerance of the system to large doses of it. Very recently, Dr. Philipp has put on record a most interesting case of the kind.^ There are, indeed, some patients whose alimen- tary canal is too irritable to bear this remedy at all; but it is usually well borne, and often extremely efficacious. Arsenic may also be eftectively administered by subcutaneous injection. The preparations of zinc^ and more es- pecially the valerianate, enjoy a high reputation with some practitioners. It is necessary to record this fact ; but I can- not say that I have ever seen any good result,' which could be confidently attri- buted to these remedies, in Neuralgia. [d) Last, among the constitutional re- medies, we have to mention those which are directed against a real or presumed depravation of "the blood by some special poison. Neuralgia may certainly arise from syphilis ; but then it is probably al- ways due to a local deposit somewhere in the course of the aftected nerve. Where this can be suspected, iodide of potassium should be administered in large doses; 1 Dr. Radcliffe tells me he. finds that ex- tract of hop enables arsenic to be better tol- erated than when given alone. 2 Berlin. Klin. Wochensch. 4, 1865. 1044 NEURALGIA. and if this fail, the bichloride, or biniodide of mercury, in small doses. Xeural^ia is said to have frequently a r/mcty origin : but the facts on which this statement rests, perhaps hardly warrant a decided opinion. They scarcely amount to more than this, that in a certain ill-deflned group of cases, the subjects of which are perhaps more often than not of a gouty constitution, a form of aSTeuralgia occurs which yields more speedily to treatment with colchicum than to any other remedy. Twenty to thirty minims of the tincture or the wine, three times a day, will be sufficient ; and if a marked good effect be not produced in two or three days, the medicine should be abandoned, or even earlier, if any tendency to weakness or irregularity of the heart's action be per- ceived. "Kheumatic" ISTeuralgia is a phrase which, under the precautions above indi- cated, must still be retained, as signifying a class of cases in which inflammation of circumjacent fibrous tissues seems to cause the neuralgic pain by producing mechan- ical damage to the nerve. Iodide of po- tassium in five to ten grain doses twice or thrice daily is often useful ; causing the absorption of local deposits, or rather of local proliferations of fibrous tissue. Even in cases where the Neuralgia was the pri- mary affection, and the fibrous hypertro- phy secondary to it, the local tenderness and swelling appear to be often dimin- ished by the use of this remedy. I have never seen colchicum produce the slightest benefit in these cases, in which local ten- derness is a prominent symptom. [In gouty cases, however, as above said, colchi- cum is the most efficacious of remedies. -H.] '2. We have now to consider the large group of narcotic-stimulant remedies for Keuralgia. In this class, I include not onlj' the substances generally recognized as belonging to it, such as opium, bella- donna, alcohol, &c., but also many others, such as ammonia, turpentine, &c., which are commonly spoken of merely as " stim- ulants ;" and also substances which, like aconite, are ordinarily ranked either as pure "sedatives" or as " acro-narcotics. " I shall not retrace here the arguments which I have given at large, in my work on " Stimulants and JTarcotics, '" to prove that all these substances possess the com- mon property of assisting nerve function when given in small doses, and of para- lyzing it when given in excess. The narcotic-stimulant group of reme- dies, when administered internally or by subcutaneous injection, may be said to hold an intermediate position between the constitutional and the local agencies which we may employ against Neuralgia. On ' London : Macmillan. 1864. the one hand, they enter the general eir> culation, and pervade tlie organism. On the other hand, it may be suspected that in many cases their efiect is produced mainly by a local action, either upon the central nuclei of affectetl nerves, or per- haps upon their spinal ganglia. Indisputably, at the head of all this class of remedies stands opium. And we may consider opium, as used against Neu- ralgia, to be fully represented, for every useful purpose, by morphia. But the gastric administration by opiates can, after all, be only considered as jjalliative. The invention of the subcutaneous injec- tion (which was imperfectly forestalled by the enclermic method) has thrown quite a new light on the capabilities of opium as an anti-neuralgic. It may be confidently said that in the right use of this remedy, we possess the means of permanently and rapidly curing very many cases, and of alleviating, to a degree quite unknown before, the suffering caused by even the most inveterate forms of Neuralgia. The local injection of alkaloids, as first systematically employed by Dr. Alexan- der Wood, is a proceeding which is spe- cially applicable, in my opinion, only to a few cases. In many instances the nature of the integument at or near the point of severest pain, is such as to render the local operation inconvenient or even im- possible. In the great majority of cases, especially those which are seen early, the injection may be more advantageously performed in some indifferent place, such as the loose skin over the front of the biceps muscle, or, in fact, in any place where a fold of skin can be conveniently picked up. The substance injected, if properly dissolved in a convenient quan- tity of fluid, quickly enters the general circulation, and, in a large majority of instances, produces just as decided an effect on the local nerve pain, as if it had been locally injected. I cannot doubt that, in the greater number of cases, the "local" injection is such only in name; the injected substance producing no effect till it has entered the absorbent vessels or the veins, and thence travelled all round the circulation to the small arteries, either of the spinal and ganglionic centres, or, perhaps, to the arteries which supply the peripheral branches of nerves. The dis- covery of the great utility of the plan of general, as opposed to local injection, is due to Mr. Charles Hunter, and is of the highest importance, not merely as a prac- tical fact, but in the suggestions which it gives as to the general subject of the place of origin of Neuralgia. There is, how- ever, a class of cases in which the local injection of morphia becomes desirable. In advanced cases, in which very great local hypersesthesia exists, and there is reason to think that thickening and hyper- TREATMENT. 1045 trophy of the structures round the nerve has taken place, I have several times known injection at a distant point to fail, when local injection of the same substance, in the same dose, has immediately pro- duced a marked eftect ; and the same thing has been recently pointed out to me by several medical men. It happens sometimes, however, that in the very cases which seem most to demand the local injection, the local tenderness makes the operation intolerably painful : in such a case I should recommend a plan which Mr. Hart introduced to my notice, viz. : that of first rendering the skin insensible with ether spray, and then injecting. As the freezing process renders the tissues quite hard, a steel canula to the syringe is needed to penetrate them. As regards the dose to be employed, I cannot but think that the received ideas are much in fault. One hears constantly of as much as half a grain or one grain, even, of morphia being employed, even at the outset. That such quantities are necessary, sometimes, where the cellular tissue injected into is already irritated and thickened, I have no doubt ; and I explain it by the hypothesis that a good deal of the injected substance never en- ters the general circulation, nor even the vessels of the part, but lies encysted, just as is undoubtedly the case when one in- jects an irritant substance like pure chlo- roform into the cellular tissue anywhere. But I am quite certain that when injec- tion of any non-irritant solution of mor- phia into a healthy cellular tissue is neatly performed, it is unnecessary, and even unsafe to commence with larger quantities than ^ gr. Both in my own practice and in that of a friend, I have knovyn so little as { gr. produce danger- ous symptoms of poisoning in a person not especially sensitive to opium ; and I am convinced that the activity of reme- dies hypodermically used is generally much underrated. I have produced all the desired effects by injection of not more than j\ gr. in slight cases, and very rarely indeed (where the morphia is in- jected at an indifferent spot) do I increase the dose beyond | gr. The best medium dose is ^ gr. ; and the injections should be repeated, if possible, daily, or even twice a day in severe cases. In visceral Ifeuralgia, it need hardly be said, we are obliged to be contented with injection at an indifferent spot ; yet (as e. g. in ova- rian N"euralgia) we sometimes produce excellent effects. IN'ext to opium in value, amongst the stimulant narcotics, is belladonna and its alkaloid atropia. The value of bella- donna, as given by the stomach, is con- fined pretty much, according to my ex- perience, to painful affections of the pelvic organs, on the sensory (as notoriously in the motor) nerves, on which it seems to have a special influence. In doses of 4 gr. to -^ gr. of the extract, it will fre- quently relieve ovarian dysmenorrhea as also some forms of superficial lumbo- abdommal N'euralgia. But by far the most nnportant use of belladonna is by the subcutaneous injection of atropia From the -ris up to the j-j of a grain is about the range of doses for adults ; and I can confirm the statements of Mr. Hunter that by repeated applications of this treatment, even very severe and in- veterate Neuralgias are often greatly re- lieved and sometimes cured. It is a question whether there is not less ten- dency to relapse after this treatment than after that by morphia. On the other hand, I have met with more than one person in whom it has been found impos- sible to give a dose sutficieut to reheve the pain -without producing distressing head symptoms. Next in value to morphia and atropia comes Indian hemp, which has been es- pecially brought forward by Dr. Eeynolds. A good extract of this, in doses of from | to I grain or (rarely) 1 grain, given in pill, is very effective in some forms of Neuralgia, particularly in clavus hysteri- cus and migraine. Even in the severest and most intractable forms it often palli- ates greatly. It should be given every night, whether there be then pain or not. Muriate of ammonia is an excellent stimulant remedy in migraine and clavus, and in some cases of iutercostal Neural- gia. It should be given in 10 to 20 gr. doses. In cases of suspected hepatic Neuralgia I have also found it very use- ful ; and I believe that its action on the liver (in disorders of secretion) is through the nervous system entirely. Sulphuric ether, wiiich in the severer forms of superficial Neuralgia is of little or no effect, is suprenaely useful in certain visceral Neuralgias. It sometimes re- lieves gastralgia, and Neuralgia of uterine or ovarian origin, with magical rapidity. But it is still more valuable in the most purely nervous form of angina pectoris. I have now under my care a case of this latter affection, which I am convinced would have ended fatally long since, in one of the agonizing attacks of spasmodic heart-pain, but for the discovery that, by taking a spoonful of ether immediately on its commencement, the patient can greatly mitigate the attack. This patient had tried arsenic, but from the irritability of his intestinal canal, could not take it. The same dose of ether has continued to produce the same happy effect on each occasion of its use for the last three years. Aconite, in the form of Flemming's tincture, is of very great use in some forms of Neuralgia, especially in that 1046 NEDRALSIA. kind of ocular Neuralgia, with secondary iutlammatiou, which is so frequently called rheumatic iritis. But, unfortu- nately, it is a verj- uncertain remedy in one respect : with some persons it pro- duces nausea, burning in the throat, and a sense of cardiac depression, with doses which are quite harmless to other pa- tients. In a case where I recently em- ployed it, in only three-minim doses every six hours, 1 was compelled to abandon it after the third dose, from the intensely depressing effect which it produced. The oil of turpentine is a remedy which enjo3'S, or enjoyed, considerable reputa- tion for its eftect in a certain class of cases. In the more obstinate forms of sciatica it is at least worth a trial, although it is commonly very disagreeable to the patient ; ten minims, three times daily, is the proper dose. Still, after the enumeration of all the narcotic-stimulant substances which have been, and many more that might he, named, it would be idle to pretend that any of them are to be compared, for wide and general efHcacy, to the subcutaneous use of morphia and atropine, and the in- ternal use of Indian hemp in small doses. I have reserved to the last, under the head of Stimulant Narcotics, what must be said about alcoholic drinks. There can be no question about the power of alcohol to relieve neuralgic pains ; it is as distinct as that of opium. But the dan- gers of prescribing it as a remedy are very great, since the patients cannot always be induced to use it in the strictly medical manner in which alone it is safe. Too often, instead of employing it in the moderate stimulant doses which really are of service, they accustom themselves to drowning the pain with a large narcotic dose, and thus they contract a liking for the oblivion of drunkenness. It is of much consequence, where this is possible, that they should be forbidden to take alco- hol otherwise than at meal-times. If once they are induced to take it for the mere relief of acute pain, there is great danger that they will drink to excess. I am, never- theless, convinced that a fixed daily al- lowance of wine or brandy (beer more rarely agrees), which shall contain not more than one ounce of absolute alcohol, is a decided help to recovery from every form of Neuralgia ; and in the case of persons of firm character, who can be trusted to exercise self-control, a larger quantity than this may sometimes be allowed. Without pretending to specu- late on the physiological reason for it, I must add my testimony to the fact, which has been observed by Dr. Eadcliffe, that saccharine liquors and saccharine foods, except in very moderate quantities, de- cidedly disagree with neuralgic patients. [For many women (the most frequent subjects of neuralgia), an ounce of alcohol daily, however divided, will be too disturb- ing to the system to be beneficial ; and will endanger the tippling habit. Less than half an ounce of alcohol (equal to tAvo tablespoonfuls of whisky) daily, will be ample in most cases. — II. J 3. We now come to consider the exter- nal remedies for Neuralgia. Incompara- bly the most valuable of these is the use of so-called counter-irritation ; that is, the application of various irritants to the skin. Valleix comes to the conclusion that there is no one remedy which ap- proaches hlisteriiig in value, and (putting aside the recently discovered hypodermic treatment) that saying remains absolutely true at the present day. It is to be ob- served that Valleix latterly always em- ployed the milder form of the flying blis- ter. Such an application as this to the foci of pain must, if we consider it, be supposed to excite a directly stimulant eftect upon the painful nerve. This kind of blistering, and the analogous use of mustard plasters, have ahvays yielded good results, in my experience, solacing even when the}' did not cure. And in numerous earlj- cases one or two flying blisters, appUed successively over different points in the course of the painful nerve, have at once and permanently - arrested the disease. It is a remedy which ought always to be tried in cases of any severity, especially if the subcutaneous injection of morphia and of atropine has failed. There is one method of blistering which I have recently tried with grent success, viz. the application of a blister close to the spine, as nearly as possible opposite the intervertebral foramen from which the affected nerve issues. The effect pro- duced is, I suppose, a reflex stimulation through the posterior branches. This method is of course not so applicable to Neuralgias of the fifth as to those of spi- nal nerves. Yet even in these, blistering of the nape has sometimes appeared to do marked good — through the occipital nerve, I presume. The application of various stimulating liniments and ointments to the skin of the painful parts is sometimes very useful. Of these the use of chloroform diluted with seven parts of oil or soap-liniment is by far the most efficacious. This pro- duces no antesthesia, but a mild stimu- lation. Strong coimter-irritation may be produced by the use of tartar-emetic or of veratrine ointment. JSlectricity. — The efficacy of various forms of electricity in Neuralgia is a large subject, and as j'et, it must be owned, only very partially cleared up. The com- parative merits of Faradization and of the continuous, current are hardly settled. But the weight of testimony is now in favor of the belief that in the majority of TREATMENT. 1047 instances the continuous current is tlie most valuable. As regards one or two points, one may speak with some confidence. In the first place I may say, after extensive trials of the ordinary rotatory (magneto-electric) machine for the induced current, that this method of treatment is most unsatisfac- tory. I have never seen it produce, in- disputably, good effects. Secondly, as regards that form of cwitimmus current which is generated by Pulvermacher's chains, I am reluctantly obUged to give up the hope of doing any real service with it in Neuralma, however great its utility is in other diseases. As is remarked by Dr. Althaus, the current generated by these chains is too irregular, and their activity is too soon exhausted for us to get a sufflL-iently uniform dose of electric- ity applied continuously for a definite period by their means. It appears probable that we shall ulti- mately find that for neuralgic affections of all kinds the most useful form of electri- cal element is by the continuous current generated from a Bunsen's or a Daniell's battery ; and that the three principles on which we must act in its use are : — 1. The maintenance of the current, with only a very few breaks, for a considerable time. 2. The application of the positive pole over the seat of pain. 3. The employ- ment of a very low-tension current. I am informed by Mr. J. IS". Radcliffe, whose experience in this matter is very large, that the use of this mode of electri- zation in Keuralgia is as yet, in his opin- ion, only beginning to be developed, but that it promises to effect great things. In short my present opinion as to the value of electricity in JSTeuralgia may be thus expressed : that as used, up to the present time, it has achieved no results which entitle it to more than a third or a fourth rate place among remedies ; but that if the desideratum of a low-tension continuous current, which can readily be applied for long periods together, can be obtained by means of apparatus of mode- rate portability and cheapness, it is prob- able that we may obtain that which will equal or exceed in value any of the reme- dial measures which are at our disposal. A few words must be given to the rather uninviting subject of the surgical treat- ment of inveterate Neuralgia. The section of a neuralgic nerve, or rather the excision of a piece, is still, I suppose, to be reckoned among the measures which it may be oc- casionally justifiable to employ. Nothing, however, either in the two cases of its use which I have seen, or in the records of similar operations, would lead me to re- commend it in any case. The relief given is nearly always very transient ; and, in- deed, the nearly infallible certainty with which the pain returns in the central end of the divided nerve is only what I should expect from the many considerations which point to the central origin of the nerve as the most peccant part. With such remedies in our hands as the sub- cutaneous injection of morphia, &c., I cannot see that we need to be tempted to perform such an operation for the sake of a temporary alleviation. [Nerve-stretch- ing is an operation recently somewhat in vogue, of which the same remarks may be made.— H.] The removal of any distinct source of peripheral irritation by surgical means is quite another matter, and may be highly proper and necessary. Yet even here it is always necessary to calculate whether the shock of the procedure itself may not be injurious ; and it will be desirable before inflicting it to fortify the system, as far as possible, with tonics ; and sometimes to diminish the shock, not merely by giving chloroform, but by prolonging the chloro- form narcosis by subcutaneous injection of a large dose of morphia. This precau- tion is especially advisable where we ex- tract one or more carious teeth, which may seem to be keephig up neuralgic pain. Too often we find that the extrac- tion has been in vain ; and then, unless some such precautions have been taken, it may be discovered that the shock has aggravated the Neuralgia. A most important subject, with which I may conclude these remarks on treat- ment, is the employment of suitable pro- phylactic measures. First, as regards nu- trition ; it is absolutely necessary that this should be as abundant as may be pos- sible without deranging the digestion. It must also contain a liberal allowance of fatty matters ; no amount of dislike on the patient's part — and they often show great dislike — should induce the physician to give up this point. If one form of fat cannot be tolerated, another must be tried ; perseverance will, I believe, always bring success ; and the effect of an im- provement of this kind in the diet will rarely fail to tell upon the constitution, rendering the nervous system less sensi- tive to the ordinary exciting causes of neuralgic pain. Equally important is the avoidance of exposure to cold and damp air with insufficient clothing, for cold is much the most frequent immediately de- termining cause of neuralgic attacks. Flannel underclothing, thick veils for the face, &e., are quite as, important as any direct remedies. It cannot be doubted that everything which tends to set up the habit of pain, directly tends also to aggra- vate that obscure vice of the organism on which the disposition to Neuralgia de- pends, and vice versA. Physical exercise must be so regulated that it may improve nutrition without inflicting severe fatigue. And as regards mental influences, which, 1048 LOCAL PARALYSIS FROM NERVE DISEASE. unfortunately, are often bej'ond control, one can only say, that the two extremes, of a specially laborious and exciting life, and an existence spent in the dreary mo- notony of idleness, are equally hurtful. [SunMne is, usually, very beneficial. Let the neuralgic patient live in the light as much as possible. I have repeatedly known a severe attack of liemicrania to be relieved by the patient sitting or lying directly in the rays of the sun. — H. J In the foregoing article I have followed the plan also adopted in my article on Alcohol- ism ; namely, of stating my own view of the subject connectedly, and without pausing to answer all the statements and opinions of the numerous writers who differ from me. The necessary limits of a work like this ' ' System of Medicine," makes it almost impracticable for an author to follow any other course with success, if he happens to hold a view of his subject which conflicts with, or differs from, the views of well-known authors on a consid- erable number of points. But the following selected list of the more important treatises will enable the reader to study the questions connected with this disease from every point of view. It has been my purpose to bring out clearly and consistently that view of Neu- ralgia which seems warranted by the majority of the facts recorded by others or observed by myself; and the result has been that I have given much prominence to the arguments for the existence of an element of organic change in the centres in all true Neuralgias. Those who desire, however, to hear all the argu- ments which can be urged for a chiefly or solely peripheral origin of Neuralgia will find abund- ant material in the undermentioned treatises : Trousseau, "Nfivralgie Epileptiforme," vol. i. of his "Clinique Medicate," 2me Edit.; "NiSvralgies," vol. ii. of the same work (Trousseau's insistance on the constant pres- ence of a painful ' ' point apophy saire, ' ' seems to me an overstatement ; but it is still more strange that this author should think its constant presence could consist with a peri- pheral origin of Neuralgia) ; Beau, Trait! des Nevralgies, Arch, de M^d. 1847; Brown-S^- quard, Lectures on the Therapeutics of Ner- vous Diseases, Lancet, ISHG, vol. i. (see also his Lectures on tlie Physiology and Pathology of the Central Nervous System, 8vo. Philadel- i phia, 1860). Of authors who allow at least | a large share in the production of many case* of Neuralgia to the centres, are Teale, Treatise on Neuralgic Diseases, &c., London, 1829 ; C. Handlield Jones, on Functional Nervous Dis- order, London, 18U4; alsoLumleian Lectures, Med. Times and Gaz. 1865, vol. ii. But the most suggestive and important treatise, and one which has been unaccountably neglected, is the Observations on the Functional Affec- tions of the Spinal Cord, by William and Daniel Griffin, London, 1834. I have, in the text, given Valleix just credit for laying the foundation of the current knowledge respect- ing Neuralgia; but it must be allowed that in the work of the Griffins, which is little known, there are the germs of a great im- provement of that knowledge. Of essaj'S which illustrate the serious secondary com- plications which may attend Neuralgia, the following may be mentioned, besides the treatises of Barensprung, of Notta, the work of the Griffins, and the other papers already specified : Schiff, Hyperaemia of the Eye, Ul- ceration of Cornea, &c., after a Wound of the Superior Maxillary Nerve ; Untersuch, p. 116 ; Allcock, Disease of the Eye from Injury to the Infra-orbital Nerve ; Todd's Cyc. of Anat. and Physiology, vol. ii. p. 132. A great many cases also are quoted in Hand- field Jones's Lectures on Functional Nervous Disorders, already cited. It is only just to Dr. Handfield Jones to acknowledge that he has long advocated the opinion that nerve-pain is invariably, and in all its phases and consequences, an expres- sion of debility of function ; an opinion which has been strongly expressed also by myself not only in the present article, but in many- other papers. LOCAL PAEALYSIS FEOM NEEYE DISEASE. By J. Warburton Begbib, M.D., F.R.C.P.E. There can be no doubt that for a lengthened period, and till a compara- tively recent date, the attention of path- ologists was too exclusively directed to the great nervous centres in explanation of the causes of nearly all nervous disor- ders, including paralysis. So much so was this the case as 'fully to justify the language employed by the late Dr. Graves, of l5ublin. " If, " says he, "you examine the works of Kostan, Lallemand, Aber- crombie, and those who have written on disea,ses of the nervous system, you will find that their inquiries consist in search- ing after the causes of functional changes, either in the cerebrum, cerebellum, or LOCAL PARALYSIS FROM NERVE DISEASE. 1049 spinal marrow, forgetting that these I causes may be also resident in the nervous ' cords themselves or their extremities, which I shall call their circumferential tracts." ' Since 1S43, however, when the first edition of Graves's Lectures appeared, it has been satisfactorily determined by physiological investigation and by the careful observation of disease in numer- ous examples, that paralysis, or the loss of the power of motion, may result from one or other of two causes. It may de- pend either on a central nervous lesion, that is, a lesion of the Brain or Spinal Cord, or on an abnormal condition of a particular nerve in some part of its course. It is with the latter, as giving rise to a local form of paralysis, that we are now exclusively concerned. We are abundant- ly familiar with the effects of mechanical injury as applied to nerves. When a nerve is cut across, there results immedi- ately a paralysis of the parts below the section supplied by that nerve. Further, if a nerve be included in a ligature, or subjected from any cause to much pres- sure, a similar result is produced. The paralysis of the arm caused by pressure on the axillary plexus of nerves, is an ex- cellent and familiar illustration of injury so occasioned. It is thus described by Dr. Todd: — "A man gets intoxicated, and falls asleep with his arm over the hack of a chair ; his sleep under the in- fluence of his potations is so heavy, that he is not roused by any feelings of pain or uneasiness, and when at length he awakes, perhaps at the expiration of some hours, he finds the arm benumbed and paralyzed. It generally happens that the sensibility is restored after a short time, but the palsy of motion continues. Cases of this kind sometimes derive benefit from gal- vanism, but if the pressure which caused the paralysis has been very long continued, they seldom come to a favorable termina- tion. Nerve-tissue is one which never regenerates quickly, and seldom com- pletely, so that great or long-continued lesion of its structure is not likely to be removed. "2 Although by no means so distinctly witnessed as the result is, in the class of cases now referred to, there seems no reason to doubt that, equally with me- chanical injury, interference with the pro- per nutrition of nerves may lead to forms of local palsy. Illustrations of such occur- rences will be adduced, more especially when directing attention to one of the most interesting of all the varieties of lo- cal paralysis, namely facial palsy. Again, familiar as we are with the action of vari- ■ Clinical Lectures on the Practice of Medi- cine, Lecture xxxiii. 2 Clinical Lectures on Paralysis, certain Diseases of the Brain, and otlier Affections of the Nervous System, Lecture i. ous poisons — such as alcohol, opium, chlo- roform—on the great nervous centres, and on the same portions of the nervous sys- tem of certain poisons formed in the living body, as urea, and the morbid materials in rheumstism and gout ; having also im- portant knowledge regarding the influence which is exerted on the nervous and mus- cular systems generally, but especially on the nerves and muscles of the upper ex- tremities by the poison of lead, we cannot hesitate to account, in a manner closely similar, for the other forms of local paral- ysis which from time to time present themselves to our notice. Dr. Todd alludes to cases of local par- alysis occurring in states of the constitu- tion which, if not rheumatic, are at least allied to it, and associated with imperfect action of the kidneys. ' ' Of this, "he says, " the following affords a good example : — A medical man, eetat. 53, extensively en- gaged in practice in the county of Bucks, applied to me in August, 1847, with com- plete paralysis of the deltoid muscle. He was a stout, full man, tall, of large build, and very active in his habits ; fed well, and drank beer, but not to excess. He had been subject to a shifting neuralgia of the scalp, and to a discharge from the right ear, wliere he thought the tympanic membrane was destroyed ; he was deaf on that side. Six weeks before he came to me he suffered from pain in the left side of the neck and shoulders, followed by complete paralysis of the left deltoid muscle and weakness of the whole arm. On examining, I found a total inability to raise the left arm to a right angle with the trunk, or to perform any of those ac- tions which are usually effected by the deltoid muscle, which was very much wasted. He could, however, grasp per- fectly with the left hand, and execute all the other movements of the arm and fore- arm. There was some degree of numb- ness of the arm. There were no symp- toms distinctly referable to the head. His tongue was coated ; appetite good ; the discharge from the ear had ceased. The urine was pale, of low specific gravity, and contained albumen in small quantity. I viewed the case as one of local palsy, connected with a deranged state of sys- tem, rheumatic or gouty. I regulated his diet, and gave him small doses of the mineral acids. After a fortnight of this treatment he improved considerably, and could raise his arm slightly. The albu- men in the urine had much diminished : and crystals of lithic acid ^veve precipi- tated. He was now ordered three grains of iodide of potassium, with ten mmims ot liquor potasste thrice daily. He only fol- lowed this treatment for ten days, as the iodide of potassium purged him. Still, he was improving. I continued the liquor potassse, and advised galvanism to the 1050 LOOAL PARALYSIS FROM NERVE DISEASE. muscle. This plan was diligently pur- sued for a fortnight, at the end of which time he had so far improved that he could raise his arm nearly to a right angle, — he could put on his coat, and tie his cravat ; and in three weeks more he was quite well. All signs of albumen had disap- peared from his urine.'" The writer's experience has furnished cases bearing a remarkable resemblance to the one now quoted. He calls to remembrance more especially that of a young and plethoric as well as highly rheumatic female, who suf- fered from paralysis, succeeding severe pains of the left lower extremity, and in whom a plan of treatment which secured the copious discharge of urine, previously much diminished as well as disordered, and free action of the skin, proved emi- nently successful in removing the palsy of the limb. Besides the gouty and rheu- matic poisons, it is well to keep in view the very decided action of the syphilitic in inducing this among other local disor- ders. iNTo one calls in question the injuri- ous effects which are capable of being produced on the nervous centres by the syphilitic poison ; there is, however, good reason to believe that some local palsies are thus created. The writer has been able to trace the occurrence of paralysis of the portio dura, of paralysis of the third pair, as shown by a marked ptosis ; and also of palsy of the limbs, slight although threatening, to the same cause, when neither brain nor spinal cord appeared to be implicated. And it is probable that the experience of many physicians has not been dissimilar to his own, in finding the iodide of potassium administered in large doses, and steadily persevered with, a most useful remedy in such cases, re- lieving the palsy as effectually as it is so frequently the means of doing, the neu- ralgic and wearing-out headache, or the painful node on the shin bone, which are evidently due to the same cause. Allu- sion has been made to the influence of di- rect pressure external to the body, in producing such injury of nervous struc- ture as leads to a form of local paralysis. Palsy thus induced is generally merely temporary in duration. Tumors within the body, involving nerves, are frequently the direct occasion of local palsies. No more interesting variety of such palsy ex- ists than that which is due to the inter- ference with the recurrent or motor laryn- geal ner^'e produced by an aneurism of the arch of the aorta, or by a cancerous mediastinal tumor. Well-marked atro- phy of the muscles of one side of the lar- ynx has under such circumstances been found. The dyspnoea, which is induced by the implication of the vagus, or as sometimes happens of the phrenic nerves ' Loc. cit. p. 72. in strumous or tubercular tumors, is abundantly recognized since the writings of Risberg and Ley. There seems reason to believe likewise that pressure upon or other injury of some parts of the sympa- thetic nervous system may occasion local palsies. Of this the paralysis of the radi- ating fibres of the iris caused by cutting the sympathetic in the neck in Budge and Waller's experiments, but especially a similar contraction of the pupil to that physiologically produced, due to the pres- sure of an aneurism projecting into the neck or malignant tumor similarly situ- ated, are now quite familiar to the physi- cian. Attention will now be directed to some of the more important varieties of local palsy dependent on nerve disease, and first to Facial Palsy. This most interest- ing local paralysis is known under differ- ent names, of which the more commonly employed are Facial Hemiplegia, Histri- onic Paralysis, BelVs Palsy, and Paralysis of the Portio dura. Occurring as it usually does on one side of the face only, nothing can be more striking than the peculiar features of the disease. This is owing to the palsied condition of a few or all of the superficial muscles— the muscles of ex- pression — on the affected side, and the heightened antagonism of muscular action on the unaffected side. The patient can- not knit the forehead,' neither can the eyebrows be raised or drawn together. The eye remains open, as the power of closing the lids is lost, and their blinking movement no longer exists. This open condition of the ej'e, seen both in waking and sleeping, and which is due as well to the increased action of the levator palpe- brse muscle as to the palsy of the orbicu- laris palpebrarum, is a characteristic, it has indeed been styled a pathognomonic, feature of facial palsy. ^ The ala nasi is dependent, and on full inspiration on smelling or blowing the nostrils there is no expansive movement. The angle of the mouth hangs down. Purther, the patient cannot whistle, for he is unable to purse up his mouth for that purpose, and for the same reason he can neither spit, ' In alluding to the smoothness of the brow in the aged, who are affected by facial palsy, owing to the disappearance of all wrinkles, Romberg facetiously observes, "fur alte Frauen kein wirksameres Cosmeticum ex- istirt." ^ "The leading character of cases of facial palsy," writes Dr. Todd, "is the inability to close the eyelids from paralysis of the orbicu- laris palpebrarum : this is the pathognomonic sign which determines the peculiar nature of the palsy, and distinguishes it from the most serious form of facial palsy, which is depend- ent on diseases of the brain and palsy of the fifth or third nerve." (Clinical Lectures, Lecture iv.) LOCAL PARALYSIS PKOM NERVE DISEASE. 1051 nor can he distend the buccal cavity with air, or blow wind from the mouth. Pro- nunciation of labials is notably impaired. The saliva and fluids frequently trickle from the mouth. In mastication portions of food are apt to collect between the cheek and gums, as the support of the lips and cheeks necessary for its proper performance is lost. Let the patient laugh, cry, sneeze, yawn, or be the sub- ject of any violent emotion, and the dis- tortion of the features becomes much more conspicuous, the face being forcibly drawn to the sound side. Motionless and void of expression is the one side, con- trasting in a very remarkable manner with that on which intelligence remains visible and power of movement unaltered. Trickling of the tears down the cheek, owing to the immobility of the lower eye- lid, with consequent dryness of the corre- sponding nostril, and redness of the conjunctiva, it may even be severe con- junctivitis, determined by the operation of cold, dust, or other external influences on the constantly exposed eye, are among the accompanying phenomena of thispals3'. To Sir Charles Ball we are indebted for pointing out the true nature of this affec- tion. He showed that one nerve only was involved, that the muscles governed by the portio dura of the seventh pair were alone affected, that strictly it is a local palsy. The sensibility of the face is usually unimpaired ; a slight affection of the filaments of the fifth may, however, cause a little facial pain, but that is to be accounted rare. In instances of long- standing facial palsy, Romberg has drawn attention to the relaxed and flaccid condi- tion of the skin covering the affected mus- cles, while Dr. Todd has insisted on increasing flacoidity of the cheek, and es- pecially a rapid development of that con- dition, as a symptom of unfavorable omen as regards the patient's prospects of re- covery. But while this form of local palsy is clearly dependent on lesion of one nerve only, there is reason to beUeve, as Eomberg has more particularly shown, that its features are subject to modifica- tion, according to the precise seat of the disease. That may be peripheral or cen- tral. Kot only so, but the diagnostic marks may vary under the former head, according as the superficial distribution of the portio dura, or the nerve as it passes through the temporal bone, or the nerve within the cranium and near its central origin, is affected. Viewing these very briefly in their order, it may be remarked —that, facial palsy, due to an affection of the superficial clistribiition of the nerve, is generally met with as the result of expo- sure to cold.' " A very common cause of ■ Some writers speak of facial palsy as spe- cially a disease of northern climates. Thus this palsy," writes Dr. Todd, "is the in- fluence of cold ; as by exposure at an open window, in a coach or railway carriage, to a current of cold air.'" "A blast of cold air on one side of the face," remarks Dr. Graves, "has been known to cause paralysis and distortion of several months' duration."^ External injuries, such as blows on the cheek and surgical opera- tions on the face, have been followed by this form of local palsy. Of the cases which occur, there are not a few in which no traumatic cause can be found, neither can any marked exposure to cold be traced. In such circumstances it is proper to make a very careful inquiry into the condition of the general health of the suf- ferer, when it is not unlikely that the connection of the palsy with a gouty or rheumatic taint may be satisfactorily es- tablished. Dr. Todd, alluding to the dependence of periodic neuralgic affections on the determination of some poison to a particular nerve, as the paludal poison or some matter generated in the system, ex- presses the opinion that morbid matter* may aflTect a motor nerve just as they affect a sensitive, causing in the former case paralysis, as in the latter they deter- mine neuralgia. Facial Palsy caused by an affection of the portio dura in its passage through the tem- pcn-al hone. —The connection of this paraly- sis with local strumous affections in chil- dren is well known. These may be simple and easily remediable, as for example the parotid and more general glandular en- largements consequent on measles, scarla- tina, and other disorders ; but of much more serious nature is the otitis resulting in caries of the petrous portion of the temporal bone. Here the palsy is asso- ciated with deafness, and very probably also with purulent discharge from the meatus. Direct violence, likewise, as m a case related by Sir Charles Bell, in which a pistol-shot through the ear had splintered the bone, and torn the nerve in its osseous canal, may of course deter- mine the palsv. The diagnosis of the disease or iniury affecting the nerve, in its passage through the bone, rests, ac- cording to Romberg, not only on the co- existence of such phenomena as otorrhoea, removal of necrosed portions of bone, perhaps of one or other of the small bones of the ear, and deafness, - symptoms which are not hkely to occur m cases of Joseph Frank, after alluding to the collection of cases by various authors, remarks, Nosque plur ma exempla vidimus. Morbus iste m ?egi^nihus septentrionalihus tarn commuBis est, ut spatio quindecim anuorum vigmti duo mihi ohvenerint exempla." (De i'araiysi, Praxeos Medica! Universfe Prascepta.) 1 Loc. cit. p. 69. 2 Loc. cit. n. 380. 1052 LOCAL PARALYSIS FROM NERVE DISEASE. simple peripheral facial palsy, — but, fur- tlicr, upoa certain peculiarities in the observed paralytic phenomena. One of these is the diminution of taste on the side of the tongue corresponding to the palsy, another is a unilateral paralysis of the velum palati. On the latter point the statements of writers have been very con- tradictory. Eomberg remarks that in four patients afflicted v\rith facial palsy he has noticed the paralyzed condition of the velum palati, the uvula, having a slanting direction, being arched and the tip pointed to the paralyzed side. While failing to offer any explanation of the peculiar posi- tion of the uvula, Romberg evidently at- taches very great importance, in a diag- nostic point of view, to the palsied condition of the velum, and the marked curving of the uvula ; concluding from their existence, that the seat of the dis- ease miist be in the petrous portion of the temporal bone. And he again emphati- cally repeats when the disease is in the peripheral distribution of the nerve, the velum is not affected, "wovon ich mich in vielen Fallen tiberzeugt habe." It is the implication in the diseased condition, of whatever nature that may be, of the nervus petrosus superflcialis major, of Arnold — which takes its origin from the knee-shaped bulb on the trunk of the por- tio dura as it lies in the Fallopian aque- duct, and which communicates with Meckel's ganglion, whence the muscles of the palate derive their nerves, — that in the view of Eomberg causes the displace- ment of the velum and uvula. Dr. Todd, while admitting the occasional occurrence of this phenomenon, combats the notion of Romberg, and maintains that undoubted instances of disease of the aqueduct, caus- ing paralysis of the nerve, are met with, in which affection of the velum does not exist. In his own. experience the symp- tom in question was of very rare occur- rence, and he regarded it as a coincidence. Since the publication of the views of the authors now referred to, the paralj'sis of the palate in facial palsy has received re- newed attention from M. Davaine and Dr. Sanders. The former recorded one case of unilateral paralysis of the palate, in connection with facial palsy of right side, observed by himself, and has com- mented on several instances furnished by Romberg and others. His description of the phenomena he observed is given as follows: "The velum palati is not regu- lar ; the arch formed by the right anterior pillar is less elevated than the left. The posterior pillar of the same side descends directly downwards, without being curved Uke that of the other side. The uvula is bent like a bow ; its point is directed for- wards and towards the paralyzed side, while its base is carried a little towards the sound side. The patient's voice is slightly ua^al.'" Dr. Sanders, in a valu- able paper,^ gives an interesting case of paralysis of the velum in connection with facial palsy of the right side, and enters at some length into a consideration of the mechanism of the deviation of the palate. Dr. Sanders is satisfied that a partial hemiplegia of the palate does exist in connection with facial palsy, and, like it, is dependent on affection of the portio dura. He believes that this form of pal- atal palsy consists in a vertical relaxation or lowering of the corresponding half of the velum palati, with diniinislied height and curvature of the posterior palatine arch, on the paralyzed side, and that it is due to paralysis of the levator palati, — that muscle and the azygos uvula-, also supplied by the seventh pair, being the only muscles affected. Among several conclusions at which Dr. Sanders has ar- rived, the following appear to be specially important : that the partial paralysis of the velum in facial palsy, due to implica- tion of the levator palati muscle, is by no means so rare as palsy of the velum (hith- erto not accurately described) has been generally supposed, and that the progno- sis is not necessarily rendered more un- favorable in facial palsy when the palate is implicated. The lesion in facial palsy may exist at the cerebral origin of the seventh pair of nerves. We are not, however, called upon to con- sider this variety of facial palsy : suffice it to say, that its existence may be deter- mined, and the differential diagnosis be- tween it and the other forms — already briefly considered — established, by the oc- currence, sooner or later, of sj'mptoms due to the implication of other nerves, such as deafness, strabismus, ptosis and anassthesia. While either the presence of inflammatory products, or apoplectic ex- travasations in the vicinity of the pons Varolii, may be the precise lesion which gives rise to the palsy, the probability is that, in such cases, a tumor of one nature or other, and subject to gradual extension, exists. The duration of facial palsy is subject to considerable variety, according to the precise seat and nature of its determining lesion. Dr. Todd remarks that " it rarely, if ever, lasts a shorter time than ten days, whilst it very often extends to as many weeks ; perhaps three or four weeks may be assigned as an average duration for the non-traumatic cases ;" and Romberg warns us not to expect its duration to be brief. It is in those cases which have been evidently connected with rheuma- ' Gazette MSdicale De Paris. 18r)2. 2 Edinburgli Medical Journal, August, 1865. LOCAL PARALYSIS FROM NERVE DISEASE. 1053 tism that he has found the paralysis least enduring. ' The writer has seen simple cases of the disease, in so far as their cause was con- cerned, lasting a very lengthened period, many months, and even a year. It is incumbent on the phjsician to be very careful in oftering an opinion as to the prognosis in cases of facial palsy: that must always be founded on a considera- tion of the probable cause. Those cases are nearly certain to terminate favorably in which cold or rheumatism is to be look- ed upon as the determining agent. On the other hand, when the palsy has been due to mechanical injury the prognosis cannot be favorable, and this very specially in those instances where a division of tiie nerve has been caused. "We cannot be too careful in the expression of our opin- ion in cases characterized by nerve disease within the temporal bone. The records of medicine contain reports of such, which have given rise to meningeal inflamma- tion, intracranial, even cerebral and cere- bellar, abscess and death. If prognosis is to be guided by a just consideration of the causes, so also is the treatment of facial palsy when amenable to cure. The remedial measures at our disposal may be conveniently classed under the heads of internal and external agents. In the use of the former, regard should always be had to the diathetic condition of the patients — rheumatic, gouty, stru- mous, syphilitic, ansemic, or suffering from the injurious influence of a paludal poison. "VVe are disposed to think that this is one of the forms of local palsies in which the loss of power may be due to changes in nerve structure determined by neuritis. In such examples, and still more so if there be reason to conclude that a syphilitic taint is in existence, iodide of jiotassium will prove a most ser- viceable remedy. We have ourselves found it to be so. The iodide should be administered in doses of five grains twice or thrice daily, simply dissolved in dis- tilled water. The efficacy of the remedy is secured by its being administered while the stomach is empty, but food may be taken very shortly thereafter. Should a rheumatic or gouty habit be found in con- nection with the palsy, alkaline remedies, colchicum, and lemon-juice may exert a beneficial influence, and so probably will quinine or arsenic in the not unknown examples of the disease allied to inter- mittent fevers. Mercury in the form of ' " Die Dauer der mimischen Gesiclitslah- nning ist selten kurz. Am kiirzesten fand ioh sie bei der rheumatischen ; doch habe ich sie aucli hier in gunstigen Fallen nur selten unter sechs Wochen wahrgenommen, einmal sail ich die Heilung innerhalb acht, ein an- dermal in vierzelm Tagen." — P. 664. blue pill has been extolled by several practitioners. Sir Thomas Watson coun- sels the exhibition of mercury "so as just to touch the gums," adding, "I should always take this precaution, lest any eftu- sion of lymph should cause abidin"- pres- sure on the nerve.'" Iron is likely to be useful when an ansemic condition of the system exists. The muriate of lime, the iodide of iron, and cod-liver oil, are avail- able remedies when a strumous cachexia obtains. The writer can bear a decided testimony to the therapeutic value of strychnine as an internal remedy in one loug-existing instance of the disease, which had bid defiance to the more ordi- nary-remedies; he cannot, therefore, coin- cide in the observation of Dr. Todd, that "strychnine is of no use in such cases." As to external remedies. Blisters, strongly recommended by some physi- cians, are discountenanced by others, on the ground that they sometimes cause enlargement of the neighboring glands, which by pressure may m their turn in- juriously influence the nerve twigs. Lo- cal hot fomentations and the application of leeches are ver-y useful remedies at an early part of the disease, the employment of the latter being generally limited to persons of full habit, and otherwise in the enjoyment of fair health. The cndermical application of strychnine — over a blistered surface — the use of \'arious stimulating liniments, and particularly, in the writer's opinion, galvanism, are the more approved remedies in cases which have lasted for a little time. Before concluding our notice of facial palsy, we must add a few remarks on the occasional occurrence of the disease on both sides of the face, and very briefly refer to the statements of Dr. Todd re- specting the integrity of the seventh pair in cases of cerebral hemiplegia, a view which has recently been ably controverted by Dr. Sanders. Double Fadal Paralysis.— This is un- questionably a rare affection, and espe- cially rare when the double palsy is solely dependent on nerve disease. Eomberg and Dr. Christison^ refer to cases of what may be styled simple bilateral paralysis of the face, while the seventeenth case in Dr. Todd's lectures is a very remarkable example of paralysis of the portio_ dura on both sides connected with affection of the portio mollis ; for the patient was "perfectly deaf in both ears;" and the loss of function of both branches of the seventh pair evidently resulted from dis- ease in the temporal bone. In addition to the writers already named, M. Davaine has especially directed attention to the ' Lectures, vol. i. p. 563. 2 MontMy Journal of Medical Science, 1850. 105^ LOCAL PARALYSIS FROM NERVE DISEASE. subject in a valuable memoir, the title of which is given below,' and to which Pro- fessor Gairduer,^ of Glasgow, in giving an account of a \evy interesting case of double facial palsy, has referred. Dr. Gairdner considered the paralysis to be due to cold, and connected with rheuma- tism of the external branches alone ; and in the course of his paper he alludes to another case of double paralysis of the portio dura, evidently connected with syphilis. In the latter case iodide of po- tassium, with iodide of mercury and corro- sive sublimate, were employed in alter- nate doses, and the result was an excellent recovery. One example of double facial palsy has occurred under tlie writer's ob- servation ; it was associated with tuber- cular disease within the chest, and the patient, a man of thirty years of age, subsequently died of what appeared to be strumous meningitis. Unfortunately an examination of the body after death was not permitted. This is scarcely the op- portunity for entering on a consideration of the view which was so strongly enter- tained and expressed by the late Dr. Todd, that the seventh nerve was very rarely involved in facial palsy depending on cerebral disease, and that the affected facial muscles were those governed by the fifth pair. It will, however, tend to com- plete the brief exposition of facial paral- ysis now given, if we state in this con- nection, that there is, in our opinion, no reason to doubt that the view taken by Dr. Todd, and in which several systematic writers in this country have closely fol- lowed him, is erroneous, and that, on the other hand, the current doctrine on the Continent, and which has been recently ably unfolded and extended by Dr. San- ders, is correct; viz. "that in cerebral hemiplegia, as in peripheral face-palsy, it is the motor seventh nerve which is affected.* Disease of other of the motor cerebral nerves than the portio dura may likewise determine local palsies. A short refer- ence to such may be made here. Paralysis due to disease of the third pair of nerves {oculo-niotor). — Ptosis or blepha- roplegia, the falling down of the upper eyelid, is the notable feature of this affec- tion. When this is due to a cause seated ' Jlemoire sur la Paralygie gengrale ou par- tlelle des deux Nerfs de la septieme paire : lu a, la Socifitfi de Biologie (Mars, 18.'52) par M. C. Davaine. See also Gazette Medicale de Paris, 1852. 2 Clinical Observations, Lancet, May 18, 1861. ' On Facial Hemiplegia and Paralysis of the Facial Nerve, by Wm. R. Sanders, M.D. Lancet, 1865. See on the same subject Dr. Hughlings .Jackson in Clinical Lectures and Reports of the London Hospital, 18t)4. within tlie cranium, such as an inflamma- tory exudation, or a tumor, it is almost invariably accompanied by palsy of those muscles of the eyeball, and those fibres of the iris which are likewise governed by the motor oculi. Hence in such cases, and they are far from being uncommon, external squint and dilatation of the pupil are associated with the ptosis. Not only so, but other adjacent cerebral nerves are for the most part implicated, while the indications of the existence of some form- idable cerebral lesion are under such cir- cumstances not likely to be absent. On the other hand, when the determining cause of the local paralysis is peripheral in its seat, the ptosis exists alone. Romberg remarks that rheumatism may be the cause of paralyzing the palpebral branch of the motor oculi, although not so fre- quently as is the case with the facial nerve ; and he distinctly states that when so induced, the ptosis occurs without the participation of the muscles of the eye- ball, and the contractile fibres of the iris.' The writer remembers to have seen this dependence of ptosis on rheumatism illus- trated in the case of a young lady, who, after having frequently suffered from dis- tinct rheumatic affections, became within a limited period the subject of facial palsy and ptosis, the immediate peripheral im- pression on both the seventh and third nerves being evidently due to severe cold. A complete and speedy recovery occurred after the local application of warmth and the use of anti-rheumatic remedies. M. Marchal de Calvi has directed attention to the occurrence of oculo-motor paral- ysis, consequent on very severe tic of the face. M. Marchal, and likewise the late M. Jobert de Lamballe, found the muscles of the eyeball affected as well as dilata- tion of the pupil, the vision^ disordered, and insensibility of the conjunctiva in this affection. Such cases, however, are rather illustrative of the reflex form of paralysis, our knowledge of which has been of late greatly increased by the ob- servations of M. Brown - Sequard and others. In the same way as peripheral affection of the oculo-motor nerve exists, so may local paralysis result from disease of the fourth pair {trochlear), and of the s'ixth pair ' " Der rheumatische Anlass paralysirt, obgleich nicht in soldier Frequenz wie den Facialis, den Ramus palpebralis des Oculomo- torius und hat eine einfache Blepharoplegie ohne Theilnahme der Augenmuskeln und der contractilen Irisfasern, nach der Norm der isolirten Leitung, zur Folge." (Augenmus- kellahmung.) 2 M^moire sur la Paralysie de la troisifeme paire consecutive h la Ngvrose de la cinquifeme. (Archives G^nerales de Medecine, Juillet, 1846.) LOCAL SPASMS. 1055 (abducens). Such are, however, much less frequent in their occurrence, and espe- cially so, as Komberg has observed, that resulting from affection of the abducens. The author just named has made refer- ence to a case seen by Dr. Dahlino- and pubUshed by Stromeyer, in which t?ie fa- cial and abducens nerves on the left side were paralyzed in consequence of a sud- den cooling of the heated face. Palsy of the tongue from affection of the hypoglossus nerve in its distribution is of great rarity, offering a marked contrast to the frequency with which a central lesion gives rise to the same form of local palsy. The lesser branch of the fifth pair may be the seat of disease and consequently give rise to masticatory palsy. The move- ments of the face in mastication on one or both sides, as the case may be, are thus arrested or impeded. The temporal and masseter muscles are readily recog- nized to be inactive ; and their condition when the disease is unilateral offers to the touch a marked contrast with the firmness of the same muscles on the unaffected side during the process of mastication. This variety of local palsy, when due to disease of the nerve, is generally caused by tumor of the dura mater, or disease ot the sphenoid bone, or such a morbid con- dition of the gasserian ganglion as com- presses the nerve itself. LOCAL SPASMS. By J. Warburton Bbgbib, M.D., F.R.C.P.E. The term Spasm {spasmus, from ando, I draw) is used to indicate the sudden and involuntary contraction of muscular fibres or of muscles. Hypercinesis {vnip, in ex- cess, xivr/ais, motion) is likewise employed in a sense precisely similar. This pecu- liar vital phenomenon may be general or local, involving apparently all, or nearly all, the muscles of the body, or, on the other hand, limited to a few muscles — it may be, to one. In every occurrence of Spasm there is increased action of the motor nerve, the result of which is the sudden contraction of muscular fibres, the act itself being wholly removed from the control of the will. The expressions clonic and tonic are used, the former to denote a Spasm which is characterized by rapidly alternating contraction and relaxation of muscular fibres, while the latter implies the exist- ence of the contractions for a certain time, and of this condition rigidity of the affected muscles is also an invariable feature. Attention is now to be directed to local as distinguished from general or universal spasms. To the latter, the term convul- sions is correctly applied. Local Spasm is not necessarily attended by pain, but it generally is so, and as ex- pressive of painful Spasm we find a suita- ble term in cramp (Saxon Icramp). The term cramp is most frequently applied to painful muscular contraction in the ex- tremities, and to the same phenomenon affecting the stomach or intestines, and also the heart. Such pain as occurs in connection with Local Spasm is in all probability due to injury done to the sen- sory nerves supplying the muscle during its violent contraction. Both kinds of muscular fibre, both or- ders of muscles, the voluntary and invol- untary, are liable to be affected by Spasm. Of the former the most familiar illustra- tion is cramp in the extremities. Of the latter are cardiac and intestinal Spasms. Romberg has pointed out that, as a gene- ral rule, when the muscles of animal life, those under the control of the cerebro- spinal nerves, are affected by Spasm, the fibres exhibit a uniform contraction throughout their whole extent ; while, on the other hand, the muscles of organic life, over which the sympathetic system is dominant, when similarly aflected mani- fest successive contractions moving like waves.' It need scarcely be observed that, al- though the abnormal condition now de- scribed as Spasm is evidenced by a dis- order of muscular filn-es or muscles, the cause of this disturbance is always resi- dent in the nervous system. There is a very important and interesting variety in the connection which subsists between the nervous stimulus and the phenomenon of muscular contraction. The former may be central, that is, operating directly on the great nervous centres, the brain, or spinal cord ; or, and in the case of Local ' Romberg, Lclirbnch der Nervenkrank- heiten des Menschen: Hyperchieses, Kraiapfe. 1056 LOCAL SPASMS. Spasm this is far the more frequent, the irritation is peripheral, and consequently the induced action is retlex. Our knowledge of the causes of Local Spasms is as yet far from heing perfect, and in not a few instances the attempt to determine these, notwithstanding the most careful inquiry, signally fails. The etiology of general convulsive disorders is indeed more advanced, and may serve to elucidate doubtful points in relation to the more limited and less serious affection. The late Dr. Graves of Dublin was one of the earliest to direct attention to the frequency with which various nervous affections, of which Spasm is one, and not the least interesting, are dependent on reflected nervous irritation. He has gra- phically described the sudden and com- plete relief aftbrded to a joung lady, who had suffered most severely from spasmodic cough, after the discharge of a tapeworm, which had been effected by a large dose of oil of turpentine with castor oih' The subject thus adverted to by Graves has more recently attracted the attention of several competent observers, more espe- cially of M. Davaine in France,* and Dr. Heslop^ of Birmingham. Their state- ments show that the presence of worms in the intestinal canal is a frequent cause of remote nervous phenomena, including Spasms, and tlirow doubt on the assertion of Itoniberg, that the influence of worms in producing convulsions has been for- merly over-estimated. Again, a careful study of the whole phenomena in that most interesting disease, spasmodic asthma, has led to the conclusion that the spas- modic affection in it, seated in the smaller bronchial tubes, may be induced by an irritation of the nervous system, which is ' Clinical Lectures, Lecture xl. , Bronchitio Asthma, Cough. ' Traite des Entozoaires. Paris, 1860. M. Davaine remarks : "Tons les organes, pour aiusi dire, peuvent ressentir I'influence sym- pathique des vers du canal intestinal ; la fausse perception des odeurs, la dilatation de la pupille, I'amaurose permanente ou pas- sagere, I'exaltation de Touie, la perversion du gofit, le prurit et les fourmillements k la peau, temoignent de Taction sympathique des vers sur les sens ; d'un autre oot^, la somno- lence ou les vertiges, les reves facheux, les spasmes, les douleurs vagues, la toux, la dyspnee, les palpitations, les intermittences du pouls, la faim insatiable ou I'anorexie, la salivation, la quality des urines, I'amaigrisse- ment, temoignent egalement de Idwt action sur le systfeme nerveux, sur les organes de la respiration, de la circulation, de la diges- tion, sur les secretions, eufin sur la nutri- tion."— Page 48. 3 The Cerebro-spinal Symptomatology of Worms, especially Tapeworms: Dublin Quar- terly Journal of Medical Science, vol. xxvii. 1859. either centric or eccentric. In the former case the irritation is in the nervous cen- tres themselves, the brain, or spinal cord. In the latter, and it is by far the more common in its occurrence, the irritation is applied at a distance from the nervous centres. This subject has been very fully and ably illustrated by Dr. Hyde baiter, in whose work examples the most inter- esting and conclusive as to the essentially nervous origin of asthma are to be found.' In treating of what may be styled cen- tral asthma, Dr. Salter gave, among others, the following case : — A man about fifty was subject to epilepsy. His fits had certain well-known premonitory symp- toms, and occurred with tolerable regu- larity about once a fortnight. On one occasion his medical attendant was sent for in haste, and found him suffi3ring from violent asthma. The account given by his friends was, that at the usual time at which he expected the fit he had experi- enced the accustomed premonitory symp- toms, but instead of their being followed as usual by the convulsions, this violent dyspnoea had come on. Within a few hours the dyspnoea went off, and left him as well as usual. At the expiration of the accustomed interval after this attack, the usual premonitory symptoms and the usual epileptic fit occurred. On several occasions this was repeated, the epileptic seizure being as it were supplanted by the asthmatic. Nothing seemed to be amiss with the lungs either before or after the attack. Dr. Salter truly observed, that such a case as this appears to admit of only one interpretation, that the particular state of the nervous centres that ordinarily threw the patient at certain times into the epileptic condition, on certain other occa- sions, from some unknown cause, gave rise to bronchial Spasm ; that the essen- tial diseased condition was one and the same, but that its manifestation was al- tered, temporary exaltation and perver- sion of the innervation of the lungs in the asthmatic paroxysm supplanting uncon- sciousness and clonic convulsion in the epileptic seizure. It has occurred to the writer to witness in one instance an alter- nation of phenomena bearing a close re- semblance to that observed by Dr. Salter. The patient, a young man, was admitted to the Koyal Infirmary of Edinburg, on the recommendation of Dr. Turner of Keith. He had for several months pre- viously been subject to cerebral attacks, attended by loss of consciousness, and oc- casionally by convulsive movements of the muscles of the face and extremities. These continued to occur during the pa- tient's residence in the hospital, observing ' On Asthma: its Pathology and Treat- ment. London, 1860. See also article on Asthma, Vol. II. LOCAL SPASMS. 1057 for a time the same periodicity whicli had antecedent to that time always distin- guished them, when, on three separate occasions, and in the most distinct man- ner, an attaclj of asthma tooli the place of the more manifest cerebral disorder. The loss of consciousness and convulsive move- ments again recurred in a modified form : and after the lapse of several weeks, during which various remedies were em- ployed, the patient left the Infirmary to return home, his condition having mate- rially improved. Besides instances of the nature just alluded to, there are other ex- amples of asthma, which, althougli in by no means so distinct a manner, must be held as caused by some impression taking origin in the nervous centres, and respond- ing in a mysterious manner with certain feelings or emotions of the mind ; such are the cases in which fear, excitement, and fatigue operate. Now, passing to a very brief considera- tion of bronchial Spasm, dependent not on centric but peripheral irritation. Dr. Sal- ter speaks of three degrees of remoteness of the application of the stimulus produc- ing asthma, and consequently of three groups into which the reflex cases of the disease may be divided : — 1st. Those in which the source of irritation is aliment- ary, and chiefly gastric. 2d. In which the irritation is more remote, but still confined to the organic system of nerves ; as, for example, asthma produced by a loaded rectum, by the presence of tape- worm, or ascarides. 3d. Cases in which the cerebro-spinal system is the recipient of whatever irritation is the cause provo- cative of the attack, as, for example, was illustrated in a most remarkable instance recorded by Dr. Chowne, where the appli- cation of cold to the instep produced in the most direct manner the asthmatic paroxysm. Looking to the first, and by a long way the largest, of these three classes of cases, the nerve irritated is the gastric portion of the pneumogastric ; through it the stimulus reaches the me- dulla oblongata, and from that portion of the nervous centre it is again transmitted to the bronchias by the pulmonary fila- ments of the same nerve. It is indeed of the highest importance in a therapeutical point of view to notice this chain of con- nection. We are thus called to recognize in the paroxysm of asthma a disease not unfrequently originating in disorder of the stomach ; and it may be assumed, as a correct conclusion, that a large propor- tion of the sufferers from this severe spasmodic affection are to be relieved by attention being given to their diet and reo-imen. But even here we should be adoptino- too limited a notion of the influ- ence of The digestive and assimilating pro- cesses in the production of asthma, did we conclude that those cases alone are exam- VOL. I.— 67 pies of this nature, in which broncliial spasm is induced by reflex stinmlation directly through the important nervous trunk — the pneumogastric. There are, over and above, numerous instances in which this direct communication of the influence exerted will not apply. In such the occurrence of the Local Spasm does not so speedily follow the introduction of food into the stomach as in many of the former cases, and therefore we must look for a somewhat difl'erent explanation. We find it in the disordered condition of the blood ; the faulty assimilation is no doubt the primary cause of this, but the un- healthy blood is in such instances the direct irritant ; by its operation on the nervous distribution through the lungs the bronchial spasm is caused. This humoral origin of asthma affords in all probability the most satisfactory explana- tion of the frequent occurrence of this nervous disorder in persons who are gouty. The accuracy of the view thus expressed is further evidenced by the circumstance that such sufferers are benefited by a plan of treatment which tends to eliminate the essential poison of gout from the system ; often, indeed, are benefited by such a plan of treatment only. In these cases reme- dies need scarcely be directed to the chest : it may be possible to relieve, it is impossi- ble to subdue, by antispasmodics a bron- chial spasm so induced ; but on the other hand, by acting freely on the great emunc- tories of the body, on the skin and kidneys, the disease is to be met and overcome.' Allusion has been made to the produc- tion of bronchial Spasm as determined by reflex irritation, and also by an impure condition of the blood. The same pre- cisely holds true of cardiac Spasm. The • Laennec, who, while strongly insisting on the connection between asthma (asthme spasmodique) and catarrh, admitted the ex- istence of a purely nervous asthma (sans ancune complication de catarrhe), has ac- knowledged the great difficulty there is in the satisfactory treatment of the disease. "Beaucoup de moyens," he remarks, "peu- vent etre opposes aux troubles de I'influence nerveuse qui constituent principalement I'asthme : mais id, comme dans toutes Us affec- tions nerveuses, rien n'est si variable que Tac- tion des medicaments ; les remiides qui reus- sissent le mieux chez un grand nombre de sujets sont sans efficacite pour beaucoup d'autres ; et chez le meme individu. tel moyen qui avait produit d'abord des effets heroiques, et d'une promptitude surprenante, devient tout a fait inefficace au bout d'un petit nom- bre de iours. II faut suocessivement en es- sayer plusieurs, et souvent de tr^s-disparates: nous aliens, en consequence, parcourir les diverses series de moyens dont on a tire le plus d'avantage dans Va.st\ime."—Traile de I' Auscultation MMate: Affections Nerveuses du, Poutnon. 1058 LOCAL SPASMS. irregular, unrhythmical, and painful con- tractions of tlie lioart known under the name of palpitation, are found in close connection with various derangements of the general health, and of special organs. Among the latter, those of the alimentary canal, but particularly of the stomach, and of the uterus, occupy the chief place. Perhaps the most painful of all the forms of cardiac palpitation is that resulting from either an imperfect depuration of the blood, or from a regular blood im- poverishment, or ansemia, as is so fre- quently observed in cases of amenorrhcea and chlorosis. We pass to a brief consideration of Spasm as occurring in the muscular or- gans which constitute the alimentary canal. It affects the stomach and intestines as well as the cesophagus and pharynx, while the severe pain determined by its occurrence in any part of the alimentary tract is very generally accompanied by other and various symptoms which can- not with any propriety be referred to now. Painful peristaltic spasm of the intestines is usually known under the name of colk. During its occurrence, and as affording proof of its occasional violence, intassus- ceptto, and prolapsus of the rectum may take place. Foremost among the detei'- mining causes of colic is to be placed the presence of indigestible articles of food and morbidly altered secretions in the intestinal canal. But, besides this, the influence of the emotions, and more espe- cially of fear and fright, is well known ; just as bronchial Spasm may be due to reflex nervous irritation, so may intesti- nal-spasmodic stricture (as it is called, to distinguish a temporary and functional from an enduring and organic contraction, similarly produced) have its seat in any part of the alimentary canal. In some instances the direct exciting cause is seat- ed at a great distance from the induced disorder : of this nature no more common or manifest example can be given than tliat of colic, often very severe, resulting from the exposure of the lower extremi- ties, it may be of the feet only, to cold and damp. Spasm of the pharynx and oesophagus is one of the most interesting of all the varieties of Local Spasms. It is of common occurrence, particularly in females, in whom it shows itself either as a reflex phenomenon dependent on uterine irritation, or — and this still more frequently — as one of the most striking features in a paroxysm of hysteria. It is not alwaj'S an easy task to distinguish between spasni of the cesophagus due to organic disease and that which is simply the result of a nervous irritation. The cautious introduction of the probang or oesophageal bougie is the most ready and certain means for establishing the diag- An irritation of the pharynx or ceso- phagus, of the stomach, bowels, or liver, is sometimes the direct cause of hiccup or singultus, a spasmodic affection extremely interesting in its nature. Sudden power- ful jerking inspirations, accompanied by a peculiar noise, and succeeded by a brief expiration, interrupting speech, distin- guish hiccup. It is essentially a reflex phenomenon ; in the vast majority of in- stances depending on some peripheral irritation, but occasionally, as its pres- ence in apoplexy, meningitis, and hydro- cephalus testifies, determined by a central cause. There seems to be some difiiculty, in accounting for the occurrence of hiccup from an irritation of the phrenic nerve, as has been suggested by various writers ; nevertheless it is consistent with the writer's observation in several instances of long-continued and distressing hiccup, that firm pressure exerted for a brief period over the lower part of the neck, corresponding to the situation of the sca- leni muscles, so as to probably compress the phrenic, has led to its temporary and even entire arrestment. In singultus and in yawning, which resembles it in being of the nature of inspiratory convulsion — also in sternutatio or sneezing, where the expiratory function is involved — what is of consequence to notice is, as Romberg has pointed out, that the spasmodic action does not affect a single muscle, but, on the contrary, groups of muscles ; and that these Local Spasms, more particularly the former, hiccup, while occurring as inde- pendent affections, are still more prone to assume the symptomatic character, affording evidence of the existence of some other malady, or distant irritation. ' Spasms of the urinary bladder and of the urethra — the latter commonly styled spas- modic stricture — are familiar to the sur- geon. Vesical Spasm is not unfrequently a truly reflex phenomenon : this is wit- nessed on the introduction of the catheter or bougie, when violent and most painful efforts are made to evacuate the organ, even when at the time empty. Romberg insists on the action of the vesical muscles being due to an irritation of the neck of the bladder, that particular part being, as Sir Charles Bell demonstrated, the most vascular and the most sensitive portion of the viscus. It is when the catheter reaches, or the calculus touches, the neck of the bladder, that the ischuria is pro- duced ; and the intense pain is seen to subside whenever the irritating body is removed from that particular portion of ' ' ' Haufiger als auf einzelne Nervenbahnen beschrankt, kommen die krampfhaften Atli- cmbewegungen zu Gruppen associirt vor, ent- weder selbstandig, oder was ofter der Fall ist, abliaiigig, und in Begleitung von andern Affeotionen. " (Loo. cit. p. 354.) LOCAL SPASMS. 1059 the organ. The irritatioa upon which vesical spasm depends may, as we have seen to hold true of other forms of Local Spasm, be distant from the induced phe- nomenon. It may be resident in the kid- neys, or in any part of the intestinal canal, but very specially in the rectum. Hemorrhoids are a frequent cause of vesi- cal spasm ; and it is well known in how distressingly severe a degree that is apt to occur after the operation of their delioa- tion. Exposure of the surface of tlie body, especially of the feet, to cold and wet, and depressing mental emotions, act in the same way. As our object in this article has been, not to illustrate every example of Local Spasm, but rather to indicate the nature of this special morbid action by a brief consideration of some of its more import- ant and most frequently occurring varie- ties, we shall now take a very rapid sur- vey of a few other forms, and bring our remarks to a conclusion by offering some general observations with a special refer- ence to treatment. There is a peculiar variety of Local Spasm affecting certain muscles of the face, and giving while it lasts a very strange aspect to the indi- vidual. In the histrionic spasm of the face, by which title this affection is known, there are, in the language of Romberg, "grimaces, alternating or lasting, on one side, seldom on both sides, of the face.'" Pain is occasionally, but by no means necessarily, an accompaniment of the dis- ordered muscular action. A local malady essentially, because affecting the muscles governed by one nerve, the seat of the spasm is in some instances still further localized by there being only one of the branches of the seventh pair involved. Of the latter are blepharospasmus, or spasm of the eyelids, and the risus cani- nus. The peculiar convulsive grin thus named is caused when the molar and labial branches are affected. To it the terms spasmus cynicus and sardonic laugh are likewise applied. The relation of facial spasm to chorea must not be over- looked ; this association has been fre- quently noticed : and it is also a matter of not unfrequent observation that the Local Spasm lasts in some cases for a consider- able period after the disappearance of the general nervous disorder with which it had been in the first instance connected. Masticator)/ Spasm is witnessed in its most formidable degree when, as trismus, it accompanies, or is itself the chief ele- ment in, tetanic convulsions. In a much milder degree spasm in the muscles which are supplied by the motor division of the fifth pair is seen as a reflex action, deter- mined, as in children, by the presence of worms in the intestinal canal, or by the ' Loc. cit. "Mimischer Gesichtskrampf." progress of dentition. The spasm of tho muscles is sometimes associated with a grmding of the teeth. To the occurrence of the latter symptom in persons of the gouty diathesis attention was called by the late Dr. Graves. Such grinding of the teeth continued for years as a daily habit, and produced very remarkable changes in the conformation of these organs, affect- ing sometimes one side of the jaw, some- times both; so that in confirmed cases the teeth were frequently found ground down to the level of the gums.' Spasm of the muscles of the eye, depend- ent on an irritation of the third, fourth, or sixth nerves, is seen in strabis7nus^ which is to be distinguished from the pa- ralytic form by the movement of the eye- ball in other directions being in the for- mer case possible — and in nystaginus. These spasmodic affections equally with others acknowledge a peripheral or cen- tral origin. Both are of common occur- rence in connection with intestinal and dental disorders, but they are also not unfrequently the indications, sometimes among the very earliest, of mischief, in- flammatory or otherwise, commencing at the base of the brain. Painful Spiasm of the imiscles of the ex- tremities are of very frequent occurrence ; and with this affection, more especially seated in the lower limbs, and then in the calves, we are especially familiar under the name of cramp. The attack of cramp is usually sudden ; and it frequently oc- curs at night, tho person in bed being awakened from sleep by the seizure. During its continuance the muscular fibres are gathered up into a hard knot, which is always easily felt by the touch, and may often be seen. The pain is very severe, and produces a feeling of sickness and depression, which may even lead to syncope. The patient not unfrequently gives utterance to an irrepressible excla- mation or scream. Cramp usually lasts only for a few moments ; it may, how- ever, continue for minutes, and even hours. A sudden cessation of the S)asm may occur, or a more gradual relaxation of the muscular fibres ensue ; but in either case, if the attack have been at all severe, sufficient injury during its continuance has resulted to the sensory nervous fila- ments as to cause a feeling of soreness, always increased by touch, and frequently an inability fully to exert the affected limb or other parts for some time. The irritation of the sciatic nerve, upon which the painful spasm of the muscles of the calf depends, is intimately connected with disorder of the stomach and bowels, and is also particularly prone to occur in per- sons of the gouty and rheumatic habits. [See Athetosis, in this volume. — II. ] ' Cliu. Med., "Gout." 1060 TORTICOLLIS, In Asiatic cliolera the occurrence of in- tensely painful cramps contributes, as is well known, largely to the sufferings of its victims. Again, in persons of intem- perate habits there is sometimes observed a tendency to the development of severe spasmodic action in the muscles, of the extremities, more especially, but likewise of other parts of the body. In one in- stance which fell under the writer's ob- servation, a patient, having recently re- covered from an attack of delirium tre- mens, was seized with most violent and painful spasm of the muscles of both up- per and lower extremities, during which the lingers were powerfully flexed and bent inwards on the palms of the hands, as in the carpal contractions of children. So severe was this case, that a syncopal depression very threatening in its charac- ter, occurred. After lasting for several hours, and exhibiting for many days a marked tendency to recur, the aifection passed off", and the patient entirely recov- ered both health and strength. In the treatment of local, as of general, Spasms, the great object is to remove the cause on which they depend. In the brief consideration of the different varie- ties of Local Spasm now offered it has been shown that in a large proportion of cases the excited muscular action is in- duced by reflex action ; that the direct exciting cause is a distant nervous irrita- tion. Fortunately the removal, or at all events the lessening, of this irritation is in many instances within the power of our art. Again, in those cases, of the frequent occurrence of which proof has been afforded, which are characterized by a morbid state of the blood, e. g., gouty or rheumatic, we may often be successful in our treatment by paying due attention to the therapeutical indications — in other words, by the emplo3'raent of an altera- tive or eliminating plan, suggested by the peculiarity of each individual case. We may as effectually subdue the morbid ac- tion of Spasm as we are constantly ena- bled, by the use of suitable remedies, to relieve that of pain in neuralgia. In ad- dition, we possess in various agents a power of controlling or conipletelj' re- moving such excited nervous action as induces Local Spasm : not, indeed, one upon which we can invariably rely, be- cause we are often disappointed in the results ; nevertheless the remarkable ther- apeutical effects which succeed the exhi- bition of various of the antispasmodic and calmative remedies is such as to convince us of their eiBciency. Our knowledge, moreover, regarding the action of such remedies is on the increase. It is only quite recently that a valuable addition has been made in the bromide of potas- sium, the operation of which in removing the painful cramps of cholera, not less than in many instances averting the con- vulsive seizure of epilepsy, has been wit- nessed by numerous observers.' Pressure firmly exerted on the thigh relieves a violent cramp of the calf, while, according to Dr. AVise, the application of a tourniquet so as to compress the blood- vessels will banish the exhausting muscu- lar contractions in cholera. Finally, in the treatment of such ex- alted nervous action as determines Local Spasm, as in the proper management of every form of derangement of the nervous system, however slight or severe', let the potent influence of peculiarity in psychi- cal constitution, and of the ready suscep- tibility in some to the operation of all manner of external impressions, not be lost sight of. TOETICOLLIS. By J. EussELL Reynolds, M.D., F.R.S. Definitiok. — A spasmodic condition of the muscles of the neck — generally clo- nic, but rarely tonic — whereby the head is displaced to one side, or towards one shoulder, or is thrown backwards ; occur- ring almost exclusively in adult life, and characterized by great obstinacy and cbronicity. Stitontms. ■ — Wry-neck ; spasmodic wry-neck ; spasm in the muscular distri- bution of nervus accessorius Willisii, and of the superior cervical nerve (Romberg).' ■ See Note on the Therapeutical Effects of Bromide of Potassium, by James Beghie, M.D. ; Edin. Med. Jouru. 1866. Also, The Actions of Bromide of Potassivim upon the Nervous System, by J. Cricliton Browne, M.D. ; Ibid. 1865. ' Syd. Soc. Transl. of Manual of Nervous Diseases of Man, vol. i. p. 316. SYMPTOMS. 1061 Causes. — So far as I have seen, the male sex has been slightly more frequently aft'ected than the female ; but the differ- ence is so small, that its existence is of no diagnostic value. The affection has some- times originated, and recurred, or been exaggerated, during pregnancy. With only few exceptions, the cases that I have seen have first presented symptoms after thirty years of age ; and the majority after forty. There has been no one thing, nor any combination of circumstances, which has occurred with such frequency as to warrant a belief in its operation as an ex- citing cause. Once a strained position, maintained for a long time ; occasionally exposure to cold ; sometimes a sudden shock, either mental, moral, or physical ; and at other times the presence of long- continued anxiety, or the recurrence of pregnancy, has been referred to by the patient as the cause of symptoms ; but, in regard of such modes of causation, we can see distinctly that which might lead to disturbance of the nervous system of any kind whatsoever, but we fail to see anything which should conduce to this special form of derangement. In one case that I have seen the symp- toms were preceded by hemiplegia ; in another by paralysis agitans of the side from which the head was turned ; in a third, and fourth, and fifth, there was previous "writer's eramp ;" in a sixth there was histrionic spasm of the face ; but in the majority of cases the nervous system had exhibited no prior derange- ment, and had continued free from ulte- rior disturbance for a long period of years. The position in life and the occupations of those who have suffered from Torticol- lis have varied widely, and I have not been able to attribute the malady with anything like constancy to that common cause of nervous disease — overwork. Symptoms. — There is great similarity in the symptoms presented by different individuals, when once the disease is es- tablished, and is free from accidental complications. Sometimes the commence- ment is sudden, but much more commonly it is gradual, and often so insidious at first that the real nature of the malady is overlooked. The patient feels uneasy in the neck, thinks that somethinj^ is wrong with his cravat, or with his pillow, and only after several months discovers for himself, or is told by others, that his head is not straight. There is with this want of symmetry some uneasiness in the neck, extending from the occipital protuberance downward to one of the shoulders, and sometimes onwards into the arm, or even forearm. As the malady advances the un- easiness becomes greater, and sometimes amounts to definite pain, felt usually in the same direction. The pain is increased by voluntary efforts to bring the head into the middle line, but sometimes attains its maximum when the head is carried round to the furthest point possible by the spas- modic movement. The pain is not severe, but generally of dull, aching character ; and often is relieved by lying down, and keeping the head still by resting it upon a pillow. Observed casually, a case of medium severity would give the impression to a bystander that the patient's cravat was uncomfortable, and that he was trying to make it less so by moving the head, in a somewhat restless manner, towards one side; or that he was making some attempt to look at an object on one side of him, which object he 'could not "get his head round" suthciently far to see conveniently. Upon more careful examination it is seen that the head is constantly being moved, by a succession of jerks, in such manner that the occiput is depressed, and the chin raised, and that the movement is in a definite direction, hour after hour, and month after month. Early in the case the individual is able so far to an- tagonize the spasm, by a simple volun- tary effort, as to bring the head into the middle line, or even beyond it ; but as time passes on this often becomes im- possible, and the hands are used to pull the head back again into its proper po- sition. When Torticollis has existed for a few months only, the head presents a con- stant series of movements — the spasm and the voluntary effort so balancing one another that the effect is that described above. But when it has lasted for a longer period, the head is habitually "car- ried on one side ;" for the voluntary in- terference with the spasm, although fre- quent — if not constant — does not suffice to bring the head into a central position, being overcome by the spasmodic contrac- tion. Sometimes, even under these cir- cumstances, a very strong voluntary effort may restore momentary equilibrium ; but the effort is attended by distress, if not by pain, and is often followed by an exagge- ration of the spasm. The muscles of the neck on the side from which the chin is turned are found hard, contracted, and often hypertrophied; those on the opposite side are frequently soft, and sometimes wasted. Early in the history of Torticollis it would seem — so far as my experience extends — that the deeply-seated muscles at the back of the neck are the most affected : the sterno- mastoid, at such time, being often free from spasm. At a later period the sterno- mastoid is found hard, frequently hyper- trophous. Occasionally the muscles of the shoulder are so involved that the acromion is raised; 1062 TORTICOLLIS. more rarely the muscles of the face pre- sent histrionic spasm ; and not unfre- quently there is some difficulty in con- trolling the movements of the arm. I have noticed sometimes difficulty of deglu- tition, and in a very few cases some mor- bid condition of motility in the leg : but these symptoms must be regarded as com- plications rather than conditions of the disease now under consideration ; for it more frequently happens that the muscles of the neck are alone involved in the mor- bid contraction. As a rule, to which the exceptions are very rare, the spasms cease during sleep ; and not only so, but when the patient lies down and supports the head. They are increased by all that lowers or disturbs the general health, and by emotional ex- citement. The electric irritability of the contract- ing muscles I have found much increased when tested by faradization : the electric sensibility is sometimes so greatly aug- mented that an interrupted current, not in the least degree painful on the healthy side, was perfectly intolerable when passed through the seat of spasm. It has ap- peared often that the relaxed muscles, on the side opposite to the contraction, have exhibited less than their normal contrac- tility ; but I have never found them so defective that it was impossible to restore the head to equilibrium by theu" direct faradization. The battery current, when continuous, and passed through the con- tracting muscles, relaxes the spasm and allows of temporary equilibrium ; but, when interrupted, its action is similar in kind to that exerted by the induced cur- rent of faradization : there is, however, less intensity of contraction, and much less display of electric sensibility. The effects of either the battery current or of faradization appear to be singularly tran- sient, in whatever manner they may have been produced. It has often happened to me to see that a head which had been maintained in equililtrio for many minutes, and that day after day for a considerable number of days, returned at once to its spasmodic jerkings the moment that the application was suspended. Sometimes it has been obvious that the spasm was subsequently increased by the electricity. The side to which the twisting occurs has been sometimes the right, sometimes the left. There appears to be no special proclivity to the affection of one side rather than the other in either sex ; but when once the malady has shown itself, its pertinacity is remarkable : it remains in exactly the same position, with slight tendency to extend ; or it may in rare in- stances disappear for eight or nine years, and then return to the muscles that it had previously affected. In many cases jjro- grcss is so slow that no change is observa- ble after several years — i. e. no change as to locality — whereas in others the malady seems to extend either upwards or down- wards, and involve muscles not implicated at the first. In this manner the face may be distorted or the arm may be rendered partially useless by either rigidity or weak- ness ; the head becomes more or less fixed in an oblique position, the ear of one side being drawn down to the shoulder, and the chin thrown upwards and outwards in the opposite direction. When left en- tirely to itself — i. e. when not interfered with by either the will, the ideas, or emo- tions of the patients, or by any influence from without — the spasm is tonic, and the head may remain for hours drawn to one side, but motionless. This is rarely, if ever, noticed early in the history of a case, and sometimes it is never observed ; but, even when it occurs after several years' duration of the spasm, the slightest emo- tional disturbance or attempt at voluntary movement brings back the clonic contrac- tion : and the only difference to be recog- nized between the early and the later stages of the malady is, that in the latter the head is never brought back to the position of exact equilibrium, and that there is less obvious movement of the head ; for, as it seems, the habitual strug- gle between volition and clonic spasm is given up, and the latter, having gained the day, allows tonic spasm to take its place. The mental faculties, the sensibility of the skin, the special senses, and the gene- ral health undergo no necessary changes in Torticollis, but I have often observed great mental depression. In some highly- marked instances there has been complete integrity of function in every direction ; the one thing that has been wrong has been the disease itself. Sometimes the general health has been impaired, the pa- tient has been anaemic and weak; but this has been frequently the result of the an- noyance occasioned by the spasm, and very rarely the supposed cause of its de- velopment. Numbness and anaesthesia may occur in the arm, together with oedema, when the scaleni are so much affected as to press upon the brachial plexus and its adjacent veins.' Insomnia is by no means unfre- quent. Diagnosis. — The symptoms that have been now described are sufficient when carefully regarded to enable the prac- titioner to distinguish this disease from every other. An accidental exposure to cold may produce " stiff-neck ;" but here the head is permanently fixed in one posi- tion, and maintained therein, not by spas- modic rigidity of muscle, but by the fear ' Romberg, loc. cit. p. 317. PATHOLOGY — PROGNOSIS — TREATMENT. 1063 of pain which, as tlie patient knows, any movement may occasion. Sucli malady has its relations to pleurodynia, lumbago, and " muscular rheumatism;'' it is sudden in its development, and temporary in its duration, and could only be accidentally mistaken for Torticollis. The opposite error is sometimes made — viz. that of re- garding genuine spasmodic Torticollis as a simple stiff-neck from rheumatism or cold.' In its earliest stage, however. genuine Torticollis should be at once dis- tinguished by the clonic character of the spasm, and freedom from pain on move- ment. Injuries to the S2nne occasionally pro- duce stiffness of the neck, and this to such a degree that the head may be perma- nently placed in some awkward position. In such cases the spasm is tonic ; there is marked tenderness of the spinous pro- cesses, and with this some fulness or hardness around or behind the vertebral column ; and there is also some impair- ment of the motor or sensory properties in the arms and legs. In certain organic diseases of the hrain accompanied by hemiplegia, there is sometimes Torticollis, just as there is synergic movement of the eyeballs ; but the mode of onset of symptoms is such that a case of cerebral apoplexy cannot well be confounded with the malady now under consideration. The opposite mis- take has, however, sometimes been made, and an individual who is beginning to suffer from Torticollis spasmodica has been supposed to be the subject of organic disease of the brain. For the distinction between these two very different condi- tions it is sufficient to bear ia mind that in the one the disease is limited to the neck, in the other it occurs in combina- tion with marked hemiplegia ; that in the former the spasm is clonic, in the latter tonic ; and that in the first the develop- ment of symptoms is insidious, gradual, and local, whereas in the second it is sud- den, and of wide distribution. It is enough to mention the existence of cases in which growths, benignant or malignant, may affect the position of the head" in order to prevent the occurrence of any errors in diagnosis. Pathologt. — Anatomical inquiry has not yet shown the locality or existence of any special lesion of the nervous centres with which Torticollis is necessarily asso- ciated. Physiological experiment has proved that it may exist when the spinal accessory nerve is irritated at its passage through the foramen lacerum,' or when injury is inflicted on certain muscles, upon the olivary body, or the auditory J Volkmann, quoted by Romberg, loo. cit. p. 316. nerve. ' The disease would appear to be one of those curious conditions — not yet fully understood — in which some "centre" of associated movements is so altered that there follows a disturbance of the normal equilibrium ; a disturbance exhibiting itself at first by dynamic change, but sub- sequently leading to structural alterations in the affected muscles. It has its analo- gies in writer's cramp and histrionic spasm, and its peculiar and intimate pathology is a question as yet reserved for further investigation. Peognosis. — When once established, — i. e. , when fully developed and of three or four months' duration, — Torticollis is one of the most obstinate of maladies. It has sometimes yielded to treatment, under favorable circumstances ; Imt it has al- most invariably recurred, and has proved capable of resisting all efforts made for its relief. When the case departs widely from the ordinary type, — as, for example, when the chin is drawn either backwards and upwards, or downwards and forward, by bilateral contraction of the muscles at the back of the neck, or at its front,— the prognosis is more favorable. Such cases frequently improve, and sometimes get well by rest, and other measures. Unfortunate as the prognosis is with regard to the cure of this special malady, there is one ground for consolation,— viz. that it is not by any means necessary, nor is it at all highly probable, that the vic- tim of Torticolhs should suffer from any other nervous disease. Sometimes it forms "but part of a general nervous dis- order ; bvit, as a rule, it exists alone ; and although it may continue for many years, the source of great but measurable annoy- ance, it does so without entaihng any danger to life, or any high probability of ulterior change. Prognosis, therefore, is based upon the duration of the disease, and its comphcation with other signs of nervous malady. When it exists alone, the patient may look forward to a trouble- some and obstinate affection ; but he may, at the same time, know its hmits, and be directed to go on without fear of further mischief. Tbeatmekt.— In its early stages Tor- ticollis has yielded to various plans of treatment ; iron, setons, moxK, rest, mer- curials, electricity, pressure on the cervi- cal sympathetic, and the division of nerves or of muscles, have each been followed by a cure : but in the advanced stages no one nor any combination, of these modes of treatment has availed to cure, or even to modify, the disease. I have used all kinds of soothing appli- 1 Brown-S^quard, Lectures, p. 194. 1064 LOCAL AN^STHESI^. cations, have employed electricity in every form, and have failed to influence the dis- ease when once it has become fairly fixed ; but have found that the continuous cur- rent has been useful when the malady has existed for a few months only, and have also at that period seen notable advantage from the continued application of morphia by the method of hypodermic injection. It would seem desirable to enjoin rest ; to secure the regulation of the general health ; to apply a moderate continuous current to the muscles which exhibit spasm, and a mild induced current to their antagonists ; and to inject morphia, hypodermically, for a lengthened period. It is not essential that the morphia should be injected into the neck ; it may be intro- duced into the arm or thigh, or any other convenient locality : but it is important that its use be steadily continued, and that the quantity injected be gradually increased until a definite effect is produced upon the spasm. Beginning with the tenth part of a grain, the quantity may be increased, if necessary, until two, or even three, grains are injected twice daily; and when the patient can bear this amount, the spasm has sometimes yielded. But it often happens that morphia, even by hypodermic administi'ation, cannot be borne, from the fact of its producing nausea, constipation, and ai\ amount of malaise that is greater than the evil it is intended to relieve ; and in such cases the Torticollis is positively increased by the injection. Several patients whom I have known with Torticollis have positively re- fused to continue the injection of morphia from the misery which it has thus occa- sioned. Mechanical contrivances have been em- ployed in order to force the head into po- sition ; but these, although so managed ] as to be borne for a short time — e. g., to \ enable a clergyman to get through a ser- vice, or a doctor to visit two or three pa- tients in succession — are often found to be productive of so much annoyance, or even pain, that the patient would rather trust to his own hands or to the " chapter of accidents" in order to get through his work. The most simple, and at the same time most effective, appliance that I have seen for mild cases is that devised by Dr. Hearne of Southampton ; but it has tailed to be of service when the disease has been of long duration. Mr. Heather Bigg has constructed several machines which meet the difficulty for short periods of time ; but I have not yet seen any apparatus which a patient with confirmed Torticollis could bear habitually. Division of the nerves has been useless,' and division of the sterno-mastoid worse than useless, for it has led to an exag- geration of the spasm in the deeper-seated muscles at the back of the neck, as I had occasion to observe in a well-marked case that came under my notice some years ago. LOCAL Al^^STHESI^. By J. Warburton Begbie, M.D., F.R.C.P.E. The term Ansesthesia (a privitive, atceijffij, sensibility) indicates deprivation or loss of sensibility, and was first em- ployed by the distinguished Cappadocian physician, Aretteus.' There exist three abnormal modifications of the function of sensation : first, it may be lost ; second, it may be exalted (hypereesthesia) ; third, it may be perverted. By Local Ansesthesia we understand a morbid state of sensibility, in which the normal physiological sensation of a part is abolished entirely, or nearly so. Since the introduction of ether and ' ^v Js atpy] ExXetTTTi fxovvn xote — vnrknw Je to toiotJe — OMttls^ii^lrt ^aXXov ri 7rapEff-(f xixX^s-HETat.-^TTBcI Jlx^a.y^-JS-1-yi;. ITEpi AiT(a;V xai 2»)iWElftiv XjJOVlwv niflajv. Blf3\(0V rifiiTOV. chloroform inhalation, for the purpose of destroying pain, it has been customary to describe these valuable agents as anses- thetics, and the condition of insensibility into which the person is thrown by their action as Ansesthesia. With this inter- esting phenomenon we have at present no concern. In Local Ansesthesia the want or failure of the due impression must arise from a morbid state of the extremities of nerves, or of an afferent nerve ceasing to convey the impression to the sensorium, or of the sensorium itself. Thus we are entitled to limit the seat of the morbid influence, because these three organs, or classes of organs, are ' Romberg, loo. cit. p. 319. LOCAL AN.ffi!STHESI^. 1065 concerned in the production of each sen- sation. With precisely the same signification as Ansestliesia, tlie expression paralysis of sensation, or of the nerves of sensation, has been employed. It were better, how- ever, to abandon the use of paralysis in this sense altogether, and to restrict it to the loss of power of motion. The inti- mate connection of paralysis and Ana;s- thesia is abundantly conspicuous : the latter is very frequently noticed as an antecedent phenomenon of the former, or they occur simultaneously ; and while paralysis lasts Anesthesia may continue, or sensation may be restored long before the recovery of the power of motion. The special situations in which Anaes- thesia is met with, or may be considered apt to occur, are various. For conveni- ence of illustration the following classifica- tion may be made, and to the forms now to be mentioned attention will be very briefly directed : (a) Anaesthesia of the skin (cutaneous AnEesthesia). (6) Antes- thesia of muscular nerves, (c) Anesthe- sia of sensorial nerves. (cZ) Anaesthesia of the fifth pair of nerves, (e) Anesthesia of mucous surfaces. (/) Anaesthesia of the viscera. (a) Ancesthesia of the Cutaneous JSferves. — The notable and lasting diminution, or the entire loss, of the tactile sense of the skin is what is understood by cutaneous Ansesthesia. It is by a careful examina- tion as to the delicacy of tactile sensi- bility, and the perception of degrees of temperature, that we are enabled to deter- mine the extent to which Anesthesia of the surface exists. For the former pur- pose the mere statements of the patient will not sufiice. Besides measuring the degree and determining the precise seat of Anesthesia by the point of the needle, re- course must be had to the method of ex- periment suggested by Weber, testing the consciousness of the patient, while blind- folded, to the two points of a pair of com- passes, placed at different parts upon the skin, or, which is still more satisfactory, employing the delicate little instrument known as the esthesiometer of Dr. Sieve- kino-. The ready and accurate determina- tion "by the patient of degrees of tempera- ture, heat and cold, is impaired or de- stroyed : it is not uncommon to find hot things styled cold, and cold things hot. In marked instances of the cutaneous Anes- thesia the power of resisting the injurious influence of temperature is lost : and not only so, but, owing to a similar defect, superficial sores are readily formed on parts of the body exposed to even a slight decree of pressure. Evidence of the de- rano-ement of the circulation is afforded by a change in the color of the affected part ■ it is°apt to become livid or blue in appearance, and extravasations of serum, and even of hematin, occur. Distressing sensations are experienced by the patients, — chiefly numbness and pricking ; also formication. In aUuding to the treatment of cuta- neous Anesthesia, the distinguished Ger- man writer on nervous diseases truly ob- serves, "Die Behandlung der Anesthesia cutanea war bisher eine oberfldchliche, im wahren Sinne des Wortes ;" but while this is to be regretted, we may reasonably anticipate an increase of our knowledge, owing to the much more satisfactory man- ner in which the causes and seat of dis- ease have of late, and are at the present time, being investigated. (h) Anaesthesia of Muscular Nerves. — The loss of the power of motion is usually un- associated with any marked degree of muscular Anesthesia. On the other hand, instances are on record in which a very perfect insensibility to pain has existed in muscles, while the power of moving them has been retained. It is of the utmost importance to distinguish between the loss of tactile sensation (cutaneous Anesthe- sia) and the definition of sensation in mus- cles, for without carefulness in examina- tion these two are capable of being, and in some instances have no doubt been, con- founded. Romberg makes the interesting observation, that muscular Anesthesia, without the loss of or any damage done to tactile power, exists in tabes dorsalis.' (c) Aiicestliesict of Sensorial Nerves. — The nerves of special sense which thus suffer are the optic (Anesthesia optica), the Auditory (Anesthesia acoustica), the Olfactory (Anesthesia olfactoria; Anos- mia), and the Gustatory (Anesthesia gus- tatoria ; Ageustia). To the many inter- esting affections included under these terms — for example, amblyopia and amau- rosis under optic Anesthesia — it is not de- sirable to make any reference now. Such important diseases demand a separate and detailed consideration not contemplated in this System of Medicine. [d) Anesthesia of the Fifth Pair of Nerves (Facial or Trigeminal Anesthe- sia).— Physiological experiments have de- monstrated the remarkable effects pro- duced by section of the fifth pair ; of these, insensibility of the face, eye, nostrils, cavity of the mouth and tongue, is the most conspicuous ; while the extent of the Anesthesia is of course determined by the nervous injury being limited to one or more branches, or, on the other hand, involving the trunk before division. Ex- perimental inquiry, as well as clinical ob- servation, have further shown that when injury or lesion of the nerve exists within the cranium, the resulting phenomena are not such as are included in Anesthesia merely, but paralysis and impairment or ' Miaskelanasthesie. 1066 LOCAL AN^STHESI^. loss of special sense are also induced. Romberg,' in directing attention to the diiferent diagnostic symptoms, has indi- cated certain very important particulars, as follows : (a) The more the Anaesthesia is confined to single filaments of the fifth pair, the more peripheral the seat of the cause will be found to be. (6) If the loss of sensation affects a portion of the facial surface, together with the corresponding facial cavity, the disease may be assumed to involve the sensory fibres of the fifth pair before they separate to be distributed to their respective destinations ; in other words, a main division must be affected before or after its passage through the cranium, (c) When the entire sensory tract of the fifth nerve has lost its sensa- tion, and there are at the same time de- rangements of the nutritive functions in the affected parts, the Gasserian ganglion, or the nerve in its immediate vicinity, is the seat of the disease. (cZ) If the Anaesthe- sia of the fifth nerve is complicated with disturbed functions of adjoining cerebral nerves, it may be assumed that the cause is seated at the base of the brain. Thus facial Anaesthesia, as a phenomenon of disease, may be in itself a simple, really trivial, affection, or it may be the indica- ' Aniisthesie des Quintus, Lehrbuch der Nervenkrankheiten, tion of serious organic disease. In the former case it will be apparently inde- pendent and isolated ; in the latter, linked with other striking features, its signifl- cancy will as little escape observation as its existence. Facial Anaesthesia in some instances comes on gradually ; in others its occur- rence is sudden. Neuralgic pain, or a condition of local hypertesthesia, may pre- cede its development ; while facial palsy and facial Anaesthesia are occasionally associated. (e) and (/) Anasthesia nf Mucous Sur- face, and of the Viscera. — The morbid con- dition in such circumstances must depend on a failure of the sympathetic to conduct the impression to the brain ; but, as a general rule, impressions made on the gan- glionic nervous system are not thus con- veyed, and it requires a powerful irrita- tion, or condition of notable hyperesthe- sia, in order that a consciousness of their existence should be established. The in- quiry into the operation of the organic nervous system is one of very great diffi- culty, and Romberg has truly remarked in regard to it, "Yon vorn herein be- kennen wir unsere unbekanntschaft mit diesen Zustiinden, die bisher nicht einmal zur Sprache gekommen sind, und deren Forschung mit grossen Schwierigkeiten Tcrbunden ist." INDEX OF VOL. I. ABDOMEN, enlargement of, in rickets, 47ij, 482 pain and tenderness of, iu measles, 107 In typhoid, 204 pain in, in eercbro-spinal me- ningitis, 297, 299 in tetanus, 971 retraction of, in meningitis, 810, 821 Bwelling of. In dysentery, acute, 376 tenderness of, in dysentery, mild, 375 acute, 370 Abdominal diseases, connection of, with melancholia, 590 Abortion, in influenza, 43, 45 malignant smallpox, 132, 137 relapsing fever, 279 smallpox generally, 138 syphilis, 430 typhoid fever, 208 typhus, 201 yellow fever, 289 under influence of malaria, 354 Abortive epilepsy, 772 Abscess of the brain, a cause of convulsions, 700 article on, 934 diagnosis of, from tubercular meningitis, 831 Abscesses, ecchymotic, iu yel- low fever, 289 gouty, 517 in glanders, 189 in pyaemia, 333, 335, 346 in scarlet f^cver, 80, 90 intracranial, in tertiary syphi- lis, 433 in typhus, 263 of brain, iu pyasmia, 334 of cavity of abdomen, in ty- phoid, 208 of ear, in smallpox, 133 of heart, in pytemia, 332 of intermuscular cellular tis- sue, in smallpox, 133 of kidney, in pytemia, 333 of liver, in dysentery, 380 of lungs, in pytemia, 332, 345 oflymphatic glands, ««e Bubo, of muscles, iu pyaemia, 334 of pharynx, iu diphtheria, 76 of prostate, in pyasmia, 324 of spleen, iu pyaemia, 333 of subcutaneous cellular tis- sue, in dengue, 101 of testicle, in pyaemia, 334 of tongue, in pyismia, 334 of tonsils, in diphtheria, 76 Abscesses — post-pharvngeal, iu diphthe- ria, 76, 91 treatment of, 97 secondary, in pyismia, 331, 332, 345, 346 sub-periosteal, in syphilis, 433 Absorption of fluids from erup- tion, a probable cause of secondary fever iu smallpox, 133 ^ ' Abstinence from drink, essen- tial in treatment of alcohol- ism, 684 relation of, to the induction of delirium tremens, 671 Accelerated cow-pox, 160 Acephalocysts, iu the brain, 899 in the spinal cord, 1016 Acetic acid, uselessness of, in scurvy, 456 Acids, mineral, in syphilis, 437 Acne, in gout, 520 in interval between secondary and tertiary stages of syphi- lis, 439 Acne of the face, diagnostic value of, 682 due to alcohol, 677 Aconite, external application of, iu gout, 541 to rheumatic joints, 572 internal administration of, in measles, 115 in rheumatism, 570 Acouitine, external application of, in gout, 541 Acute alcoholism, 678 Acute mania, 596 treatment of, 619 Acute softening of the brain, 857 Acute specific diseases, the, a cause of convulsions in children, 745 of insanity, 591 [Acute spinal paralysis of adults, 1007] Acute tuberculosis iu the child, symptoms of pulmonary form, 828 of typhoid form, 828 Adventitious products in the brain, article on, 883 in the meninges, 843 Aflfective, or pathetic insanity, 603 Age, as a cause of disease, 22 at which rickets appear, 475 for vaccination, 183 Age, influence of, on diagnosis of hypochondriasis, C^ij on mortality in influenza, 43 in relapsing fever, 2iJ0 in typhus, 266 on vaccination, 160 on occurrence of cerebro- spinal-mcningitie, 308 of cholera, 390 of diphtheria, 63 of erysipelas, 323 of gout, 527, 536 of heart disease in rheuma- tism, 563 of hooping-couijh, 48 of muscular rheumatism, 574 of parotitis, 130 of purpura, 463 of pyaemia, 344 of relapsing fever, 274 of rheumatism, 564 of rheumatoid arthritis, 551, 554, 555 of scarlet fever, 84, 95 of typhoid fever, 2);5 of typhus fever, 252 of varicelli, 135 on prognosis in cerebro-spinal meningitis, 304 in erysipelas, 327 in gout, 53S in rickets, 494 in smallpox, 137, 145 in typhus, 253, 2,;5 of epilepsy, 774, 779 of insanity, 018 of chronic mercurial poi- soning, 804 of neuralgia, 1030, 1041 of softening of the brain, 882 Age of parents, influence of, in production of rickets, 473 Age, predisposing to chorea, 697 to cerebral hemorrhage, 905 to chronic hydrocephalus, 836 to congestion of the brain, 848 to convulsions, 738 to cysticerei in the brain, 897 to epilepsy, 764 to essential paralysis of chil- dren, 1004 to general paralysis of the in- sane, 607 to hydatids iu the brain, 899 to hyi^ochondriasis, 626 to hysteria, 631 to insanity, 588 to laryngismus stridulus, 741 (1067) 10G8 INDEX OF VOL. I. Age, predisposing — to locomotor ataxy, 9S8 to neuralgia, 1029 to paralysis agitans, 725 to sciatica, 1035 to simple meningitis, 814 to softening of the brain , 873 to tubercular meningitis, 818 to wasting palsy, 78(3 to writer's cramp, 734 Agminated glands, see Peyer's patches. Ague, see Intermittent fever, 354 Air,ehangeof, after cholera, 419 [benelicial in hooping- cougli, 54] in gout, 549 in hooping-cough, 56 in rheumatoid arthritis, 558 in rickets, 496 in syphilis, 438 condition of, in relation to cholera, 386 impure, as a cause of cholera, 388 of dysentery, 375 of purpura, 463 of pyasmia, 344 of riclsets, 473 of typhoid fever, 341 of typhus, 253 Aix-3.-Savoy waters in gout, 547 in muscular rheumatism, 575 Aix-la-Chapelle waters, in gout, 547 in muscular rheumatism, 575 presence of litliia in, 544 Albumen, increase of, in blood of cholera, 406, 414 in urine, in acute rheuma- tism, 503 in cerebro-spinal meningitis, 398, 303 in diphtheria, 65, 66, 67, 73 influence of, on prognosis in diphtheria, 77 in erysipelas, S24 in gout, 518, 533, 534, 537 pathology of, 534 prognosis of, 538 in intermittent fever, 358 in measles, 111 in purpura, 463 in pycemia, 346 in remittent fever rare, 367 after scarlet fever, 91 in scarlet fever, 91 treatment of, in scarlet fever, 97 in the urine in typhoid fever, 208 an occasional sequel of ty- phoid fever, 309 in typhus, 260 treatment of, 268 an unfavorable symptom in typhus, 266 in yellow fever, 285, 286, 290, 293, 368 Albuminoid degeneration, see Amyloid. Albuminuria, a cause of con- vulsions, 745, 759 chronic, resulting from cho- lera, 415 see also Bright's disease. Alcohol, effects of, on the sys- tem, 671 Alcohol, effects of — on the pulse, 671 elimination of, by the urine, 673 oxidation of, in the system, i;y4 test for, in the urine, 928 useful in treatment of chorea, 715 of neuralgia, 1046 of tetanus, 979 when taken In excess, a cause of cirrhosis of the liver, 677 Alcoholic beverages as a cause of gout, 537 no influence on rheumatoid arthritis, 554, 558 Alcoholic stimulants. In cere- bro-spinal meningitis, 313 cholera, 416, 417, 418 chronic dysentery, 383 diphtheria, 78, 81 dysentery, 376 erysipelas, 337 gonorrha2al rheumatism, 579 influenza, 45 gout, 548, 549 intermittent fever, 361, 363 measles, 114 parotitis, 133 pyaemia, 353 relapsing fever, 280 rheumatism, 573 scarlet fever, 96 smallpox, 143 the plague, 317 typhoid, 249 typhus, 267 yellow fever, 294 Alcoliolism, article on, 670 definition, 670 synonyms, 670 history, 670 etiology, 671 symptoms of the chronic form, 675 of the acute, 678 diagnosis, 681 prognosis, 683 complications, 683 pathology, 684 treatment, 684 Alcoholism, acute, diagnosis of, from apoplexy, 937, 928 Alcoholism, chronic, relation of, to hypochondriasis, 637, 630 Algide stage of cholera, 400 AUfalies, in acute gout, 539 in chronic gout, 643 in diphtheria, 83 acute rheumatism, 569 hooping-cough, 56 rheumatoid arthritis, 556 rickets, 495 scarlatinal rheumatism, 97 Alum, in diphtheria, 80, 83 in hooping-cough, 56 lotion for otorrhcea, 116 topical use of, in hemorrhages in purpura, 468 ij-maurosis, a common symp- tom in locomotor ataxy, 985 a rare sequel of convulsions in children, 744 in cerebro-spinal meningitis, 300 in hereditary syphilis, 439 Amaurosis — in relapsing fever, 270 in tertiary syphilis, 440 Amenorrhosa, a cause of pur- pura, 463 cure of, by influenza, 43 Ammonia, in the air of marshes, 353 in stage of collapse in cho- lera, 417, 418 in diphtheria, 83 in erysipelas, 328 in influenza, 45 in pyaemia, 351 in rheumatoid arthritis, 557 in rickets, 496 in scarlet fever, 96 in syphilis, 438 in typhoid fever, 347 in typhus, 268 salts of, in chronic gout, 545 Ammonia, acetate of, in gout, 540 in measles, 115 in muscular rheumatism, 575 in smallpox, 143 in typhoid fever, 247 in ura3mia after cholera, 419 in yellow fever, 294 Ammonia, carbonate of, in chorea, 715 Ammonia, hydrochlorate of, in muscular rheumatism, 575 Ammonia, phosphate of, in gout, 54.5 Ammonia, muriate of, in neu- ralgia, 1045 Ammoniacum plaster in rheu- matoid arthritis, 557 [Amyl, nitrite of, in epilepsy, 782] Amyloid corpuscles in the brain, 844 numerous in the insane, 615, 616 Amyloid degeneration of organs in purpura, 463 of organs in rickets, 494 Anffimia after cholera, 415 after intermittent fever, 358 after rheumatism, 572 after scarlatinal dropsy, 93 a predisposing cause of rheu- matoid arthritis, 554, 556 in hereditary syphilis, 430 in purpura, 463 in riclcets, 483 in mother, a cause of rickets, 473 AnEemia, predisposes to insan- ity, 590 to neuralgia, 1037, 1030 Anaemic bruit in ague, 358 Anesthesia, hysterical, 636 complicating facial neuralgia, 1038 sciatica, 1036 paraplegic, in myelitis, 958 Anaesthesia, in yellow fever, »93 Anaesthesia, local, article on, 1064 definition, 1064 cutaneous anaesthesia, 1065 muscular, 1065 facial, &c., 1065 Anaesthesia, muscular, article on, 783 definition, 783 nomenclature, 783 INDEX OF VOL. I. Anaesthesia, muscular- symptoms, 783 causes, 784 diagnosis, 784 patliology, 785 prognosis, 785 treatment, 786 Anasarca, see CEdema. Aneurisms, intra-cerebral, 895 a cause of fits, 759 of death, 759 rupture of, a cause of cere- bral hemorrhage, 904, 910 Aneurisms,miliary,iuthebraiu, found after death from chronic cerebral conges- tion, 853 from chronic softening of the brain, 877 from general paralysis, 615 pathology and morbid ana- tomy of, 894 predispose to cerebral hem- orrhage, 907 Angina, a consequence of scar- let fever, 90 in scarlet fever, 86 Angina pectoris, treatment of, by arsenic, 1043 by sulphuric ether, 1045 Angular curvature of the spine, 1017 Ankylosis of the fingers after dengue, 103 of joints in gout, 514, 516, 525 favored by local bleeding, 540 from gonorrhoeal rheuma- tism, 576, 577, 578 Anomalous smallpox, 129, 133 Anterior columns of the spinal cord, functions of the, 943 [Anterior cornua of spinal cord, affected In wasting palsy, 796 in infantile paralysis, 1005] Anterior pyramids of the me- dulla oblongata, functions of the, 943 Anterior roots of the spinal nerves, functions of the, 943 atrophy of, in wasting palsy, 791 Antimony, in acute mania, 621 in acute rheumatism, 568 in chorea, 714 in delirium tremens, 688 in dengue as an emetic, 104 In hooping-cough, 56 in Influenza, 46 in purpura, 467, 468 in relapsing fever as an emetic, 280 in rickets, 495 in scarlatinal dropsy, 97 in typhus, 268 [Antiphlogistic treatment, 31] Antiscorbutics, 458 et seq. Anus, a frequent scat of ery- sipelatous inflammation, 323 condylomata of, tn syphilis, 424, 441 Anxiety, excessive, a cause of writer's cramp, 734 Aphasia after infantile convul- sions, 744 Aphasia — an occasional symptom of meningitis, 8G1) of abscess of the brain, 938 ' causes of, 861, 911 following epilepsy, 753 varieties of, 801 Aphemia, 801 Aphonia, hysterical, diagnosis of, 643 treatment of, G45 Aphthous ulcers of mouth, in dengue, 101 in measles, 110 Apnrea, in diphtheria, 07 in erysipelas, danger of, 837 treatment of, 839 Apoplexy, a consequence of cerebral congestion, 846 of cerebral hemorrhage, 930 of epilepsy, 776 of mercurial poisoning, 804,805 of softening of the brain, 858 article on, 903 definition of the term, 903, 920 diagnosis of, from alcohol- ism, 938 from concussion of the brain, 939 from opium poisoning, 929 from ura-mia, 881, 930 differential diagnosis, 880 the capillary form (of Cru- veilhier) , 860, 874 the serous, 930 simple, 931 without local paralysis, 927 Apoplexy, cerebral, in gout, 518 in purpura, 461, 464 pulmonary, in diphtheria, 76 in purpura, 461 in pyo3mia, 832 Apoplexy, congestive, relation of, to cerebral hemorrhage, 851 [Apoplexy in hooping-cough, 53] [Apyretic remedies in typhoid fever, 250] Apyrexia, period of, in intermit- tent fever, 355 incomplete in remittent fever, 355 Arachnitis, in hereditary syphi- lis, 430 Arachnoid hemorrhage, 841 a cause of chronic hydro- cephalus, 836 Arachnoid membrane of cord, supposed inflammation of, in yellow fever, 291 Arachnoid, opacity of, after chronic mania, 614 thickening of, in cerebro-spi- nal meningitis, 305 Areola, surrounding pustules in smallpox, 130 of vaccine vesicle, 159 Areolar tissue, infiltration of, in erysipelas, 333 Arsenic, In cerebro-spinal men- ingitis, 313 in glanders in the horse, 193 in hooping-cough, 55 1069 Arsenic — in intermittent fever, 363 in muscular rheumatism, 575 in purpura, 468 in pysmia, 350 in relapsing fever, 280 in rheumatoid arthritis, 557 Arsenic, value of, in treatment of chorea, 712 of neuralgia, 1043 Arteries, atheroma of, in gene- ral paralysis, 014 a cause of cerebral hemor- rhage, 907 Arteries, morbid anatomy of, in pyaemia, 835 supposed paralvsis of, in cho- lera, 413 Arthritis, rheumatoid, see Rheu- matoid arthritis. [Arthropathy of ataxic pa- tients, 987] Articular rheumatism, see Rheumatism. Articulation, impairment of, in general paralysis of the in- sane, 605 in abscess of the brain, 938 in softening of the brain, 860 see also Speech, changes in. Articulations, see Joints. Arytenoid cartilages, gouty de- posits in, !j'2~) Ascarides, a cause of roseola, 106 Ascarides lumbricoides, vomit- ing of, in cerebro-spinal men- ingitis, 301 Ascites, as the result of syphi- litic disease of the liver, 434 Ash-leaves in chronic gout, 545 Asphyxia, in diphtheria, 67 treatment of, 83 [Assafcetida in hooping-cough, 53] in rheumatoid arthritis, 5.j7 enemata, in typhoid fever, 248 Asthenia, in diphtheria, 66, 03 Asthma, a species of, dependent on gout, 515 spasmodic, causes of, 1056 Astringents, in cholera, 416 [Athetosis, article on, 731] Atrophy, muscular, diagnosis of, from muscular rheuma- tism, 575 Atrophy, muscular, progres- sive, 786 Atrophy, muscular, from in- jury to nerve-trunks, 10.50 from essential paralysis, 1006 from lead palsy, 790 Atrophy, of the spinal cord, 1015 found after death from para- lysis agitans, 7:37 from wasting palsy, 7D1, 793 Atropia, external application of, in gout, 540 to rheumatic joints, 573 subcutaneous injection of, in neuralgia, 1045 Auditory nerve, irritation of, a cause of vertigo, 004 Aura epileptica, 753, 770 1070 INDEX OF VOL. I. BADEN-BADEN waters, pres- ence of lithia iu, 544 use of, in gout, 547 Bael fruit, in scorbutic dysen- tery, 383 Bandaging of the head, in chronic hydrocephalus, 839 Barberry iu intermittent fever, 203 BarSges waters, in muscular rheumatism, 575 Barometric pressure, influence of, on spread of cholera, 387 Bath waters, in gout, 547 Baths, in rickets, 495 in rheumatoid arthritis, 558 cold, after measles, IIG hip, in chronic dysentery, 383 hot air, in gout, 540, 545 in hydrophobia, 200 in acute rheumatism, 570 hydrochloric acid, in rickets, 495 mercury, for syphilis, 438 salt, in rickets, -i'.io Turkish, in chronic gout, 545 in gonorrhceal rheumatism, 579 vapor, in gout, 540, 545 warm, in cerebro-spinal men- ingitis, 313 in cholera, 418 in mild dysentery, SSO in parotitis, 123 in jjya'mia, 350 to prevent profuse sweating, 123 at the end of smallpox, 145 Baths, in treatment of catalepsy, 058 of chorea, 716 iu acute mania, 620 in paralysis agitans, 730 Bathing after measles, 116 Battlcy's solution in hooping- cough, 55 Bcd-ciothes, kicking off, in rickets, 476 Bedsores, in cerebro-spinal meningitis, 303 in cholera, 404 in typhus, 257 tendency to, in myelitis, 901 [Beef-tea without filtration, 114, 470] Belladonna, in cerebro-spinal meningitis, 313 external application of, in gout, £40 in muscular rheumatism, 575 to rheumatic joints, 572 pericarditis, 573 in rheumatoid arthritis, 558 internal administration of, in gouty affections of the bladder, 547 in hooping-cough, 54 supposed preventive of scarlet fever, 95 in treatment of myelitis, 964 of neuralgia, i045 [Bell's disease, 508] palsy, 1050 Benghazi, epidemic of plague at, 318, 319 Benign smallpox, 129, 133 Bibecrine, sulphate of, in inter- mittent fever, 303 Bile, absence of, in stools of tj'- phoid, 207 alterations of, in typhoid fever, 215 condition of, in typhoid fever, 315 in blood in pysemia, 346 in stools of rickets, 476 in urine in pyaemia, 346 in relapsing fever, 273 in scarlet fever, 88 vomiting of, in cerebro-spinal meningitis, 801 in dengue, 100 in relapsing fever, 273 in remittent fever, 367 in yellow fever, 285 Bilious fever, see Remittent fever, 305 Bismuth, in typhoid fever, 247 Bismuth, trisnitrate of, iu diar- rhoea in scui-vy, 438 Bites of rabid animals, treat- ment of, 200 Black bile, the, 623 Black death, see plague. Black measles, 107 Black pock, 131 Black vomit, 285 chemical analysis of, 289 microscopical examination of, 289 in relapsing fever, 373 Bladder, hemorrhage from, in purpura, 461 implicated in gout, treatment of, 546 inflammation of, in gout, 520 irritability or paralysis of, in dysentery, 70 irritability of the, in spinal irritation, 994 paralysis of, in myelitis, 960 in spinal meningitis, 95 Blebs in purpura, 400 * [Bleeding at the nose in tj-- phoid fever, 202] Bleeding, in treatment of acute mania, 619 of catalepsy, 656 of cerebral hemorrhage, 933 of infantile convulsions, 751 of meningeal hemorrhage, 843 of simple meningitis, 815 of sunstroke, 669 of tubercular meningitis, 835 [for yellow fever, 293] [Blending of types of fever, 380] Blindness, during erysipelas, 524 from syphilitic disease of the optic nerve, 435 iu hydrophobia, in wolves, 197 in keratitis of congenital syphilis, 443 in scurvy, 453 Blisters, in acute rheumatism, 573 in gout, 541 in intermittent fever, 360 In muscular rheumatism, 575 in rheumatic pericarditis, 571 in rheumatoid arthritis, 557 in treatment of chrome me- ningitis, 817 of hysterical paralysis, 646 Blisters, in treatment — of neuralgia, 1C46 of spinal irritation, 098 to epigastrium for vomiting iu cholera, 418 to the head in typhus, 268 uric acid in fluid of, iu gout, 523 Blood, abdominal conditions of the, relation of, to insanity, 611 eifusion of, in malignant mea- sles, 108 in purpura, 461 In scurvy, 452, 450 examination of, in diagnosis of gout, 520, 537 in stools in cholera, 405 in dysentery, mild, 375 acute, 376 malignant, 377, 378 in urine after scarlet fever, 91 in cerebro-spinal meningitis, 303 in diphtheria, 68 in intermittent fever, 358 iu malignant measles, 108, 111 smallpox, 131 in Pali plague, 318 in purpura, 461 iu pyaimia, 346 in remittent fever, 307 in the plague, 315 in yellow fever, 290 less alkalinity of, in gout, 534 loss of salts from, in cholera, 414 odor of, in yellow fever, 288 state of, in cerebro-spinal meningitis, 306 in cholera, 400, 405, 410 in diphtheria, 72, 73 in gout, 530 in influenza, 43 in intermittent fever, 358 in intervals between attacks of gout, 531 in purpura, 463, 464 in pysemia, 335 in relapsing fever, 279 in rheumatism, acute, 503 chronic, 563 sub-acute, 563 in rheumatoid arthritis, 553, 554 in rickets, 485 in scurvy, 455 iu the plague, 317 in typhoid fever, 318 in typhus, 264 in variola maligna, 131 iu yellow fever, 23S uric acid in, in lead poison- ing, 530 Bloodletting, in dengue, 103 in diphtheria, 83 [for inflammation, 31] in influenza, 45 in intermittent fever, 356, 360 in smallpox, 141 in the plague, 317 in typhus, 268 general, in acute rheumatism, 507 in cerebro-spinal meningi- tis, 313 in cholera, 419 in choleraic diarrhoea, 431 INDEX OP VOL. I. 1071 Bloodletting-, general — in dysentery, 381 in erysipelas, 337 in gouorrhceal rheumatism, 579 in gout, 540 in purpura, 467 in relapsing fever, 280 in remittent fever, 309 in rickets, 495 local, in cerebro-spiual men- ingitis, 313 in cholera, 419 in dysentery, 381, 384 in gonorrhceal rheumatism, 579 in gout, 540 in muscular rheumatism, 575 in parotitis, 121 in rheumatic pericarditis, 571 in typhoid fever, 248, 249 Bloodvessels, degeneration of, in purpura, 403 ulceration into, In scurvy, 465 Blows on the head, a cause of abscess of the brain, 934 of cerebral hemorrhage, 904, 929 of chronic hydrocephalus, 836 of congestion of the brain, 848 of meningitis, 814 Boils, in cholera, 404 in chronic dysentery, 377 in dengue, 103 in farcy, 184 in smallpox, 133 treatment of, 143 Bones, aifections of, in scurvy, 453, 456 arrest of growth of, in rickets, 493 chemical constitution of, in rickets, 491 condition of the, in chronic hydrocephalus, 837 dise'ase of, a cause of pyaemia, 330 eburnation of articular ends of, in rheumatoid arthritis, 553 extremities of long, enlarge- ment of, in rickets, 478, 481, 488 gouty deposits in, 525 microscopic characteristics of, in rickets, 4SS morbid anatomy of, in py- emia, 334 in rickets, 4.37 necrosis of, in pyaemia, 334 occasionally involved in ery- sipelas, 336 pains in, in rickets, 476, 48^ in syphilis, 425 suppuration of, a frequent cause of pyaemia, 367 tubercle of, diagnosis of, from rickets, 486 Borax in diphtheria, 79 Bowels, state of the, in mania, 597 in simple meningitis, 809 in tubercular meningitis, 821, 828 Bowels — I set', also. Diarrhoea, Constipa- tion. Brain, abscess of the, article on, 934 diagnosis, 940 etiology, 934 morbid anatomy, 936 pathology, 938 symptoms, 937 treatment, 941 Brain, adventitious products in the, article on, 883 diagnosis, 886 morbid anatomy, 889 prognosis, 901 symptoms, 883 treatment, 901 Brain, affection of, in gout, 518 cancer of the, 891 chronic softening of, predis- poses to cereljral hemor- rhage, 908 compression of, by hemor- rhage, 920 compression of, by osseous nodes in teriiary syphilis, 433 concussion of, causing ab- scess, 934 condition of, in hydrophobia, 199 in typhus, 365 in yellow fever, 291 degeneration of, in chronic alcoholism, 684 in insanity, 616 hemorrhage into, in purpura, 461 membranes of, state of, in cerebro-spinal meningitis, 305 morbid anatomy of, in cho- lera, 412 in pyaemia, 334 in scurvy, 456 softening of, in pyemia, 334 after typhus, 259 syphilitic deposits in, 435 Brain, congestion of the, article on, 844 causes, 848 diagnosis, 848 morbid anatomy, 851 prognosis, 853 symptoms, 845 treatment, 853 Brain fever, essential, in chil- dren, 832, 847, 849 Brain, hypertrophy of, 888, 899 inflammatory softening of, secondary to abscess, 939 malformation of, in idiocy, 603 melanosis of, 891 oedema of, in tubercular men- ingitis, 833 syphilitic tumors in, 890 tubercular masses in, 889 tumors of, a cause of hem- orrhage, 904 wounds of, causing abscess, 934 Brain, softening of the, article on, 856 definition, 856 causes of, &57 diagnosis, 880 Brain, softening of the — morbid anatomy, 873 pathology, 8C5 prognosis, SS3 symptoms of the acute form, 857 of the chronic form, 864 treatment, 883 Broalt-bone fever, see Dengue. Breath, coldness of, in cholera, 400 odor of, in pyaemia, 345 peculiar smell of, in alcohol- ism, 077 Breathing, difficulty of, see Dyspncea. Bnght's disease, predisposes to cerebral hemorrhage, 905 to cerebral softening, 935 Bromide of potassium, as an antaphrodisiac, 766 value of, in treatment of acute mania, 622 of chronic alcoholism, 685 of delirium tremens, 688 of epilepsy, 780 of hysteria, 645 of infantile convulsions, 750 of muscular cramps, 1060 of tumor of the brain, 9U3 Bromide of sodium, in epilepsy, 781 Bromism, symptoms of, 781 Bronchi, dilatation of, in hoop- ing-cough, 53 implication of, in diphtheria, 67 morbid anatomy of, in diph- theria, 75 in pyaamia, 333 plugging of, in hooping- cough, 51 smallpox eruption in, 131 [Bronchial cough in typhoid fever, 203] spasm, 1050 Bronchitis, a predisposing cause of measles, 106 a sequela of measles. 111 concealing the commence- ment of rickets, 476 in cerebro-spinal meningitis, 303 in chronic glanders, 190 in gout, 519 in hoopinir-cough, 51 treatment of, 56 in influenza, 43 in relapsing fever, 373 in rickets, 483 in scarlet fever, 90 in smallpox, 143 in typhus, 258 treatment of, 368 Broncho-pneumonia, a sequela of measles, 113 in hooping-cough, 50 in relapsing fever, ~73 treatment of, 56 Brow-ague, 1029 Bubos, in chronic farcy, 199 in Pali plague, 318 in plague, 314 in relapsing fever, 379 in scarlet fever, 90, 95 in syphilis, 424 morbid anatomy of, in plague, 317 107i INDEX OF VOL. I. Bubos — not pathognomonic of plague, 315 Bubo, parotid, a seq^uela of ty- plius, 2C3, 265 diagnosis of, from parotitis, 120 Buffy coat in acute rheumatism, 5B2 [Bulbo-nuclear paralysis, 1010] BuUse, in congenital syphilis, «1 In erysipelas, 324 in glanders, 189 in smallpox eruption, 130 Burial, ante-mortem, 655 Bursse, effusion into, in gout, 514 gouty deposits in, 516 syphilitic inflammation of, 433 Buxton waters in gout, 547 C-^ECUM, perforation of, in typhoid fever, 311 Calcareous deposit in urine in rickets, 477 Calcareous masses in the brain, 896 Calculi, urinary, common in rickety children, 484 diagnosis of, from gouty in- flammation of kidney, 530 in gouty diathesis, 520 Calomel, in cerebro-spinal men- ingitis, 313 in cholera, 415 in choleraic diarrhoea, 430, 431 In dengue, 104 in diphtheria, 83 topical use of, in diphtheria, 81 In gout, 540 in influenza, 45 in intermittent fever, 360 in purpura, 467 in remittent fever, 369 in acute rheumatism, 568 in smallpox, 141 In syphilis, 438 in typhoid fever, 347 in yellow fever, 393 vapor bath for syphilis, 438 Calvaria, affections of, in ter- tiary syphilis, 433 Camel, traditional origin of smallpox from, 138 Camphor, in cholera, 417 in scarlet fever, 96 in typhus, 268 Cancer, simulation of, by syphi- litic nodes, 433 by syphilitic tumors of muscles, 433, 440 Cancer of the brain, 891 of the spinal cord, 1016 Cancrum oris, a rare sequela of scarlet fever, 93 Capillaries, condition of, in cholera, 410, 413 of skin, degeneration of, in purpura, 464, 465, 466 Capillaries in the brain, de- generation in the walls of, a cause of cerebral soften- ing, 871 Capillaries in the brain — aneurismal dilatation of, 851, 877 obstruction of, a cause of cerebral softening, 870 Capsular ligaments of joints, thickening of, in rheumatoid arthritis, 553 Carbolic acid, glycerine of, in diphtheria, 80 Carbonic acid, in the air of marshes, 353 Carbuncles, in cerebro-spinal meningitis, 304 in the plague, 314, 315 not pathognomonic of plague, 315 Carburetted hydrogen in the air of marshes, 353 Cardiac disease, connection of, with chorea, 699, 705 Cardialgia, treatment of, by arsenic, 1043 Caries of bones in scurvy, 453 Caries of the vertebral column, 1017 Carlsbad waters, in gout, 547 danger of, in rheumatoid arthritis, 557 presence of llthia in, 544 Carotid, internal, hemorrhage from, a rare sequela of scar- let fever, 90 Carpus, deposit in joints of, in gout, 525 Cartilage, excess of water in, in rickets, 491 Cartilage cells, changes of, in rickets, 488 Cartilages, articular, absorp- tion of, in rheumatoid arth- ritis, 553 deposit of urate of soda into, in gout, 534 destruction of, in gonorrhoea] rheumatism, 577 in pyaemia, 335 opacity of, after rheumatism, 564 inter-articular, destruction of, in rheumatoid arthritis, 553 Cascarilla, its use in relieving thirst in parotitis, 121 in measles, 114 Castor-oil, in dysentery, 380 Casts, of gastric tubuli, in vomit in scarlet fever, 94 of tubuli uriniferi, in urine, in cerebro-spinal menin- gitis, 303 in cholera, 401 in diphtheria, 68 in gout, 533 in intermittent fever, 358 in purpura, 463 in scarlet fever, 91 in yellow fever, 390 Catalepsy, article on, 653 definition, 653 description, 652 causes, 654 treatment, 658 Catalepsy, connection of, with epilepsy, 654 with hysteria, 657 Catarrh, diagnosis of, from diphtheria, 70 earliest symptom of hooping- cough, 49 Catarrh, liability to, after in- fluenza, 41 in varicella, 136 occasional absence of, in measles, 107 Catarrhal fever, diagnosis of, from influenza, 44 Catechu, in chronic dysentery, 383 in typhoid, 248 Causes of disease considered generally, 21 predisposing, 31 exciting, 33 Causes of alcoholism, 671 of catalepsy, 654 of cerebritis, 855 of cholera, 386 of chorea, 709 of congestion of the brain, 848 of dengue, 103 of diphtheria, 61 of dysentery, 373 of epidemic cerebro-spinal meningitis, 308 of epilepsy, 763 of erysipelas, 331 of glanders in the horse, 184 in man, 188 of gonorrhoeal rheumatism, 576 of gout, 536, 534 of hooping-cough, 48 of hypochondriasis, 638 of hysteria, 631 of influenza, 34 of insanity, 587 of intermittent fever, 356 of hydrophobia in animals, 195 in man, 197 of locomotor ataxy, 989 of simple meningitis, 814 of tubercular meningitis, 817 of metallic tremor, 801, 807 of miliaria, 123 of mumps, 130 of muscular anaesthesia, 784 of myelitis, 963 of neuralgia, 1027 of paralysis agitans, 735 of purpura, 463 of pyasmia, 338 of remittent fever, 366 of rheumatism, articular, 664 muscular, 574 of rheumatoid arthritis, 554 of rickets, 473 of roseola, 105 of scarlatina, 84 of scarlatinal dropsy, 93 of scurvy, 445 of smallpox, 188, 139 of cerebral softening, 857 of somnambulism, 658 of spinal congestion, 908 of spinal irritation, 997 of spinal meningitis, 955 of sudamina, 123 of sunstroke, 664 of tetanus, 977 of torticollis, 1061 of typhoid fever, 335 of typhus fever, 252 of varicella, 125 of vertigo, 691 of wasting palsy, 786 INDEX OF VOL. I. 1073 Causes — of writer's cramp, 734 of yellow fever, '281 Celibacy, a predisposing cause of insanity, 588 of hysteria, 633 Cellular tissue, gangrene of, in erysipelas, 826 morbid anatomy of, in pyse- mia, 335 nodes of, in tertiary syphilis, 433 Cellulitis, diffuse, diagnosis of, from erysipelas, 835 Cephalodynia, 574 Cerebellum, symptoms of hem- orrhage into, 915 of tumor in, 8o7, 900 Cerebral fever (of Trousseau') , 808 Cerebral hemorrhage, and apo- plexy, article on, G03 deflnilion, 903 morbid anatomy, 903 etiology and pathology, 905 predisposing constitutional state, 905 localization of lesions, 910 the apoplectic condition, 916 diagnosis, general, 933 special, 937 prognosis, 931 treatment, 933 Cercbritis, article on, 854 causes, 855 symptoms, 855 diagnosis, 855 pathology, 855 prognosis and treatment, 856 Cerebro-spinal meningitis, epi- demic, article on, 396 bibliography, 314 complications, 303 definition, 29o description of disease, 207 diagnosis, 304 duration, 303 etiology, 308 geographical distribution, 306 history, 806 mode of death, 804 morbid anatomy, 305 nature, 311 prognosis, 305 synonyms, 396 terminations, 304 treatment, 313 Cerebro spinal meningitis, epi- demic, fulminant, 393 purpuric, 298 simple, 397 Cerebrum, see Brain. Ccrvico - brachial neuralgia, 1033 Cervico - occipital neuralgia, 1033 Cerviodynia, 574 Cesspools, gases from, a cause of cholera, 388 Chalk, in typhoid fever, £i7, 348 Chalk-stones, in chronic gout, 516, 638 analysis of, 517 influence of, in prognosis, HbS, treatment of, 545 Chancre, hard, description of, 434 VOL. I. — 68 Chancre — soft and hard, relation, 434 soft, the result of syphilitic inoculation on a syphilized person, 427 Change of scene, importance of, in treatment of insanity, 618 Charcoal in sloughing wounds, 349 [Charcot's account of pa- thology of paralysis agitans, 738] Chemosis in pysemia, 384 Chest, paralysis of the muscles of, from hemorrhage into corpus striatum, 913 in wasting palsy, 789 Chicken-pox, see Varicella. Child-bearing, too rapid, a cause of rheumatoid arth- ritis, 554 Chloral, in delirium tremens, 688 in mania, 631 Chloric ether in parotitis, 133 [Chloride of iron in cerebro- spinal fever, 313] Chlorides, diminution of, in urine of acute rheumatism, 583 erysipelas, 324 intermittent fever, 358 scarlet fever, 87, 91 typhoid fever, 208 typhus, 309 Chlorinated soda, in diphthe- ria, 80 Chlorodyne in yellow fever, 204 Chloroform, in treatment of chorea, 715 of infantile convulsions, 669, 751 of delirium tremens, CSS of epilepsy, 780 of sunstrolve, 639 of tetanus, 979 Chloroform, inhalation of, for cramps, in cholera, 418 for hiccup in cholera, 419 in iniluenza, 47 in hooping-eough, 55 in remittent fever, 370 internally, in yellow fever, 294 in typhus, 268 [tolerance of, in hydropho- bia, 201] [Chlorosis, article on, 423 causation of, 409 history, 468 pathology, 470 prognosis, 470 symptoms, 408 treatment, 470] Chlorosis, diagnosis of, from scurvy, 454 [Choked disk with brain tu- mors, 884] Cholera, epidemic, article on, 396 cryptogamic theories of, 397 deiinition, 384 departure of epidemics of, 391 diagnosis of, 409 difiusion of, 893 duration of, 408 etiology, 386 Cholera, epidemic — history, 385 limitation of areas of, 891 mode of invasion of localities by, 891 morbid anatomy, 410 mortality of, 408 mortality to populations from, 393 pathology during life, 413 portability of poison of, 395 prognosis, 415 prophylaxis, 431 symptoms, 398 synonyms, 384 treatment, 415 limitation of areas of, 391 resemblance of, to enteric fever, 331 spasmodic, 407 [Cholera, since 1866, 385 antispasmodic treatment of, 416 contagion of, disputed, 396 pathology of, 411 , 414 venesection in, 421] Cholera fever, 407 Cholera pills, 417 Cholera typhoid, 403 Choleraic diarrhoea, 407 treatment of, 430 Cholerine, 407 [Cholestcro3mia a cause of ver- tigo, 003, 0'.;5] Chondrine, absence of, in rickety bones, 4i>l Chorea, article on, 696 symptoms, COS exceptional forms, 704 patliology, 700 causes, 709 prognosis, 711 treatment, 711 Chorea in acute rheumatism, 660 [Chorea from subacute rheu- matic meningitis, 707] Chorea senilis, synonym of pa- ralysis agitans, 718 Choreic mania, 590 Choroid membrane of the eye, tubercle in the, 824 Choroid plexus, abnormal for- mations in the, 844 Chronic cerebral softening, 864 Chronic hydrocephalus, article on, 836 Chronic meningitis, 816 Chronic pycemia, 343 Chronic rheumatic arthritis, see Rheumatoid arthritis. Cicatrix after vaccination, 159 in prognosis of smallpox, 137 the sign of effleieney, 108 Cicatrization after cerebral hemorrhage, 904 Cicatrization of ulcers of in- testine in typhoid, 215 Cicuta virosa, poisoning by, re- semblance to typhoid fever, 344 Cider as a cause of gout, 538 useless as an anti-scorbutic, 459 Ciliary muscles, paralysis of, lu diphtheria, 74 Cinchona bark in erysipelas, 328 in chronic gout, 543 1074 INDEX OF VOL. I. Cinchona bark — in purpura, 468 in acute rheumatism, 569 in riclcets, 495 Circulation, cerebral, peculiari- ties of the, 908 Cirrhosis, of the liver, con- nection of, with alcoholism, 677 Citric acid, influence of, on scurvy, 456 Civilization, high, a cause of insanity, 5S7 Clairvoyance, 660 Classification of diseases, "3 Classification of diseases gener- ally, 581 of nervous diseases, 583 of convulsions, 737 of the varieties of insanity, 585, 603 Clavicles, deformity of, in rickets, 479 a frequent seat of nodes in syphilis, 433 Clavus hystericus, 1031 Claw-shaped hand, the, of wasting palsy, 788 Climacteric insanity, 593 Climate, change of, a cause of increased liability to small- pox, 156 a predisposing cause of re- currence in smallpox, 139 essential in chronic dysen- tery, 383 Climate, in relation to hysteria, C33 to insanity, 587 predisposing to tetanus, 978 influence of, as a cause of cercbro -spinal meningi- tis, 308 cholera, 388 diphtheria, 63 dysentery, 373 gout, 520 rheumatism, S65 typhus fever, 253 yellow fever, 284 Clitorldectomy, In epileptics 767, 783 Clots in the brain, changes in, 904 size of, 903 in heart during death from diphtheria, 68, 74, 76 from yellow fever, 291 In small arteries in pyaemia, 336 In veins in pyaemia, 335 disintegration of, 335, 340 suppuration of, 335, 340, 341 Clothes, disinfection of, after cholera, 433 dissemination of cerebro- spinal meningitis by, 309 of cholera by, 394, 395 of scarlet fever by, 84 of smallpox by, 139 of typhus fever by, 2~A of yellow fever by, 2S2 Clothing after acute rheuma- tism, 573 in muscular rheumatism, 575 in rheumatoid arthritis, 558 in rickets, 495 Coagulation of the blood im- perfect in cholera, 406, '110 in malignant smallpox, 131 in purpura, 463 in pyoemia, 335 in typhus, 264 in yellow fever, 288 Cod-liver oil, after measles, 116 in rheumatoid arthritis, 557 in rickets, 496 in smallpox, 143 in treatment of chronic alco- holism, 686 of chorea, 717 of hypochondriasis, 629 of neuralgia, 1043 of spinal irritation, 993 Coffee in scarlet fever, 96 In typhus, £68 supposed prophylactic power of, for gout, 549 Colchieum, in dengue, 104 in acute gout, 539, 540, 541 chronic gout, 543 mode of action of, in gout, 539 in acute rheumatism, 568 [in gouty rheumatism, 568] in muscular rheumatism, 575 rheumatic pains in influenza, 47 in rheumatoid arthritis, 556 poisoning by, resemblance of, to typhoid fever, 343 Cold, a cause of dysentery, 374, 375 of erysipelas, 333 of gonorrhoeal rheumatism, 576 of intermittent fevers, 356 of muscular rheumatism, 575 of rheumatism, 559, 505 of rheumatoid arthritis, 551, 554 of rickets, 473 of scarlatinal dropsy, 93 of scurvy, 450 Cold affusion in influenza, 45 in remittent fovcr, 369 in scarlet fever, 96 danger of, in erysipelas, 328 influence of, on diphtheria, 63 in remittent fever, 369 [Cold baths in typhoid fever, 250] Cold exposure to, a cause of congestion of the brain, 818 of facial palsy, 1051 of muscular anaesthesia, 784 of neuralgia, 1033 of sciatica, 1036 of tetanus, 977 of torticollis, 1061 of wasting palsy, 787, 790 Cold, external application of, in epilepsy, 782 in mania, 030 in meningitis, 815 in sunstroke, 669 Cold water, immersion in, for hydrophobia, 200 Collapse, a cause of death in rheumatic pericarditis, 550 in cerebro-spinal meningitis, 398 in malignant scarlet fever. Collapse — from perforation in typhoid fever, 208 stage of, in cholera, 400 pathology of, 413 treatment of, 417 Collapse, fatal, in mania, 621 stage of, in meningitis, 810 sudden, in delirium tremens, 080 Collodion in erysipelas, 328 Colloid corpuscles in the brain in insanity, 015 Colon, morbid anatomy of, in cholera, 411 Coma, from acute alcoholism 673 om 920 from cerebral congestion, 846 from simple meningitis, 810 from tubercular meningitis, 833 from sunstroke, 667 from softening of the brain, 859 from uraemia, 930 Coma, in ccrcbro-spinal men- ingitis, 298, 299, 301 in cholera, 400, 401, 403 in erysipelas, 337 in glanders, 189 in hydrophobia, 199 in malignant measles, 108 in the plague. 315 in pyaemia, 344, 347 in relapsing fever, 380 in remittent fever, 368 in scarlet fever, 85, 89, 93 in typhoid fever, 303 in typhus, 259 in yellow fever, 285, 295 uraemic, in cholera, 403 Coma- vigil in typhus, 259 Compound inflammation cor. puscles of Gluge, 807, 876 Compression of the brain by hemorrhage, 920 of the spinal cord, 1017 Concretions In the brain, 896 Concussion, of the brain, a cause of abscess, 934 of the spinal cord, 1016 Condylomata, syphilitic, 434, 430, 441 Condy's fluid in diphtheria, 80 Confluent smallpox, 123, 130 Congenital malformations, of the brain, 603 of the meninges, 844 of the spinal cord, 1018 Congenital syphilis, see Syphilis. Congestion of the brain, article on, 844 of the spinal cord, 965 Congestive apoplony, 8i3 Conium, in hooping-cough,. 54 in influenza, 46 in rickets, 495 application of, to rheumatic joints, 572 Conjunctiva, pustules on, in smallpox, 134 ConjunctivEe, injection of, in dengue, 99 in diphtheria, 65 in influenza, 41 in measles, 1C7, 110 in typhus fever, 2C0, 259 INDEX OF VOL. I. Conjunctivas — hemorrhage under, in malig- nant smallpox, 132, 1:J7 hemorrhage under, in pur- pura, 461 Conjunctivitis after smallpox, 135 treatment of. Hi Consanguinity a cause of dis- ease, see Hereditary predis- position. Consciousness, double, 659 Consequences, of epilepsy, 776 of sunstroke, 070 of convulsions, 744 Constipation, elTect on the tem- perature of fevers, 1:31 Constipation, in cerebro-spinal meningitis, 298, 301 in dengue, 100 in diphtheritic paralysis, 70 treatment of, 82 in glanders, 189 in gout, 515, 519 in acute gout, 513 in measles, 107 in meningitis, 809 In parotitis, 118 in the plague, 519 in purpura, 4G2 in acute rheumatism, 559 in rickets, 476 treatment of, 495 in roseola, 105 in scarlet fever, 87 in scurvy, 451, 453 in typhus, 258 in yellow fever, 258 Constitutional syphilis, see Syphilis. Contagion, in cerebro-spinal meningitis, 309 of cholera, 394 in diphtheria, 63 in erysipelas, 322 of glanders among horses, &c., 185 among men, 188 in hooping-cough, 48 in hydrophobia, 195 in influenza, 87 in parotitis, 120 in the plague, 316, 320 in pyaemia, 389, 343 in relapsing fever, 274 [of relapsing fever ques- tioned, 269] In scarlet fever, 84 in smallpox, 138 in syphilis, 429 through fostus, 429 imperfect effects of, on syphi- lis, 428 in typhoid fever, 233, 238 in typhus fever, 253 in varicella, 135 in yellow fever, 281, 295 Convulsionnaires, 647 Convulsions, article on, 737 infantile, 738 symptoms, 740 sequelse, 744 causes, 745 prognosis, 749 treatment, 749 occurring in adults, 732 unilateral, 752 causes, 754 general or bilateral, 7.j8 Convulsions — treatment, 761 Convulsions, from abscess of the brain, 938 from congestion of the brain, 846, 849 ' from cerebritis, 855 from meningeal hemorrhage, 842 from simple meningitis, 809 from tubercular menin'^itis, 820, 823 from chronic hydrocephalus, 837, 838 from opium poisoning, 929 from softening of the brain, 863 ' from sunstroke, 667 from tumors of the brain, 746, 885 Convulsions, in diphtheria, 05 in hooping-cough, 51 treatment of, 56 in hydrophobia, 199 in measles, 106, 111 treatment of, 115 in the plague, 816 in pyemia, 342, 347 in riclcets, 483 in scarlet fever, 86, 89, 95 in smallpox, 130, 132 in typhus, almost always ursemic, 259 in yellow fever, 292 [puerperal, 761] Convulsions, infantile, diagno- sis of, from tubercular meningitis, 745 reflex, diagnosis of, from epi- lepsy, 778 value of, in diagnosis of cere- bral hemorrhage, 927 influence of, on prognosis of sunstroke, 668 Co-ordination, muscular, courd^c of the conductors of, in spinal cord, 945 loss of, in alcoholism, 670, 678 in locomotor ataxy, 984 in general paralysis of the in- sane, 606 in writer's cramp, 735 from section of tlie posterior columns of the cord, 942 from section of the lateral columns, 943 Copper, sulphate of, 315 in dysentery, 8S3 in hooping-cough, 55 in typhoid fever, 248 salts of, local use of, in diph- theria, 80 Cord round the body, sensation of, in myelitis, 959 Cornea, interstitial inflamma- tion of, in hereditary syphi- lis, 429, 430, 441, 443 opacity of, in syphilitic kera- titis, 443 ulceration of, in cerebro- spinal meningitis, 393,300 in cholera, 403 in scarlet fever, 93 treatment of, 98 in smallpox, 133, 134 treatment of, 144 Corpora amylacea in the brain, 844 1075 Corpus striatum, the, a fre- quent seat of cerebral hemorrhage, 903 of cerebral softening, 972 arrangement of arteries in, 909 ' symptoms of hemorrhage into, 911 Corymbose smallpox, 128, 131 Coryza, in diphtheria, 65 an early symptom of hoop- ing-cougli, 49 in measles, 107, 110 occasional absence of, 110 in scarlet fever, 85, 87, 89, 95 treatment of, 96 as a sequel of scarlet fever, 90 Cough, in diphtheria, 67 in glandorF3, 189, 190 in hooping-cough, 49, 51, 52 in influenza, 43 in laryngitis complicating measles, 111 in measles, 107, 111 in pyaemia, 345 in typhoid fever, 204 in typhus, 258 in rheumatoid arthritis, 5.53 in smallpox, 131 Cough, spasmodic, a symptom of spinal irritation, 994 Counter-irritation in epilepsy, 781 in insanity, 620 in neuralgia, 1046 in spinal irritation, 998 [in tetanus, 980] Coup de soleil, 661 Course of disease considered generally, 25 Cowpox, see Vaccination. Cowpox, accelerated, 160 retarded, 100 spurious, 161 not prophylactic of chicken- pox, 124 Cramp, writer's, 732 Cramps, in cholera, 399 treatment of, 410, 418 in yellow fever, 335 in choleraic diarrhcea, 407 in the legs in gout, 513, 515, 518 Cramps, muscular, in the ex- tremities, causes of, 1059 treatment of, 1060 in epilepsy, 774 in paralysis agitans, 721 Cranial bones, softness of, in rickets, 477 Cranial nerves, paralysis of, from syphilitic neuromata, 435, 440 Creasote, in yellow fever, 294 inhalations for chronic laryn- gitis after measles, 116 Crescentic form of syphilitic ulceration, 432 Crescents in rash of measles, 108 of smallpox, 129 Cretinism, 604, 605 Crick in the neck, 575 Crimea, scurvy in tlie, 447 Cross-paralysis, 913, 914 Croton oil, externally, in rhc:i- matoid artiiritis, 5.)7 1076 i INDEX OF VOL. I. Croup, association of, with ty- phoid fLTcr, 22J: formerly confounded with diphtheria, 60, 61 Crowding In houses, a cause of eerebro-spinal meningitis, 313 of the plague, 318 of typhus fever, 253 Crural neuralgia, 1035 Crus cerebri, symptoms of hem- orrhage Into, 913 Cruveilhler's atrophy, 786 Cry, the peculiar, of epilepsy, 771 of meningitis, 809, 823 Cryptogamic theories of origin of cholera, 897 Cubic space required In small- pox, 140 Cultivation, eilect of, on ma- laria, 353 [Curara, used in hydrophobia, 200] Curvature of the spine in rickets, 478, 491 Cutaneous anaesthesia, 1065 Cutis anserina, occasionally present In scarlet fever, 85 in typhoid fever, 318 Cutis, inflammation of. In ery- sipelas, 336 Cystlcercl in the brain, 896 in the spinal cord, 1016 Cystic neuroma, 1033 Cystitis, chronic, in gout, 530 treatment of, 547 Cysts In the brain, 897 DAMP as a cause of disease, see Moisture. Dance of St. Guy, 696 Dancing mania, 047, 701 Dandy fever, see Den'^ue. Deafness, complicating facial neuralgia, 1037 in cerebrb-spinal meningitis, 398, 300 during eiysipelas, 324 in hereditary syphilis, 439 in locomotor ataxy, 985 in measles, 107, 111 after scarlet fever, 90 In scurvy, 453 in typhus fever, 255, 359 from syphilitic disease of au- ditory nerve, 435 in vertigo, 690 Death, mode of, in cerebro- spinal meningitis, 304 In cholera, 401, 402, 403, 401 in dengue, 100 in diphtheria, 67, 08, 77 in dysentery, 376, 377 in erysipelas, 324 In glanders, 190 In gout, 537, 538 in hooping-cough, 50 In hydrophobia, 199 In influenza, 43 in intermittent fever, 359 In measles, 108 in plague, 315 in purpura, 466 in pyajmia, 344 in relapsing fever, 278, 379, 280 in remittent fever, 306 Death— In rheumatism, 567 in rickets, 4S2 In scarlet fever, 89, 90 in smallpox, 130, 132 In scurvy, 453, 453 in typhoid, 301, 340 in typhus, 246 in yellow fever, 285 Death, apparent, in eatalapsy, 655 rapid, from cerebral hemor- rhage, 935 causes of, in convulsions, 750 in delirium tremens, 680 in dementia, 601 in the insane, 618 in acute mania, 597 in melancholia, 595 Debility, general, predisposes to neuralgia, 1037 Debility of parents a cause of rickets, 473 Decomposition, rapidity of, in scurvy, 456 Definition of disease, 17 Deformities, due to essential paralysis of children, 1000 to paralysis agitans, 721 to wasting palsy, 788 from gout, .516 in chronic rheumatoid arth- ritis, 559 Degeneration, albumenoid, see Amyloid degeneration. Deglutition, difficulty of, in chorea, 698 In spinal meningitis, 954 in tetanus, 971 Delirium, in cerebro-splnal meningitis, 297, 398, 299, 301 in cholera, urffimic, 403 typhoid, 403 in diphtheria, 66, 67 in dysentery, acute, 376 in erysipelas, 333, 324, 326 in glanders, 189 in gout, 518 in hydrophobia, 199 in influenza, 41, 42 in measles, 107, 108 in parotitis, 119 in the plague, 315 in pyemia, 344, 347 in relapsing fever, 277 in remittent fever, 307, 368 In rheumatic pericarditis,. 550 in scarlet fever, 85, 88, 89, 95 in smallpox, 130, 137 treatment of, 141 in typhoid fever, 203, 204, 305, 231 In typhus, 359 treatment of, 267 In yellow fever, 385, 293, 294 Delirium, character of the, in congestion of the brain, 847 in alcoholism, 679 in softening of the brain, 864 in meningitis, 809 Delirium tremens, 670 symptoms, 678 diagnosis, 681 prognosis, 683 treatment, 686 diagnosis of, from acute mania, 607 Delirium tremens, diagnosis — from meninfrltlB, 81.5 Delirium tremens, at invasion of smallpox, 130 treatment of, 141 diagnosis of, from typhus, 263 resemblance of, to delirium in cerebro-splnal meningi- tis, 397 [Delirium tremens in surgical cases, 679 inflammatory cases of, 680 warm bath in treatment of, 639] Delusion, definition of, 593 character of, in acute mania, 596 in melancholia, 593, 594 in monomania, 599 hints for the detection of, 607 Dementia, 600 senile, 601 diagnosis of, 594, 609 prognosis, 617 Dengue, article on, 98 definition, 98 diagnosis, 103 etiology, 103 history, 98 propagation, 103 symptoms, 79 synonyms, 98 treatment, 103 Dentition, predisposes to infan- tile convulsions, 746, 749 a cause of true epilepsy, 705, 766 a cause of roseola, 105 delay of, in rickets, 480 Desiccation, stage of, in small- pox, 129 Desquamation of cuticle, in dengue, 101 in gout, 513, 514, 536 after erythema, in stage of reaction in cholera, 695 in measles, 109 in parotitis, 119 over rheumatic joints, rare, .561 in scarlet fever, 88 after sudamina, 123 in typhoid fever, 218 in yellow fever, 285 Development, arrest of, in he- reditary syphilis, 443 Diabetes mellitus, causing rheumatoid arthritis, .554 occurring in gouty subjects, 520 Diagnosis of disease, considered generally, 26 Diaphoretics, in chronic gout, 545 in gout, 540 in gonorrhoeal rheumatism, 579 in muscular rheumatism, 575 in pycemia, 3.50 in typhoid fever, 247 Diaphragm, affection of, in scurvy, 453 muscular rheumatism in, 574 spasm of, In tetanus, 977 Diarrhoea, In eerebro-spinal meningitis, 298^ 301 in reactionary stage of cho- lera, treatment of, 418 INDEX OP VOL. I. DiarrhfEa — in stage of reaction of cho- lera, 403, 403 in diphtheria, 65, 08 in erysipelas, 333 in glanders, 189, 190 in gout, 515, 519 in influenza, 41, 43 tendency to, after interait- tent fever, 858 in measles, 107, 111 in parotitis, 119 in the plague, 315 in purpura, 403 in relapsing fever, 277, 379 in remittent fever, 367, 308 in rickets, 476, 483, 483 treatment of, 496 in scarlet fever, 87, 89, 90 in scurvy, 453 treatment of, 458 in smallpox, 133 treatment of, 143 in pyaemia, 344, 346 treatment of, 351 in typhoid fever, 303 treatment of, 348 in typhus, 357 treatment of, 268 Diarrhoaa, choleraic, 407 treatment of, 420 chronic, after cholera, 415 diagnosis of, from cholera, 409 as a predisposing cause of cholera, 390 a premonitory symptom of cholera, 399 prevalence of, before and during cholera epidemics, 391 Diarrhoea, hill, 396 Diarrhoea, a cause of infantile convulsions, 747, 753 see also Bowels, state of. Dicrotism of the pulse, in deli- rium tremens, 679 in epilepsy, 773 in typhus fever, 356 Diet, the necessary, in chronic alcoholism, 685 errors of, a cause of erysipe- las, 833 of roseola, 105 in cerebro-spinal meningitis, 313 in cholera, 418, 419 in choleraic diarrhoea, 420 in diphtheria, 78, 81 in dysentery, 383, 383 in epilepsy, 781 in gonorrhoeal rheumatism. 579 in gout, .548 in hooping-cough, 54 in influenza, 45 in intermittent fever, 363 in measles, 114 in meningitis, 816 in parotitis, 131 in the plague, 317 in purpura, 468 in pyaemia, 353 in relapsing fever, 280 in remittent fever, 370 in acute rheumatism , 573 in muscular rheumatism, 575 in rheumatoid arthritis, 550 in rickets, 495, 496 Diet- in scarlet fever, 95 in scurvy, 458 in smallpox, 141, 143 in syphilis, 438 in typhoid, 349 in typhus, 366, 268 Difl'usion of cholera, 393 Digitalis, in acute mania, 621 in delirium tremens, 087 in hemorrhage in typhoid fever, 249 in purpura, 468 in rheumatic pericarditis, 573 [in scarlet fever, 97] in uraemia after cholera, 419 'Digitorum nodii" of Heber- den, 553 Dilatation of the heart as a sequela of scarlet fever, 93 Diphtheria, article on, 57 definition, 57 diagnosis, 70 etiology, 61 history, 58 morbid anatomy, 74 name, .58 pathology, 73 prognosis, 77 symptoms, 65 synonyms, 57 therapeutics, 78 formerly conlounded with croup, 60 with erysipelas, 58 with scarlet fever, 86, 58, 61 mention of, by the ancients, 68 relation of, to typhoid fever, 333 a sequela of scarlet fever, 93 Diphtheria, nasal, an occa- sional complication of scarlet fever, 93 Diphtherite, 58 Diphtheritis of labia in measles, 113 Dirt, a predisposing cause of pyjemia, 344 of typhus fever, 253 Discrete smallpox, 128, 139 Diseases, classification of, 33 causes of, 31 course of, 35 definition of, 17 diagnosis of, 26 duration of, 35 functional, 19 history of, 31 names of, 17 signs of, 33 structural, 19 symptoms of, 23 terminations of, 26 Dislocation of joints in rheu- matoid arthritis, 551, 553 [Disseminated sclerosis, 1011] Diuresis, after scarlet fever, 91 Diuretics, in relapsing fever, 380 in kidney complications in typhus, 368 in muscular rheumatism, 575 in scarlatinal dropsy, 97 [in scarlet fever, 96] Division of nerves for cure of neuralgia, 1047 of neuroma, 1025 1077 Dog, hydrophobia in, 190, 197 Dorsodynia, 574 Dorso-intercostal neuraljria, 1034 '' ' Dorso-lumbar neuralgia, 1035 Double consciousness, 659 Double facial palsy, H.53 Douche, cold, in catalepsy, 658 in hysteria, 645 in insanity, 020 in sunstroke, 669 Drains, emanations from, a cause of tj'phoid fever, 241 Dress, relation of, to sunstroke, 667 Drinking, tendency to, in hys- teria, 639 Dropsy, scarlatinal, 91, 92, 97 Drought, a cause of typhoid fever, 238 Drunlcards, morning sickness of, 677 Drunkenness, phj'siology of, 671 diagnosis of, from apoplexy, 938 Duality of syphilitic poison, question of, i'S.i Duodenum, morbid anatomy of, in yellow fever, 393 Dura mater, the hsematoma of, 843 inflammation of, 813 syphilio nodes in, 813 tumors of, 843 Duration of disease, considered generally, 35 Duration, of cerebro-spinal meningitis, 298, 399, 303 of cholera, 408 of chorea, 711 of dengue, 103 of diphtheria, 66, 70 of dj^senterj, mild acute, .373,-375 sthenic, 373 typhoid or malignant, 373 scorbutic, 373 of erysipelas, 334 of acute farcy, 190 of chronic farcy, 190 of glanders, acute, 189 chronic, 190 of acute gout, 513 of hooping-cough, 50 of hydrophobia in dogs, 196 of hydrophobia in man, 199 of intermittent fever, 356 of paroxysm of, 355 of stages of paroxysm of, 357 of influenza, 41 of locomotor ataxy, 989 of measles, 107, 109 of simple meningitis, 813 of spinal meningitis, 955 of tubercular meningitis, 835 of parotitis, 119 of the plague, 315 of pyajmia, 330, 345, 317 of relapsing fever, primary fever, 277 of the relapse, 277 of remittent fever, 305 of acute rheumatism, 559, 567 of articular rheumatism, sub- acute, 560 of muscular rheumatism, 574 of rickets, 494 1078 INDEX OF VOL. I. Duration — of scarlet fever, S8 of smallpox, 129 of spinal congestion, 968 of syphilis, 426 of syphilis, secondary symp- toms, 425 of tetanus, 979 of typhoid, 201 of typhus, 261 of vaccinia, 159, 160 of varicella, 125, 126 of wasting palsy, 789 of yellow fever, 2S5 Dysaesthesia, in hysteria, 635 Dysentery, article on, 372 causes, 373 course, malarial, 373 mild acute, 373 sthenic acute, 373 typhoid or malignant, 373 definition, 373 diagnosis, 378 history, 872 modes of commencement, 373 morbid anatomy of acute, 378 of chronic, 379 pathology, 378 prognosis, 380 terminology, 372 symptoms of acute, 376 chronic, 376 malarial, 377 malignant, 377 mild, 375 scorbutic, 377 treatment of acute, 380 chronic, 383 malarial, 382 mild, 380 scorbutic, 382 [Dysentery, astringent enemata for, 383, 383] Dysentery (Complicating scurvy, 453 treatment of, 458 connection of, with typhus, 358 relation of, to typhoid fever, 330 resemblance of syphilitic ul- ceration of rectum to, 432 Dyspepsia, acute, resemblance to invasion of typhus, 254 as a cause of gout, 530, 534 a cause of vertigo, 691 diagnosis of, from tubercular meningitis, 830 in chronic gout, 518 treatment of, 545 as a premonitory symptom of gout, 515 in rheumatoid arthritis, 551 Dyspepsia, secondary to alco- holism, 677 to hypochondriasis, 635 to hysteria, 639 Dysphagia, in diphtheria, 66, 67 from diphtheritic paralysis, 69 in chronic gout, 519 in parotitis, 119 in scarlet fever, 86, 90 Dyspnoea, in cholera, 400 causes of, 414 In diphtheria, 67 treatment of, 83 Dyspnoea — in erysipelas, 327 in chronic glanders, 190 in retrocedent gout, 483 in hooping-cough, 50 in hysteria, 636 in influenza, 41, 43 in mercurial poisoning, 803 in myelitis, 961 in parotitis, 119 in scurvy, 451, 453, 453 in spinal congestion, 967 in spinal meningitis, 954 in tetanus, 972 in typhoid fever, treatment of, 249 EAR, disease of the, a cause of convulsions in children, 746 of abscess of the brain, 935, 937 of meningitis, 813 of vertigo, 694 Ears, commencement of ery- sipelatous inflammation in, 333 hemorrhage from, in malig- nant smallpox, 133 hemorrhage from, In pur- pura, 461 hemorrhage from, in yellow fever, 289 inflammation of, in measles, 113 helix of, chalk-stones in, 516, 517, 530, 633, 535 internal inflammation of, in rheumatoid arthritis, 553 lobes of, pain in, in dengue, 99 Eccentric convulsions, 766 Eccentricity, distinction of, from insanity, 609 Ecchymoses, in cerebro-spinal meningitis, 399, 303 In diphtheria, 76 in scurvy, 451, 456 In purpura, 460, 463 in typhus, 357 in yellow fever, 389 of heart in scurvy, 459 subconjunctival in cholera, 410 submucous in cholera, 410, 411 subserous in cholera, 410 subserous in purpura, 463 traumatic, diagnosis of, from purpura, 467 Echinococci in the brain, 896 Eclampsia, 745, 748 Ecstasy, article on, 646 varieties and symptoms, 646 treatment, 648 Eczema, in gouty subjects, 530 of the lip in measles, 110 after vaccination, merely a coincidence, 177 Education, injudicious, a cause of insanity, 589 of hysteria, 643 [Effervescent drinks in yellow fever, 395] Effusions, nature of, in scurvy, 457 Elbow, deformity of, in rheu- matoid arthritis, 551 Elbow— Inflammation of skin over, in smallpox, 133 Electric chorea, 700 Electric irritability and sensi- bility of muscles, in general paralysis of the insane, 606, 699 in general spinal paralysis, 999 in hysteria, 638 in essential paralysis, 1005, 1006 in locomotor ataxy, 986 In muscular ausesthesia, 783 in myelitis, 961 in softening of the brain, 863 In spinal congestion, 967 in torticollis, 1062 in wasting palsy, 789 Electrical conditions, relation of, to influenza, 36 Electricity, in muscular rheu- matism, 575 influence of, on spread of cholera, 387 Electricity, value of, in treat- ment of chorea, 717 of hysteria, 645 of infantile paralysis, 1007 of locomotor ataxy, ','.',i'J of mercurial poisoning, 806 of muscular antesthcsia, 760 of myelitis, 965 of neuralgia, 1046 of paralysis agitans, 730 of torticollis, 1003 of wasting palsy, 798 of writer's cramp, 737 Elevation above sea-level, in- fluence of, on spread of cho- lera, 388 Elimination of alcohol from the system (with note), 072, 673 Emaciation, in scurvy, 456 in congenital syphilis, 441 in rickets, 476, 483, 494 Embolism, of cerebral arteries, in chorea, 704 a cause of convulsions, 757, 760 of softening of the brain, SOS Embolism, in arteries of brain, in erysipelas, 3.-6 in pysemia, 337, 340 in scurvy, 455 Emetics, in dengue, 103 in diphtheria, 82 in hooping-cough, 56 in influenza, 45 in intermittent fever, 360 in measles, 115 in parotitis, 120 in purpura, 468 in relapsing fever, 380 in remittent fever, 309 in acute rheumatism, 570 Emotion, sudden, a cause of catalepsy, 654 of epilepsy, 765 of hypochondriasis, 628 of insanity, 589 of paralysis agitans, 725 of somnambulism, 6."9 Emphysema of lungs, in diph- theria, 76 in hooping-cough, 51 in influenza, 43 INBEX OF VOL. I. Emphysema as a sequel of scar- let fever, 93 Emprosthotonos, in tetanus, 971 Empyema, chronic, causing ab- scess of the brain, 935 Ems waters in gout, 5i7 Endemic of syphilis at Rival ta, 180 Endocarditis in acute rheuma- tism, 560, 5uo treatment of, 571 Endocardium, changes of, in pyaemia, 333 Enemata, in hemorrhage of ty- phoid fever, 249 in hydrophobia, 201 in yello-w fever, 393 Enteric fever, see Typhoid fever. Enteritis, liable to become ty- phoid, 3o3 Entozoa in the brain, 896 in the spinal cord, 1016 in the intestines, a cause of asthma, 1057 of catalepsy, 655 of spasms, 1056 Ephemeral fever, diagnosis of, from yellow fever, 286 Epidemics, of cholera, 384 departure of, 391 health of communities be- fore and during, 891 mode of invasion of, 391 relation of, to barometric pressure, 387 climate, 388 electricity, 387 moisture, 387 ozone, 387 rain, 387 temperature, 386 of dengue, 98 of diphtheria, 58 mode of propagation of, C3 mortality of, 61 relation of, to climate, 63 season, 63 temperature, 63 of dysentery, 373 of epidemic cerebro-spinal meningitis, 306 of erysipelas, 331 of influenza. 34 course of, 34 distribution of, 34 duration of, 35 Influence of atmospheric and other conditions on, 37 occasional intermittent char- acter of, 34 phenomena of, 36 rate of progress of, 34 relation of, to other epi- demics, 38 of measles frequently pre- ceding or preceded by eji- domics of hooping-cough, 106 of parotitis, 130 of plague, 315, 318 etiolorry of, 318 phenomena of, 330 of rabies among animals, 193 of relapsing fever, 269 distribution of, 373 mortality of, 879 Epidemics — propagation of, by contaMon 274 J a , relation of, to destitution and famine, 376 of smallpox, 156 of smallpox in Bengal, 303 of typhus fever, 35i! of varicella, 135 of yellovr fever, 281 Epididymitis, in parotitis, 119 Epigastrium, counter-irritation to, for vomiting in cholera, 416 heat at, in cholera, 400 oppression at the, in rcmit- _ tent fever, 365, 300 Epiglottis, exudation on, in diphtheria, 07, 76 swelling of, in scarlet fever, 90 ulceration of, in diphtheria, 76 ulceration of, in chronic glanders, 191 Epilepsia mitior, 768 gravior, 769 abortiva, 773 Epilepsy, article on, 763 deflnition, 703 synonyms, 763 natural history, 763 causes, 763 symptoms, 767 relation between the symp- toms, 775 complications, 776 pathology, 777 diagnosis, 778 prognosis, 779 treatment, 780 Epilepsy, caused by gouty dia- thesis, 619 intermittent fever, 363 cured by intermittent fever, 363 Epilepsy, diagnosis of, in chil- dren, 748 connection with catalepsy, 655 diagnosis of, from hysteria, 043 followed by mania, 590 a sequela of sunstroke, 070 Epileptic aphasia, 753 aura, 753, 770 hemiplegia, 753 mania, 776 Epileptiform attacks, from chronic alcoholism, 678 influence of, on prognosis of mania, 617 see also Convulsions. Epistaxis, in denprue, 100 in diphtheria, 06 in erysipelas, 3C3 in hooping-cough, 50 in influenza, 41 in measles, 1C7, 113 treatment of, 115 in purpura, 461 treatment of, 468 in relapsing fever, 377 in scarlatina, 93 in typhoid fever, 303 in variola maligna, 131 in yellow fever, 235, 2C9 Epistaxis, premonitory of cere- bral hemorrhage, 934, 920 1079 Epithelial scales, dissemination of scarlet fever by, 84 Epithelium of bladder in urine after scarlatina, 91 Equinia, see Glanders. Erectile tumors in the brain, 893 Ergot of rye in cerebro-spinal meningitis, 313 in puerperal pyasmia, 350 Erratic erysipelas, 3;J7 Eruptions, see Rash, Erysipelas, article on, 321 causes, 321 deflnition, 331 diagnosis, 324 morbid anatomy, "25 natural history, 321 pathology, 325 prognosis, 326 symptoms, 323 synonyms, 321 treatment, 327 [treatment of, without alco- hol, 328 local applications for, 329] varieties, 329 Erysipelas, a cause of pyasmia, 330 after vaccination, 101 diagnosis of, from diphthe- ria, 72 in glanders, 189 in smallpox, 133, 134 treatment of, 143 in smallpox, affecting the pulmonary mucous mem- brane, 147 in typhoid fever, 335 in typhus fever, 203 treatment of, 238 relation of, to diphtheria, 73 Erysipelas, complicating facial neuralgia, 1C38 Erythema, diagnosis of erysipe- las from, 325 in cerebro spinal meningitis, 302, 303 in congenital syphilis, 441 in stage of reaction in cho- lera, 402 in vaccination, 101 Essential convulsions, 745 Essential paralysis of children, ' 1004 Essential vertigo, 693 treatment of, 695 Etiology, see Causes. Eustachian tube, disease of, a sequel of scarlet fever, 00 in measles. 111 Evacuation stage of cholera, 309 treatment, 415 Evacuations, see Stools. Examination of the insane, hints as to the, 607 Exanthema hsemorrhagicum of Dr. Graves, 403 Excision of neuroma, 1035 of piece of a nerve for cure of neuralgia, 1047 Exciting cause of disease, meaning of the term, 33 Exercise, importance of, in treatment of epilepsy, 783 Exhaustion, a cause of sun- stroke, 663, 664 diagnosis of, from tubercular meningitis, G30 1080 INDEX OF VOL. I. Exhaustion in hooping-courjh, 53 treatment of, 57 [Expectancy in management of typiioid fever, 25J] Expectant treatment in acute rlieumatisn\, 5G7 Extravasation of blood, in pur- pura, 4G1, 433 in pysemia, 831 in lungs, 332 Bubpleural, 333 in heart, 333 in spleen, 333 under mucous membranes, 334: subperitoneal, 334 in brain, 334 in cellular tissue, 334 in seurs'y, 451, 4.j0 Exnidatiou, in cholera on mu- cous membrane of intes- tines, 411, 413 in croup, how different from diphtheria, 75 in diphtheria, 65, 73, 73 chemical characteristics of, 74 how far contagious, 63 microscopic characters of, 74 on mucous membranes and slvin, 68 on wounds, 68 pathology of, 73 treatment of, 78 in dysentery, on mucous membrane of colon, 379 in influenza, 44 inflammatory in pyaemia, 331 in intestines, 334 In cellular tissue and mus- cles, 334 In digestive tract, 333 in heart, 333 in liver, 333 in lungs, 331 in pericardium, 333 in peritoneum, 334 in pleuroe, S33 in typhoid fever, 313 in typhoid fever on fauces, 324 Eye, gouty deposits in, 520 hemorrhage from, in yellow fever, 289 implication of, in rheumatoid arthritis, 553 intense pain in, in dengue, 99 morbid anatomy of, in pyce- mia, 334 j sloughing of, in pyosmia, 334 | state of, in scurvy, 451 1 Eye, syphilitic disease of, see Iritis, Retinitis, and Kerati- tis. Eyeball, suppuration of, cere- bro-spinal meningitis, 299, 300 Eyeballs, conjugate deviation of, from hemorrhage into the cerebellum, 915 lateral deviation of, from hemorrhage into the corpus striatum, 912 in acute softening of the brain, 860 Eyelids, a frequent seat of ery- sipelatous inflammation, 333 swelling of, in cmallpox, 129 FACE, ancEsthesia of, 1065 histrionic spasm of, 1059 neuralgia of, 1036 paralysis of, from hemorrhage into the corpus striatum, 913 from hemorrhage into the pons, 914, 915 from tubercular meningitis, 833 from wasting palsy, 788, 789 premonitory of cerebral hem- orrhage, 924 Bv.-elling of, in smallpox, 129, 133 Face, arrest of growth of bones of, in ricliets, 480 Face, expression of, in cerebro- spinal meningitis, 398 in cholera, 399, 400 in chronic alcoholism, 677 in chronic hydrocephalus, 838 in chronic mania, 608 in dementia, 600, 601 during incubation of cholera, 399, 409 in dysentery, 376, 377 in epilepsy, 769, 771 in general spinal paralysis, 1000 in hysteria, 1000 in measles, 107 in melancholia, 694 in simple meningitis, 809, 810 in tubercular meningitis, 821 in the plague, 314 in mercurial poisoning, 803, 804 in pysemia, 344, 345 in remittent fever, 366 in ricliets, 477, 484 in scurvy, 451 in hereditary syphilis, 441 in typhoid fever, 203 in typhus, 255 in wasting palsy, 789 in yellow fever, 284, 287,292, 293 Facial nerve, the, paralysis of, at different parts of its course, 914 Facial palsy. Bell's, symptoms of, 1050 causes, 1051 prognosis, 1053 treatment, 1053 double, 1053 Facies hysterica (of Todd), 1000 Famine, see Food, insuflicient. X'amine fever, see Relapsing fever. Faradization, in treatment of hysterical paralyds, ICOt of muscular ansesthesia, 736 of myelitis, 965 of wasting palsy, 798 see also Electricity. Farcy buds, 184 Farcy in horses, &c., acute, 134 chronic, 184 in man, acute, 190 chronic, 190 Fat, deficiency of, in diet, a cause of neuralgia, 1042, lCi7 Father, health of, in production of ricliets, 473 Fatigue, a predisposing cause of ccrcbro-spinal meningi- tis, 309 of cholera, 389, 390 of diphtheria, 64 of neuralgia, 1027 of purpura, 463 Fatty degeneration of muscles. In infantile paralytis, IGUG in wasting palsy, 848 Fauces, condition of, in diph- theria, 65, 66 In erysipelas, 337, 329 in hydrophobia, 199 in scarlet fever, 90 in smallpox, 131 Fear, a cause of death in ths plague, 315 a predisposing cause of cho- lera, 391 Febrile form of congestion of the brain, 847 Feces, see Stools. Feigned catalepsy, 658 epilepsy, 778 insanity, 607 Femur, deformity of, in ricliets, 478 Fibrin, amount of, in blood cf acute rheumatiBiTi, 663 in blood of purpura, 465 in blood of typhus fever, 964 in blood of yellow fever, 2.9 presence of, in diphtheritic exudation, 74 Flbro-plastic tumors in the brain, 893 Fibrous tumors In the brain, 893 Fifth cranial nerve, anaesthesia of the, 10C5 neuralgia of, 1030 paralyeis of, 1065 [Filth promotive of diphtheria, 64] Fingers, deformity of, in rheu- matoid arthritis, .'^51 Fistula lacrymalis after scarlet fever, GO Fits, apoplectic, 846, 858, 924 cataleptic, 653 in children, 740 epileptic, 770 hysterical, 639 Flatulence, in gout, 518 treatment of, 545 a premonitory symptom of gout, 515 in hypochondriasis, 625, 630 in hysteria, 639 Flea-tites, diagnosis of roseola from, 106 rash in measles from, 113 diagnosis of, from purpura, 467 [Fluorescence of blood, affected by quinine, 363] Foetus, communication of syphi- lis by; 429 rickets in, 475 smallpox in, 488 Folie eirculaire, 697 Follicles of sliin, how far im- plicated in variolous erup- tion, 148 of small intestines, condition of, in typhoid fever, 2C9 Fontanclle, late closure of, in rickets, 476, 480 INDEX OF VOL. I. Food, animal, want of, a pre- disposing cause of scurvv, 450 ' Food, excess of, a cause of gout, 520, 534 Insuuicient, a predisposing cause of cerebro-spinal meningitis, 809 of the plague, 818 of purpura, 463 of pyajmia, 343 of relapsing fever, 296 of rheumatiBm, 565 of scurvy, 450 of typhus fever, 253 nature of, influence of, on gout, 529 unwholesome, a cause of cho- lera, 339 of dysentery, 374 of the plague, 318 of pyosmia, 348 of riclicts, 473 ,of scurvy, 447 of typhoid fever, 243 Food, improper, a cause of in- fantile convulsions, 740, 747 see also Diet. Forehead, shape of, in rickets, 480 Foreign bodies, in a '^vound, a, cause of neuralgia, IttJS Fracture of the skull, a cause of abscess of the brain, fc34 diagnosis of, from apoplexy, 929 Friction-sound in pericarditis of rheumatism, 5tJ0 In pyemia, pleural and peri- cardial, 345 Friction, to joints. In rheuma- toid arthritis, 553 to skin in gonorrhoea! rheu- matism, 579 In chronic gout, 545 in muscular rheumatism, 575 Fright, a cause of catalepsy, 654 of chorea, 709 of convulsions, 757, 758 of epilepsy, 765 of paralysis agitans, 735 of tetanus, 978 Fright of a pregnant woman, a cause of idiocy in the child, 604 Frontal sinuses, expansion of, in rickets, 480 Function and structure, gene- ral relations of, 19 Functional disease as con- trasted with structural, 19 Ftmgi in atmosphere, as a cause of influenza, 37, 39 theory of, for the propagation of cholera, 396 Furor transitorius, 597 GAIT, the peculiar, of general paralysis of the insane, Go5 of common hemiple'!:ia, ICOl of hysterical hemiplegia, 1001 of locomotor ataxy, 984 of paraplegia, 933 in disease of the cerebellum, 990 Galbanum plaster in rheuma- toid arthritis, 557 Gall-bladder, exudation in, in diphtheria, 75 Gallic acid, in cholera, 410, 419 In choleraic diarrhoea, 430 in chronic dysentery, ;JL,3 in purpura, 408 in scarlet fever, 97 in typhoid fever, 249 glycerine of, in diphtheria, 80 Galvanism, value of, in treat- ment, see Electricity. Ganglia, sympathetic, supposed inllammation of, in yellow fever, 291 Gangrene, at cerebro-spinal meningitis, 803 in cholera, 404, 414 in glanders, 189 in measles, treatment of, 115 in the plague, 314 in pya3mia, 331 in smallpox, 133 treatment of, 143 in typhus, 257 Gangrene, a sequela of scarlet fever, 93 of genitals In cholera, 404 in erysipelas, S.^7 in smallpox, 134, 143 of the lung in mea.sles, 113 of the lungs, tendency to, in melancholia, 595 in scurvy, 453 in pyaemia, 331 a sequel of typhus, 262 of mouth, in measles, 112 of mucous membrane of co- lon in cholera, 411 in dysentery, 379 of slcin in erysipelas, 326 of vulva in measles, 113 Gastein waters in gout, 547 Gastro-enteritis, diagnosis of, from tubercular meningitis, 830 Gelatine, absence of, in rickety bones, 491 General diseases, determined by agents operating from without, list of, 33 by conditions existing within the body, list of, 445 General paralysis of the insane, symptoms of, 605, 999 diagnosis, 609 General spinal paralysis, 999 Genitals, gangrene of. In cho- lera, 404 in erysipelas, 3C6 in smallpox, 134, 143 [German measles, 117] Germs, cholera. In stools, the- ory of, for the propagation of cholera, 395 objections to, 396 Glanders, article on, 102 definition, 183 history, 182 in horse, &c., 183 acute, 183 chronic, 183 in man, 185 diagnosis of, 191 etiology, 188 morbid anatomy, 191 1081 Glanders — prognosis, 192 symptoms, 189 therapeutics, 192 Glands, see under their special names. Gliomata In the brain, 893 a cause of cerebral liemor- rhage, 904 Globus hystericus, 636 Glossitis in smallpox, 133 [Glosso-labio-laryugcai paraly- sis, 1010] Glottis, (Edema of, in erysipelas 337 in typhoid fever, 225 after typhus, -02 paralysis of, in diphtheria, 69 Gluten obtained from cranial bones in rielvets, 491 Glycerine, topical application of, in diphtlieria, 79 Goitre, relation of, to idiocy 005 Gonorrhosa, a cause of gan- grene of genitals in small- pox, 134 Gonorrha?al rheumatism, arti- cle on, 5TG definition, 576 history, 576 symptoms, 576 treatment, 579 Gonorrhc3al rheumatism, diag- nosis of rheumatism from, 607 Gout, article on, 512 after elTeets of, 515 causes of, 526 classification, 512 condition of blood in, 530 definition of, 513 description of an acute at' tack of, 513 diagnosis of, 536 diseases occurring with, 53G history of, 512 irregular, 518 morbid anatomy, 523 pathology of, 501 phenomena during an acute attack of, 613 phenomena of chronic, 516 prognosis, 537 retrocedent, 518 symptoms, constitutional, of chronic, 517 symptoms premonitory of acute, 515 synonyms, 497 treatment of, 538 Gout, a cause of local paraly- sis, 1051 of neuralgia, 1044 of neuritis, 1021 Gout, diagnosis of rheumatism from, 566 diagnosis of, from rheuma- toid arthritis, 655 Gout, chronic, diagnosis of, from rheumatoid arthritis, 555 Gouty diathesis, a cause of mus ■ cular rheumatism, 574 a predisposing cause of cry- , sipelas, 327 [of neuralgia, 1041] Gouty kidney, 525 1082 INDEX OF VOL. I. Grain, diseased, a supposed cause of eorebro-epinal men- ingitis, SIO "Grape cure" in scorbutic dys- entery, 383 Gravel in gouty diathesis, 520 Gray substance of the spinal cord, functions of the, 943 Grief, a cause of gout, .C39 of rheumatoid arthritis, 551 Growth, arrest of, in ricliets, 48S, 493 Guaiacum In chronic gout, 543 in rheumatism, 570 -n muscular rheumatism, 575 in rlieumatoid arthritis, 557 Gummata, see Nodes. Gums, bleeding from, in pur- pura, 401 in yellow fever, 289 redness of, in measles, 110 swelling of, in scurvy, 451 treatment of, 4C3 Gurglinij in right iliac fossa in typhoid fever, 203, 304 Gutta-percha, solution of, in chloroform, for pitting in smallpox, 144 Gymnastics, value of, in treat- ment of chorea, 716 of infantile paralysis, 1007 of myelitis, 905 H^MATEMESIS in alcohol- ism, 077 in cholera, 407 in plague, 315 in purpura, 460, 401 treatment of, 408 in yellow fever, 3S9 Haematine, effusion of, the cause of coloration of the skin in yellow fever, 287 Hsematoidin in urine after scar- let fever, 91 Hasmatoma of the dura mater, 843 Hffimatorachis, 1007 Haematuria, in eorebro-spinal meningitis, 303 in diphtheria, 68 in intermittent fever, 353 occasional in measles, 103, 111 in Pali plague, 318 in plague, 315 in purpura, 631 in remittent fever, 367 in pya;mia, 346 a sequel of scarlet fever, 91 In malignant smallpox, 131 in yellow fever, SCO Haemoptysis, in hooping-coughj 51 in purpura, 461 in scurvy, 457 in malignant smallpox, 131 in typhoid fever, 203 Hsemorrhoids, from chronic al- coholism, 678 as sequelos of dengue, 103 in gout, 519 Hair, loss of, in syphilis, 433 thickness of, in rickets, 476, 477 Hallucinations, definition of, 503 Hallucinations — , character of, in delirium tre- mens, 679 in general paralysis, 60fl In melancholia, 593 In mania, 597 in monomania, 599 Hands, deformity of, from gout, 516 Haut mal, le, symptoms of, 709 Head, deformities of the, in idiocy, 603 Injury of, a cause of abscess of the brain, 934 of insanity, 591 shape of. In chronic hydro- cephalus, 837 Head, deformities of the bones of, in rickets, 480 position of, in rickets, 178 Headache, absence of, in sun- stroke, 666 persistence afterwards, 670 due to cerebral diseases, gen- erally, 756 to abscess of the brain, 934, 937 to cerebritis, 855 to simple meningitis, 809 to tubercular meningitis, 833 to cerebral softening, 805 to tumor of the brain, 884 premonitory of cerebral hem- orrhage, 924 Headache, in epidemic cerebro- spinal meningitis, 297, £C 3 in dengue, 99, 100 in diplitheria, 65, 66 in erysipelas, 333 in glanders, 189 in gout, 515, 518 in influenza, 41, 43 in intermittent fever, 357 in roseola, 105 in parotitis, 118 in the plague, 314 in relapsing feyer, 277 in remittent fever, 303, 307 in scarlet fever, 85, 88 in smallpox, 133 in typhoid fever, 203, 204 in typhus fever, 254, 258 in varicella, 125 in yellow fever, 284, 286, 293 Health, previous, influence on liability to cholera, 390 Hearing, impaired, see Deaf- ness. Heart, affection of, in gout, 519 treatment of, 546 alteration of relation of, to chest walls in rickets, 4C3 degeneration of, in yellow fever, 291 disease of, a cause of pete- chiae, 461 of vertigo, 691 predisposes to cerebral con- gestion, 848 relation of, to chorea, 600 to insanity, 590 displacement of, by large spleen, in intermittent fever, 358 fatty degeneration of, in ty- phoid fever, 218 in typhus, 204 morbid anatomy of, In cho- lera, 410 Heart, morbid anatomy of — in pyaemia, 333 In scurvy, 457 hypertrophy of, predisposes to cerebral hemorrhage, 906 Inflammation of, never truly gouty, 534 palpitation of. In gout, 515, 518 paralysis of. In diphtheria, 69 relation of diseases of, to acute rheumatism, 563 sounds of, in typhus fever, 256 syphilitic muscular nodes in, 433 weakness of, in scurvy, 455 Heart-burn in gout, 515, 518 treatment of, 545 Heat apoplexy, 661 Heat, diagnostic value of, in myelitis, 900 excessive, a cause of conges- tion of the brain, 818 Heat, effect of, on scarlet fever poison, 95 sense of, a premonitory symp- tom of rickets, 476 a cause of disease, see Tem- perature of air. Hectic In rickets, 483 Ilcmeralopia in scurvy, 453 [Hemianaesthesia in hysterical cases, 630] Hemiplegia, from abscess of the brain, 937 epileptic, 753 hysterical, G"3 in cerebro-spinal meningitis, 300 in children, 742 diagnosis of, from essential paralysis, 743 due to hemorrhage into the cerebellum, 915 into the corpus striatum, 911 into the crus cerebri, and pons, 913, 914 into the optic thalamus, 913 from meningeal hemorrhage, 843 with insensibility, 936 without loss of conscious- ness, 935 Hemispheres, cerebral, symp- toms of disease In the, 911 Hemorrhage, a predicposing cause of pyaemia, 313 a predisposing cause of rheu- matoid arthritis, 554 capillary. In gout, supposed to exist by Gairdner, 533 critical, in relapsing fever, 378 from bladder, in purpura ,461 from the bowels, in cholera, 405 In dysentery, 375, 370, 377 in measles. 111 In plague, 315 in purpura, 460, 461 In remittent fever, 367, 808 in scarlet fever, 90 in scurvy, 453 In typhoid fever, 203, 208 treatment of, 349 in typhus, 358 INDEX OF VOL. I. Hemorrhage — from cervical bubo in scarlet fever, 97 from gums in scurvy, 461 treatment of, 458 from kidneys in purpura, 461 from lungs in purpura, 461 from the mucous membranes in cerebro-spinal meningi- tis, 299 In variola maligna, 131, 1S7 from pericardium in yellow ' fever, 391 from skin in purpura, 460 from sloughing in neck after scarlet fever, 90 from stomach in yellow fever 285, 293 into cellular tissue in pur- pura, 461 Into brain in purpura, 461 into muscles in typhus, 265 tendency to, in diphtheria, 66, 67, 68, 73 an unfavorable symptom of diphtheria, 67, 77 in Pali plague, 818 in the plague, 315 in purpura, 401 supposed causes of, 463 in smallpox, 137 in typhoid, an unfavorable symptom, 247 in yellow fever, 289 Hemorrhage, cerebral, 902 relation of, to congestion of the brain, 851 to softening of the brain, 908 Hemorrhage into the spinal cord, 1007 Hemorrhagic diathesis, diagno- sis of, from purpura, 467 Hepatitis, gouty, 518 in remittent fever, 868 syphilitic, 434 Hepatization of lung after measles. 111, 113 in pysemia, 331, 832 Hereditary predisposition in diphtheria, 64 In erysipelas, 323 in gout, 536, 536 in rheumatism, 564 in rheumatoid arthritis, 554 in rickets, 473 Hereditary syphilis, a protec- tion against acquired syphi- lis, 437 Hereditary taint, a cause of al- coholism, 674, 675 of infantile convulsions, 749 of epilepsy, 763 of cerebral hemorrhage, 905 of hypochondriasis, 633 of hysteria, 633 of insanity, 588 of locomotor ataxy, 989 of neuralgia, 1041 of paralysis agitans, 725 of somnambulism, 659 of spinal irritation, 997 of tubercular meningitis, 818 of wasting palsy, 786, 790 Hereditary taint, influence of, on prognosis of epilepsy, 779 of insanity, 617 of neuralgia, 1041 Hernia, an occasional result of influenza, 43 Herpes, relation of, to neural- gia, 1034, 1039 Herpes of lips, a favorable sign in intermittent fever, 359 Herpetic eruption in cerebro- spinal meningitis, 303 Hiccup, pathology of, 1058 Hiccup, in cholera, 402 treatment of, 419 in remittent fever, 867 in typhoid fever, 203 in yellow fever, 2S5, 292 Hip-disease a sequela of scarlet fever, 93 Hip-joint, condition of, in rheu- matoid arthritis, 553 Hip-joint, disease of the, diag- nosis of, from infantile pa- ralysis, 1004 Histrionic paralysis, lOoO Histrionic spasm of the face 1059 Homburg waters in gout, 547 Homicidal impulse, in melan- cholia, 594 in dementia, 601 Hooping-cough, article on, 48 causes, 48 complications of, 50, 56 definition, 48 diagnosis, 53 history, 48 morbid anatomy, 53 pathology, 53 prognosis, 53 symptoms, 49 treatment, 53 Hooping-cough, a predisposing cause of measles, 1C6 of tubercular meuincritis, C19 rickets following, 476 Horn-pock, 133, 133 Hot climates, predispose to sunstroke, 661 to tetanus, 978 Human intercourse as a means of diffusion of cholera, 393 of diphtheria, 61 of dengue, 103 of influenza, 87 of typhus fever, 253 Humerus, deformity of, in rickets, 479 Hydatid cysts in the brain, 897 Hydraemia, a predisposing cause of rickets, 473 Hydrocephalus, acute, in rickets, 483 in hooping-cough, 51 chronic, in rickets, 483 Hydrocephalus, chronic, article on, 836 morbid anatomy, 836 symptoms, 837 diagnosis and treatment, 839 Hydrochloric acid, free, in the blood, a supposed cause of rickets, 473 free, in black vomit, 290 internal administration of, in hooping-cough, 56 in rickets, 495 in typhus, 268 topical use of, in diphtheria, 78 n scarlatina, 97 1083 Hydrocyanic acid, in cholera, for vomiting in cholera, 416 in dyspepsia of chronic gout, 545 in hooping-cough, 54 for vomiting in influenza, 40 value of, in insanity, 001 in rickets, 495 in typhoid fever, 247 in yellow fever, ii94 Hydrogen in the air of marshes, o53 Hydrophobia, article on, 102 causes in dog, &c., 195 in man, 197 definition, 193 diagnosis, 199 history, 192 morbid anatomy, 109 prognosis, 200 symptoms in dog, &c., U;6 in man, 197 synonyms, 192 therapeutics, 200 Hydrophobia, diagnosis of, from tetanus, 971, 978 Hydrorachis, 1018 Hydrothorax, as a sequel of scarlet fever, 93 Hygienics generally considered, 30 i Hyoscyamus, in gouty cj'stitis, 546 in infiuenza, 46 in rickets, 495 in yellow fever, 294 application of, to rheumatic joints, 572 Hypersesthesia of skin, in cere- bro-spinal meningitis, 20S, 299 occasionally occurring in diphtheria, 69 in general paralysis, 606 in hysteria, 635 in meningitis, 809, 823 Hypercinesis, 1055 Hypertrophy of the brain, S88, 899 of the spinal cord, 1015 Hvpochondriacal melancholia, 592 Hypochondriasis, article on, 623 definition, 623 nomenclature, 023 history, 624 symptoms, 624 diagnosis, 636 prognosis, 628 etiology, 628 pathology and treatment, 629 Hypochondriasis, diagnosis of, from melancholia, 609, 627 Hypodermic injection, of atro- pia, in neuralgia, 1045 of arsenic, in chorea, 1043 in neuralgia, 712 of morphia, in delirium tre- mens, 688 in insanity, 621 in neuralgia, 1044 in torticollis, 1064 in wasting palsy, 799 in writer's cramp, 737 Hypophosphites, the, in treat- ment of chorea, 71 f of chronic alcoholism, 686 1084 INDEX OF VOL. I. Hypopion in smallpox, 134 [Hypostatic pneumonia in ty- phoid fever, 221, 249 in typhus, 258] Hysteria, article on, 630 causes, 631 symptoms, 634 interparoxysmal, 634 paroxysmal, 639 pathology, 640 diagnosis, 643 prognosis, 643 treatment, 644 Hysteria, diagnosis of, from epilepsy, 642, 7;8 from neuralgia, 1040 from tumor of the brain, 886 predisposes to alcoholism, 039 to insanity, 589 relation of, to hypochondria- sis, 626 to muscular anaesthesia, 784 et seq. Hysterical mania, 640 paralysis, 638 paralysis agitans, 724 paraplegia, 1000 [Hystero-Epilepsy, 649] ICE, Bucking of, in cholera, 416, 417 In diphtheria, 78 in dysentery, 380 in measles, 114 in parotitis, 121 in hoemetemesis in purpura, 468 in remittent fever, 3''0 for sore throat in scarlet fever, 96, 97 in typhus, 208 in yellow fever, 294 to abdomen for hemorrhage in typhoid fever, 249 to head in erysipelatous men- ingitis, 329 to head in cerebro-spinal meningitis, 313 Ice to spine, in epilepsy, 782 Ichorous fluids, entrance of, into circulation, a cause of some symptoms of pyaamia, 340 Ideation, perverted in hysteria, 634 in insanity, 592 Idiocy, description of, 603 varieties, 604 relation of, to epilepsy, 777 to meningitis, 825 following infantile convul- sions, 744 Idiopathic neuroma, 1022 tetanus, 976 Idiosyncrasy, effect of, in modi- fying syphilis, 426 Ileo-CEecal valve, swelling of, in typhoid fever, 210 Ileum, morbid anatomy of, in typhoid fever, 209 Hia, deformity of. In rickets, 480, 493 Iliac fossa, tenderness and gur- gling of, in typhoid fever, 203 treatment of, 248 Illusion, definition of an, 593 (note). Imbeciles, Intelluctual, 604 Imbeciles — moral, 602 Imbecility, a sequel of typhoid fever, 209 Imperial drink for thirst in measles, 114 Incisor teeth, malformation of, in congenital syphilis, 441 Incontinence of urine, noctur- nal, 660 in sunstroke, 666 Incubative period, of cholera, 392 of chicken-pox, 125 of diphtheria, 63 of glanders in horses, 183, 184 in man, 189 of hooping-cough, 48 of hydrophobia in the dog, 196 in man, 198 of influenza, 38 of intermittent fever, .355 of measles, 106 of parotitis, 120 of remittent fever, 306 of rickets, 476 of scarlet fever, 84 of smallpox, 129 of syphilis, primary, 443 constitutional, 424 of typhus fever, 254 of yellow fever, 282 India, residence in, as a predis- posing cause of cholera, 390 Indian hemp, in treatment of delirium tremens, 686 of neuralgia, 1045 Indigestion, predisposes to cerebral congestion, 848 to convulsions, 757 to epilepsy, 765 Induration of the brain, 888 Induration of the spinal cord, 1008 a result of myelitis, 962 Induration of syphilitic chan- cre, 424 absorption of, under mercu- rial treatment, 435 of tissues in tertiary syphilis, 431 Infantile paralysis, article on, 1004 symptoms, 1004 prognosis, 1005 treatment, 1006 Infantile remittent fever, rick- ets mistaken for, 475 Infants, convulsions in, 738 Infarcts in the brain, 875 Infection, see Contagion. Inflammation, cerebral, in cho- rea, 707 relation of, to pain and spasm, 947 Inflammation, production of, by occluded circulation, 336 [Inflammation, treatment of, 31] Influenza, article on, 33 consideration of special symptoms, 41 definition, 33 diagnosis, 43 general course of disease, 41 history, 34 morbid anatomy, 44 Influenza — mortality, 43 pathology, 44 prognosis, 44 spread of disease, 34 synonyms, 38 treatment, 45 varieties, 43 Influenza, its relation to other epidemic diseases, 38 its relation to diseases of brutes, 39 prevalence of, during cholera epidemics, 391 Infra-mammary pain, neural- gic, 1034 Inherited syphilis, diagnosis of, 440 [Inhibition in pathology of re- flex paralysis, 1003] Injections into veins in cholera, 421 Injury, an exciting cause of rheumatoid arthritis, 554 Injury of the head, a cause of abscess of the brain, 934 of cerebral hemorrhage, 904, 929 of insanity, 691 Injury to nerve, a cause of facial palsy, 1051 of neuralgia, 1028, 1033 Injury to spinal cord, effects of, in different regions, 946 a cause of spinal irritation, 997 of spinal meningitis, 955 of wasting palsy, 787 Inoculability of influenza, 38 Inoculation, in diphtheria, 63 in glanders, 185 in scarlet fever, 95 of sheep-pox, 128 of cows with variolous mat- ter, a means of obtaining vaccine lymph, 176 for smallpox, 156 in Bengal, 398 cases justifying, 157 history of, 156 modification of course of smallpox by, 139 mortality from, 157 phenomena of, 157 of syphilis, 424, 426 impossible in varicella, 124 Insanity, article on, 584 synonyms, 584 , definition, 584 classification, 585 causes, 587 varieties and their symptomc, 591 diagnosis, 607 prognosis, 616 therapeutics, 618 [Insanity, physiological classi- fication of, 586 American statistics of, 591 without cerebral disease, 613] Insanity, relation of, to alco- holism, 675 to hypochondriasis, 628 Insanity following typhus, 359 Insolation, article on, 661 a cause of insanity, 591, 666 diagnosis of, from apoplexy, 667 INDEX OF VOL. I. /neomnia, in chronic alcohol- ism, 675 in cholera, 403, treatment of, il9 in delirium tremens, 679 treatment, 685 in insanity, 596 in smallpox, treatment of, 142 In tetanus, 974 in torticollis, 1063 in typhus, 258 treatment of, 268 Inspiration, characters of, in hooping-cough, 50 difficulty of, in rickets, 481 Insufflation of lungs in rickets, 494 Intellect, state of, in cerebri tis, 8.35 in cerebro-spinal meningitis, 297, 801 in cholera, 400 in dengue, 100 in diphtheria, 65 in dysentery, 376 in erysipelas, 323 in chronic hydrocephalus, 889 in influenza, 41 in intermittent fever, 357, 358 in measles, 107 in meningitis, 809 in the plague, 814 in pyaemia, 344, 346 in remittent fever, 367 in rickets, 476, 481 in scurvy, 451, 453 in malignant smallpox, 133 in acute cerebral softening, 858 in tumor of the brain, 884 in typhoid fever, 203 in typhus, 358 in yellow fever, 284, 285 see also. Mind, state of. Intellectual occupations a cause of insanity, 588 Intemperance, a predisposing cause of cholera, 390 a cause of delirium in small- pox, 130 a cause of general paralysis, 605 of idiocy, 604, 678 of insanity, 589, 607 of purpura, 463 a predisposing cause of py- aemia, 343 a predisposing cause of ty- phus, 253 predisposes to neuralgia, 1042 to " rheumatic meningitis," 813 to mercurial tremor, 802, 805 Intercostal neuralgia, 1034 Intercostal rheumatism, 574 Intermarriage of relations a cause of idiocy, 604 a supposed cause of rickets, 473 Intermissions, in cerebro-spinal meningitis, 311 In erysipelas, 325 in influenza, occasionally, 41 in intermittent lever, 355, 357 Intermissions — in the pyrexia in typhoid fever, 228 in relapsing fever, 277 Intermittent fever, article on, 354 ' causes, 356 definition, 854 diagnosis, 358 history, 354 modes of commencement, 354 morbid anatomy, 3.58 prognosis, 359 symptoms, 356 synonyms, 854 treatment, 360 varieties of, 355 Intermittent fever, coexistence of, with typhoid fever, 228 complicating cerebro-spiual meningitis, 303 localities of, in England, 238 relation of, to typhoid feyur, 238, 233 Intestines, amyloid degenera- tion of mucous membrane of, in rickets, 483 atrophy of, in chronic dys- entery, 379 thickening of, in chronic dys- entery, 639 gangrene of, in dysentery, 379 hemorrhage from, in pur- pura, 460, 461 morbid anatomy of, in cho- lera, 411 in diphtheria, 76 in dysentery, 37'8 in the plague, 316 in pyaemia, 334 in scurvy , 457 in typhoid fever, 209 in typhus, 265 in yellow fever, 292 muscular rheumatism in, 574 pathology and lesions of, in typhoid fever, 319 perforation of, in typhoid fever, 203, 208, 210 tubercular ulceration of, diagnosis of, from typhoid ulceration, 245 ulceration of, in pyaemia, 3b- in typhoid fever, 210 ulceration of, in typhus fever, complicated with dysen- tery, 265 Intoxication, alcoholic, physi- ology of, 671 Invasion, of cerebro-spinal meningitis, 297 of cholera, 398 in dengue, 99 of diphtheria, 65 of dysentery, 873 of erysipelas, 323 of gout, 512 of glanders, 189 of hooping-cough, 49 of hydrophobia, 198 of influenza, 41 of intermittent fever, 35 i, 356 of measles, 106 of parotitis, 118 of plague, 314 of pyaemia, 344 1085 Invasion — of relapsing fever, 277 of remittent fever, 365 of rickets, 475 of acute rheumatism, 559 of muscular rheumatism, 573 in scarlet fever, 85 of scurvy, 451 of smallpox, 132 of syphilis, 424 of typhoid, 203 of typhus fever, 354 of yellow fever, 284 Iodide of potassium, in treat- ment of mercurial trumur, 806 of local poisoning, 807 of spinal meningitis, 956 of syphilitic disease of the brain, 901 see also Potassium, iodide of. i Iodine, in treatment of chronic hydrocephalus, 840 in rheumatoid arthritis, 575 in rickets, 496 inhalations for chronic laryn- gitis after measles, 116 external use of, in rheuma- toid arthritis, 557 Ipecacuanha, in dengue, as an emetic, 104 in diphtheria, 83 in dysentery, 380, 381, 883 in influenza, 46 in measles, 115 in purpura, 468 in hooping-cough, 54 as an emetic in relapsing fever, 280 in gonorrhoeal rheumatism, 579 in rickets, 496 in pulmonary complications of typhoid, 249 " Irish purpuric disease," 463 Iritis, in cerebro-spinal men- ingitis, 398, 300 in congenital syphilis, 430 in secondary stage of syphi- lis, 435 frequent relapse of, 436 influence of mercury on, 436 treatment of, 436 """ritis, complicating facial neu- rrigia, 1038, 1046 Iron, excess of, in blood in purpura, 465 presence of, in black vomit of yellow fever, 390 Iron, alter cholera, 419 after dengue, 104 in diphtheria, 78, 79 in erysipelas, 828 in chronic gout, 545 in hooping-cough, 55 after influenza, 47 [in chronic intermittent, 3114] after measles, 110 in rheumatoid arthritis, So'i in rheumatic pericarditis, 573 in rickets, 496 after smallpox, 143 Iron, value of, in treatment of chorea, 711 Iron, acetate of, in diphtheria, 79 Iron and ammonia, citrate of, in rickets, 496 1086 INDKX OF VOL. I. Iron and quinine, citrate of, in dysentery, 383 in rickets, 496 Iron, carbonate of, in hooping- cough, 55 Iron, iodide of, in rheumatoid arthritis, 557 in riclfets, 496 Iron, magnetic oxide of, in riclcets, 496 Iron, perchloride of, in diph- theria, 79 in scarlatinal dropsy, 97 for hemorrhage in typhoid fever, 249 Iron, pernitrate of, in diphthe- ria, 79 In dysentery, malarious, 382 chronic, 383 Iron, phosphate of, after inter- mittent fever, 364 in rickets, 496 Iron, potassio-tartrate of, in acute rheumatism, 573 Iron, sesquichloride of, in cere- bro-spinal meningitis, 313 in diphtheria, 79 in erysipelas, 828 in purpura, 467 in rickets, 496 Iron, sulphate of, in hooping- cough, 55 Irrigation, cold, in meningitis, 816 Irritability, muscular, in cere- bral softening, 863 electric, see Electric irrita- bility of muscles. Irritation, eccentric, a cause of epilepsy, 766 spinal, 991 Itching of skin, in dengue, 101 treatment of, 104 in roseola, 105 in smallpox, 143 treatment of, 143 in varicella, 186 JACTITATION in den^-ue, o 100 James's powder in remittent fever, 371 Jaundice, as a sequela of den- gue, 103 in hypochondriasis, 626 occasionally present in influ- enza, 43 in relapsing fever, 277, 278 in remittent fever, 368 in pyaemia, 333, 344, 345, 346 in scarlet fever, 88 in yellow fever, 2S7 purpura attending, 463 Jaw, occasionally fixed in rheu- matoid arthritis, 551 Jaw, lower, elongation of, iu rickets, 480 movements of, impaired in mumps, 119 Joints, ankylosis of, from gout, 514, 516, 525 favored by local blood-let- ting, 540 efifect of rheumatism on, 501 eifusion into, in gout, 514 in gonorrhoeal rheumatism, 576 in rheumatoid artliritis, 553 Joints — fatty degeneration of, in rheumatoid arthritis, 554 morbid anatomy of, in acute rheumatism, 563 in rheumatoid arthritis, 553 in gout, 533 number affected in gout, 515 pain in, in dengue, 99 before purpura, 462 in pyaemia, 344 in relapsing fever, 278 neuralgic, after rheumatism, 560 in rickets, 476, 483 in syphilis, 425 state of, in acute rheuma- tism, 559, 561 in gonorrhosal rheumatism, 576 in rheumatism, sub-acute, 5G0 in chronic rheumatoid artli- ritis, 551 in acute rheumatoid arthritis, 652 in acute gout, 613, 514 local treatment of, 540 stiffness of, in scurvy, cause of, 457 suppuration of, in cerebro- spinal meningitis, 298, 303 in pyaemia, 331, 334, 344, 346 after scarlet fever, 91 , SIS swelling iu flexures of, in scurvy, 452 treatment of, 458 swelling of, in dengue, 99 Jugular veins, dilatation of, in rickets, 476 Jungle fever, see Remittent fever, 365 KERATITIS, interstitial in hereditary syphilis, 430, 440, 442 Kidneys, disease of the, from chronic alcoholism, 684 deficient action of, a cause of local paralysis, 1049 effect of lead on, 530 morbid anatomy of, in ccrc- bro-spinal meningitis, 300 in cholera, 411 in diphtheria, 73, 76 in erysipelas, 326 in gout, 519, 536, 534 in purpura, 464 in pyemia, 333 iu scarlet fever, 94 in typhus, 265 in yellow fever, 293 suppuration of, diagnosis of, from pyismia, 348 see also Bright's disease. Kissingen waters in gout, rA7 Knee, condition of, in rheuma- toid arthritis, 652 Knock-knee in rickets, 473 LABIA, diphtheritis of, in measles, occasionally, 113 occasionally affected in paro- titis, 119 Lactation, insanity of, .593 Lactation, prolonged, a predic- posing cause of acute rheu- matism, 566 Lactation, prolonged, a predis- posing cause of rheumatoid arthritis, .554 Lactic acid, in the blood, a sup- posed cause of rheuma- tism, .566 frje in the blood, a supposed cause of rickets, 487 in urine in acute rheumatism, 563 in urine in rickets, 484 LacunEB of bone, formation of, iu rickets, 490 Larch bark, tincture of, in pur- pura, 468 Laryngeal asthma in rickets, 483 Laryngeal nerve, recurrent, supposed seat of hooping- cough, 53 Laryngismus stridulus, 741 connection of, with rickets. 838 common in hydrocephalic children, 742 Laryngismus stridulus, in rick- ets, 483 treatment of, 497 Laryngitis, complicating meas- les, 111 treatment of, 115 in relapsing fever, 378 complicating typhoid fever, 223 chronic, an occasional sequel of influenza, 43 of measles. 111 syphilitic, 433 treatment of, 437 Laryngotomy in diphtheria, 83 in erysipelas, 339 Larynx, affection of, in rheu- matoid arthritis, 553 condition of, in diphtheria, 67 in glanders, 191 in smallpox, 146 smallpox eruption in, 131 ulceration of, in typhoid fever, 217 in tertiary syphilis, 433 Latent scarlet fovcr, 89 Lateral columns of the spinal cord, functions of the, 943 [Lateral spinal sclerosis, 1009] Lateral ventricles of the brain, hemorrhage into, 903, 911 Lead, influence of, on excretion of uric acid by the kidney, 530 Lead-poisoning, diagnosis of pains in, from muscular rheumatism, 576 a cause of gout, 630 symptoms of, 807 treatment, 817 diaijnosis of, from tumor of the brain, 887 from wasting palsj', 790 from writer's cramp, 734 Lead, acetate of, in cholera, 416 in diphtheria, 79 in dysentery, 383 in influenza, 46 in hooping-cough, 66 in purpur,"., 468 in hemorhages In purpura, in typhoid fever, 348, 249 INDEX OF VOL. I. Lead, acetate of— as a lotion in otorrhoea, 116 [Lead cerate in rheumatoid arthritis, 558 in scrofula of bones, &c., 511] Leaping ague, 702 [Lemonade as a diuretic, 97] Lemon-juice in scurvy, 458, i59 Lichen, febrile, dia,r:nosis of, from smallpox, 105 vaccine, 159 Liebig's beef tea, 114, foot- note. Ligaments, affected in rare cases of erysipelas, 326 gouty deposits in, 516 etate of, after articular rheu- matism, 564 weakening of, in rickets, 493 Ligamentum tores, destruction of, in rheumatoid arthritis, 553 Light, intolerance of, in hys- teria, 635 in meningitis, 809 want of, a cause of rickets, 4T3 Limbs, stiffness of, in dengue, 99 paralysis of, in diphtheria, 70 Lime-juice, in acute rheuma- tism, 570 as a prophylactic in scurvy, 448, 4.05, 4.:8, 4.59 Lime, salts of, in gout, 544 Lime, phosphate of, found in rare cases in chalk-stones, 517 Lime-water, in cholera, 418 as a gargle in diplitheria, 70 in gout, 544 in rickets, 495, 496 in yellow fever, 294 Lips, redness of, in measles, 110 Llthia in gout, acute, 539 chronic, 5-M Lithia, carbonate of, external application of, to chalk- stones, 546 Liver, abscess of, in dysentery, 379 agency of, in decomposinrj poisons introduced into the portal system, 218, 234 agency in elimination of poi- son of yellow fever, 281 antiseptic influence of, on chyme, S19 cirrhosis of, in alcoholism, 077 disease of, in dengue, 103 a cause of purpura, 403, 465 derangement of, in malarious dysentery, 377 in chronic gout, 518 derangement of, the cause of all the symptoms in ty- phoid fever, 218 enlargement of, in relapsing fever, S79 In rickets, 483 in typhus, 265 morbid anatomy of, in cere- bro-epinal meningitis, 306 in cholera, 411 in diphtheria, 70 in malarious dysentery, 370 in erysipelas, 823 Liver, morbid anatomy of — in intermittent fever, 339 in purpura, 4G3 in pyaemia, 333 in relapsing fever, 279 in scurvy, 457 in syphilis, 434 in typhoid fever, 215 in typhus, 265 in yellow fever, 293 sypliilitic affections of, 434 tenderness of, in relapsing fever, 277 Lividity of the face in epilepsy, 771 Lobelia, in influenza, 46 in hooping-cough, 55 Locality, change of, to avoid cholera, 433 [Localization of brain lesions, recent researches on, 910] Localized paralysis agitans, 735 Local spasms, article on, 1055 Lochia, changes of, in puerperal pyajmia, 344 Locomotor ataxy, article on, 980 definition, 980 symptoms, 981 post-mortem appearances, 983 causes, 989 prognosis, 989 dianjnosis, 989 treatment, 990 Locomotor ataxy, diagnosis of, from muscular antesthesia, 784 from paraplegia, 789 Logwood, decoction of, in dys- entry, 383 Lucid intervals, in mania, 697 in melancholia, 597 Liimbago, 574 Lunatics, increasing number of, 687 Lung, apoplexy of, in cerebro- spinal meningitis, 303 in purpura, 463 atrophy of, in hooping-coujh, 51 collapse of, in cholera, 410 in influenza, 44 in rickets, 494 Lungs, chronic disease of the, a cause of abscess of the brain, 935 congestion of, in alcoholism, 683, 084 in apoplexy, 904 in cholera, 431 in erysipelas, 326 in hooping-cough, 50 in influenza, 41, 43, 44 in malignant measles, 108 in sunstroke, 667 a cause of death in rickets, 483 in typhoid fever, 203, 204 local, in pyajmia, 333 consolidation of, after ty- phus, 358 gangrene of, in measles, 113 in melancholia, 595 in scurvy, 453, 456 after typhus, 203 emphysema of, in rickets, 404 1087 Lungs — inflammation of, from gout, .519 treatment of, 646 morbid anatomy of, in cho- lera, 410 in diphtheria, 76 in glanders, 191, 193 in hydrophobia, 199 in influenza, 44 in pya3mia, 331 in scarlatinal dropsy, 93 in scurvy, 450 in smallpox, 146 in typhoid fever, 217 in yellow fever, 291 osdema of, in ccrebro-spinal meningitis, 303 physical examination of, dur- ing life, in complications of hooping-cougli, 51 in influenza, 43 in measles, 107, 113 in pyasmia, 345 in scurvy, 453 in typlius fever, 258 Lupus, in hereditary syphilis, 429 phagedsenic, in tertiary syphi- lis, 433 Lymph, absorption of, under mercurial treatment of syphilis, 436, 437 effusion of, in pysemia, 331 on pericardium, 333 on pleura?, 333 effusion of, in syphilitic kera- titis, 443 in syphilitic iritis, 425 in syphilitic orchitis, 434 Lymphatic glands, albuminoid degeneration of, in rickets, 483 enlarged, diagnosis of, from parotitis, 130 inflammation of, after vacci- nation, 159 state of, in dengue, 101 in diphtheria, 65, 66, 76 in erysipelas, 324 in farcy, 100 in glanders, 189, 193 in hydrophobia, 198 in measles, 109 in the plague, 314, 315, 316 in scarlet fever, 83, 88, CO in syphilis, 433 in typhoid fever, 216, 218 suppuration of, after typhus, 202 Lymphatic vessels, inflamma- tion of, in erysipelas, 321 in farcy, 190 Lymphatics, distribution of the, in the brain, 860 MACULE of typhus, 256 Ma.-'-nesia in chronic gout, .644 in rickets, 495 sulphate and carbonate of, in gout, 540 sulphate of, in chronic gout, 545 in purpura, 467 Malaria, 353 causes of, 352 distribution of, 353 1088 INDEX OF VOL. I. Mala ria — effects of, 353 supposed nature of, 353 Malaria, a supposed cause of cerebro-spinal meningitis, 311 a cause of dysentery, 374 of neuralgia, lO-'J necessary for the production of ague, 356 relation of, to cholera, CGS [Jliilaria, protection from, by trees, 353 disappearance of, with build- ing of towns, 353] Malarial cachexia, treatment of, 363 Malarial fevers, article on, 353 intermittent fever, 351 nature of malaria, 353 remittent fever, 305 [Malarial stupor, simulatin'!; congestion of the brain. Si] Malarious dysentery, 373, STT treatment of, 382 Malformations, congenital, of the brain, 603 of the meninges, 844 of the spinal cord, 1018 Malic acid in scurvy, 455 Malignant dysentery, 373, 377 Malignant measles, 107 Malignant scarlet fever, 88 Malignant smallpox, 128, 131 Malleoli, enlargement of, in rickets, 481 Malt liquors, causes of gout, 537, 538 MammEE, inflammation of, in parotitis, 119 Mania, 505 acute, 598 from alcoholism, 680 dancing, 617 epileptic, 776 hysterical, 040 partial, 51>9 puerperal, 593 recurrent, 598 sine delirio, 001 Mania in retrocedcnt gout, 519 in scurvy, 453 in tertiary syphilis, 440 JIania, acute, diagnosis of, from hydrophobia, 199 in tertiary syphilis, 433 JIarasmus, a sequel of typhoid fever, 208 Marienbad waters, in gout, 547 presence of lithia in, 544 Marshes, a cause of malaria, 353 composition of air of, 353 Mastication, difSculty of, in spinal meningitis, 954 in mumps, 119 Masticatory spasm, 1059 Masturbation, a cause of in- sanity, 589, 599 of epilepsy, 706 of wasting palsy, 788 Maturation stage of smallpox, 139 Measles, article on, 106 complications. 111 definition, 106 diagnosis, 113 prognosis, 114 symptoms, 106 Measles — synonyms, 106 treatment, 114 varieties, 107 Measles, a cause of purpura, 463 complicating vaccination, 160 diagnosis of, from smalViox, l'35 of dengue from, 103 of roseola from, li :i from scarlet fev^r, 94 from typhus, 3C2 case of, mistaken for dysen- tery, 378 hemorrhagic, diacrnosis of, from purpura, 466 malignant, 107 rash in, 107 malignant, diagnosis of, from cerebro-spinal meningitis, 304 predisposes to tubercular meningitis, 819 [Measles, typhus, in U. S. Army, 108 German, 117] Meat, diseased, how far a cause of typhoid fever, 243 Meatus auditorius occasionally aifected in diphtheria, 08 Medulla oblongata, the centrs^ of the epileptic zone, 777 symptoms of hemorrhage into, 915 congestion of, in hydrophobia, 199 how far concerned in hoop- ing-cough, 49, 53 Meloena in purpura, 461 Melancholia, 593 acute, 595 attonita, 594 from alcoholism, 680, 033 diagnosis of, from dementia, 609 from hypochondriasis, 637 prognosis, 616 Melancholia, occasional occur- rence of, in tertiary syphilis, 433 Mclanoid growths in the brain, 801 Membrane, false, see Exuda- tion. Memory, loss of, in dementia, 600 in cerebral congestion, 845 in mercurial poisoning, 804 in softening of the brain, 8:ii state of the, in epileptics, 7/4 in mania, 597 Meningeal hemorrhage, 840 treatment of, 842 Sleninges of brain, affected in tertiary syphilis, 433 congestion of, in diphtheria, 76 supposed gouty deposits in, 518 state of, in cerebro-spinal meningitis, 3(/5 suppurative inHammation of, I in diphtheria, 76 Meninges, the, adventitious products in, 843 congenital malformations of, 844 Meningitis, acute, in the young, 809 in adults, 810, 817 partial or local, 811, 813 rheumatic, 811 syphilitic, 812 tubercular, 817 a complication of epilepsy, 776 dia^osis of, from acute mania, 607 fror.i delirium tremens, 815 from typhus and typhoid fevers, 815, 830 Meningitis, chronic, 816 a c:'. ise of general paralysis, 816 diagnosis of, from epilepsy, 779 from cerebral softening, 882 from tumor of the brain, 887 Meningitis, cerebral, in erysij)- elas, 327 in influenza, 43 in typhus, 265 Meningitis, epidemic cerebro- spinal, see Cerebro-spinal meningitis. Meningitis, simple, article on, 808 definition, 808 symptoms of acute form, 808 varieties, 811 course, 813 patliological anatomy, 814 etiology, 814 diagnosis and treatment, 815 symptoms of the chronic form, 816 treatment, 817 Meningitis, spinal, article on, 951 symptoms, 951 post-mortem appearances, 955 causes, 955 diagnosis and prognosis, 955 treatment, 956 diagnosis of, from myelitis, 963 Meningitis, spinal, in gout, 619 in acute rheumatism, 560 treatment of, 573 Meningitis, tubercular, article on, 817 causes, 817 symptoms in the child, 818 meningitis of the base, 830 of the vertex, 837 symptoms in the adult, 829 diagnosis, 829 morbid anatomy, 832 prognosis and treatment, 835 Menorrhagia in purpura, 461 in yellow fever, 289 a predisposing cause of rheu- matoid arthritis, 5.54 Menstruation, a cause of ro- seola, 105 a predisposing cause of ery- sipelas, 323 eflfeet of influenza on, 43 effect of typhus on, 261 supposed influence oi', on oc- currence of rheumatism, 564 supposed preventive of gout, 537, 536 INDEX OF VOL. I. Menstruation — disorders of, relation of, to hysteria, 633 to insanity, 590 irregular, a predisposing cause of rheumatoid artli- ritis, 554 suppression of, a cause of spinal congestion, 968 of rheumatism, 565 of somnambulism, 660 Mercurial inunction in rheu- matic pericarditis, 571 Mercurial tremor, 801 Mercury, diagnosis of pains from, from muscular rheu- matism, 575 in cerebro-spinal meningitis, 813 in cholera, 418 in diphtheria, 83 in dysentery, 383 in gout, 540 in influenza, 46 in remittent fever, 371 in acuta rheumatism, 518 in rheumatic pericarditis, 571 in rickets, 495 in scurvy, danger of, 453 in typhoid fever, 347 in syphilis, 439, 435 how far preventive of consti- tutional syphilis, 439 early use of, not preventive of constitutional syphilis, 436 modes of administration of, in syphilis, 438 local use of, in syphilis, 438 value of, in treatment of chronic hydrocephalus, 839 of insanity, 633 of meningitis, 815 of syphilitic disease of the brain, 901 Mercury, bichloride of, in syphilis, 438 Mercury, biniodide of, oint- ment of, for enlarged spleen , 364 Mesenteric glands, atrophy of, after typhoid fever, 308 enlargement of, In rickets, 483 Inflammation of, in scarla- tina, 333 morbid anatomy of, in plague, 819 morbid anatomy of. in ty- phoid, 305, 315 tubercular disease of, in pul- monary phthisis, 331 tubercle of, diagnosis of, from typhoid, 345 Mesmerism, the theory of, 656 Mesocolic glands, morbid ana- tomy of, in typhoid, 315 Metacarpal bones, morbid ana- tomy of, in rheumatoid arth- ritis, 551 Metallic tremor, article on, 801 synonyms, 801 definition, 801 mercurial tremor, causes 801 symptoms, 803 course and prognosis, 804 diagnosis, S03 VOL. I.— 69 Metallic tremor — patliology and morbid ana- tomy, 805 treatment, 805 lead tremors, 806 symptoms, 807 prognosis, 807 diagnosis and treatment, 807 [Metalloscopy and metallothe- rapy, 637] Metastastis in gout, 513 treatment of, 546 in parotitis, 199 Metatarso-phalangeal articula- tion of great toe, com- monly affected in gout, 513, 535 morbid anatomy of, in gout, 524 [Methomania, 681 treatment of, 089] Microscopic appearances, of the brain, in abscess of the brain, 936 in congestion, 851, 853 in softening, 875 of nodes in the dura mater, 813 of the muscles in wasting palsy, 790 of the spinal cord, in loco- motor ataxy, 983 in tetanus, 977 in wasting palsy, 793 Middle cerebral artery, embo lism of, 809 Migraine, or sick headache, 1031 Miliaria, general pathology of, 123 in rheumatic fever, 133 in scarlet fever, 85, 88 in scarlet fever rash, 133 Miliary aneurisms in the brain, see Aneurisms. Milk, anti-scorbutic properties of, 459 [contamination of, a cause of typhoid fever, 343] want of, a cause of rickets, 474 Milk, ass's, in rickets, 495 Millbank prison, dysentery at, 374 Mind, activity of, a predispos- ing cause of diphtheria, 64 anxiety of, a cause of rheu- matoid arthritis, 554 depression of, before pur- pura, 463 depression of, as a predispos- ing cause of scurvy, 450 exertion of, a cause of gout, 529 Mind, state of, in chronic al- coholism, 076 in chorea, 699 in congestion of the brain, 845 in chronic cerebral softening, 864 in delirium tremens, 679 in epileptics, 773 in general paralysis, -606 in hypochondriasis, 635 in hysteria, 635 in locomotor ataxy, 986 in torticollis, 1003 Mineral waters in gout, 547 1089 Mineral waters — in rheumatoid arthritis, 557 Mist, cholera, of Mr. Glaisher, 387 ' Moisture, a cause of dysentery, 374 of purpura, 463 a cause of articular rheuma- tism, 559, 565 of gonorrhoea! rheumatism, 570 of muscular rheumatism, 574 of rickets, 473 a predisposing cause of scurvy, 450 influence of, on cholera, 387 Moisture of the atmosphere, relation of, to the occurrence of sunstroke, 666 Mollities ossium, diagnosis of, from rickets, 485 Monomania, course and symp- toms, .599 prognosis, 617 treatment, 623 relation of, to mania, 598 to dementia, 59o Monomanie, instinctive et rai- sonnante, 603 floral imbeciles, R03 Moral insanity, 596, 601 diagnosis, 609 treatment of, 633 Morbid anatomy, generally con- sidered, 38 Morbid sleep, causes of, 059 Morbilli, see Measles. Morning sickness, from alco- holism, 677 Morphia, in cerebro-spinal men- ingitis, 813 in cholera, 416, 418 in diphtheria, 78 In hooping-cough, 55 in influenza, 46 In acute rheumatism, 568 In smallpox, 143 In yellow fever, 394 endermic use of, in muscular rheumatism, 956 enemata of, in hemorrhage in typhoid fever, 349 external application of, in gout, 540 to rheumatic joints, 573 Morphia, value of, in treatment, see Opium. injection of, see Hypodermic Injection. Mortality, In cerebro-spinal meningitis, 303 in cholera, 408 from convulsions, 749 from dengue, 98 in diphtheria, 17 in dysentery, 881 in erysipelas, 327 in glanders, 193 from gout, 537 In hooping-cough, 53 in hydrophobia, 194 in influenza, 43 from insanity, 618 in intermittent fever, 356 in measles, 114 from paralysis agitans, 739 in plague, 317 in pyfemia, 847 in rel.apsing fever, 379 1090 INDEX OF VOL. I. Mortality — in remittent fever, 368, 370 in rheumatism, 567 from rickets, 471 in searlet fever, 94 in scurvy, 447, 457 In smallpox, 145 In inoculated smallpox, 156 from sunstroke, 608 in typhoid fever, 247 in typhus, 265 in varicella, 127 amongst workers in mercury, 804 Mortality, to populations, from cholera, 386, 388,393 from dysentery, 373, 381 from smallpox, 167 Mother, health of, influence of, in production of rickets, 473 Motorial phenomena, abnor- mal, in epileptics, 774, 776 in congestion of the brain, 845 in hysteria, 637 in meningitis, 823 in softening of the brain, 860 Mouth, bleeding from, in yel- low fever, 289 distortion of the, in cerebral hemorrhage, 913 in facial paralysis, 1050 in tetanus, 971 gangrene of, in measles, 112 scars around, in hereditary syphilis, 441 Movement cure, tbe, efficacy of, in chorea, 716 in myelitis, 905 Movement, relation of, to pain , in cerebral meningitis, 809 in spinal meningitis, 953 in neuralgia, 1033 Mucous membranes, affection of, in secondary syphilis, 434, 436 In tertiary syphilis, 431 Mucus in stools of dysentery, 375, S7G, 377 vomiting of, in dengue, 100 [Multiple sclerosis, 1011] Mumps, see Parotitis. Murexide test for uric acid, 531 Murmur, cardiac. In rheumatic endocarditis, 560 occasional, in scarlet fever, 93 Muscae volltantes, in chronic alcoholism, 676 in congestion of the brain, 845 Muscles, affected rarely in ery- sipelas, 325 extravasations of blood into, in purpura, 461 in scurvy, 456 morbid anatomy of, in pyaa- mia, 334 pain in, in epidemic cerebro- spinal meningitis, 297, 298 rigidity of, In typhus, 255, syphilitic affections of, 433 twitching of, In dengue, 100 weakness of, in rickets, 477, 483 Muscles, electrical state of, see Electric condition. Muscles, chiefly or primarily affected, in alcoholism, 676 In chorea, 698 in general paralysis of the in- sane, 605, 999 in general spinal paralysis, 999 in hysterical paralysis, 638, 1000 in lead palsy, 807 in mercurial tremor, 803 in paralysis agitans, 730 in infantile paralysis, 1006 in wasting palsy, 788, 789 in writer's cramp, 733 Muscles, prolonged contraction of, in spinal irritation, 995 spasmodic contractions of, in tetanus, 971 Muscular anajsthesia, article on, 783 diagnosis of, from locomotor ataxy, 784 relation of, to paraplegia, 784 Muscular atrophy, progressive, 786 diagnosis of, from infantile paralysis, 1006 from injury to nerve-trnnks, 1050 from lead-poisoning, 790 Muscular fibre, degeneration of, in diphtheria, 74 during purpura, 464 in scarlet fever, 94 in typhus, 204 in typhoid fever, 217 softening of, in yellow fever, 291 of heart, state of, in pyaemia, 333 of intestine, changes in, in typhoid ulceration, 210 Muscular sense, the, 785 loss of, in general paralysis, 606 in locomotor ataxy, 987 hallucinations of, in mania, 597 Muscular tremor, from alco- holism, 676 from mercurial poisoning, 802 from paralysis agitans, 730 Mushrooms, poisoning by, re- sembling typhoid fever, 243 Musk, in hooping-cough, 56 in parotitis, 123 in typhus, 268 Myalgia, diagnosis of, from neuralgia, 1040 [Myalgia, of Inman, 573] Myelitis, article on, 956 symptoms, 956 post-mortem appearances, 903 causes, 963 diagnosis, 963 prognosis and treatment, 964 Myelitis, complicating typhoid fever, 235 Myelitis convulsiva, 700 "VTACHPOCKEN, 173 1* Nails, affection of, in syphi- lis, 4:;3 Names of disease, 17 Naphtha, in treatment of cho-. rea, 715 Narcotics, In treatment of acute mania, 621 of infantile convulsions, 750 of delirium tremens, 686 Nares, discharge from, in glan- ders, 189, 190 inflammation of, In congeni- tal syphilis, 439 occlusion of, in diphtheria, an unfavorable symptom, 77 treatment of, 79 Nasal diphtheria, a complica- tion of scarlet fever, 90 Nasal fossffi, affection of bones of, in syphilis, 433 mucous membrane of, state of, in diphtheria, 65 state of, in glanders, 191 state of, in influenza, 41 Natural history of disease, 21 Nausea, with vomiting, see Vomiting. Nausea, in mild dysentery, 375 in invasioa of intermittent fever, 355, 356 an early symptom of malarial poisoning, 855, 356, 365 in purpura, 463 Necrosis of bones, a sequel of scarlet fever, 90 in scurvy, 453, 456 of jaw, a sequela of scarlet fever, 93 of long bones, from syphilis, 433 of nasal bones, in chronic glanders, 191 of palate and nasal bones, in syphilis, 433 Negroes predisposed to tetanus, 978 Nephritis, in gout, 519, 530 diagnosis from renal calcu- lus, 530 from inflammation of blad- der, diagnosis of, from py- asmia, 348 Nerves, division of, for cure of neuroma, 1035 of neuralgia, 1047 Nerves, syphilitic deposit in, 435 Nervous constitution or dia- thesis, the, predisposes to alcoholism, 673 to insanity, 588 to spinal irritation, 996 relation of, to hysteria, 633 Nervous depression as a causa of gout, 539 Nervous system, changes in, the real cause of roseola, 105 Nervous system, peculiarities of the, In children, 738 Neuralgia, article on, 1026 definition and synonyms, 1026 symptoms, 1037 varieties, 1037 complications, 1037 diagnosis, 1040 prognosis, 1040 pathology and etiology, 1041 treatment, 1043 Neuralgia, in epidemic cerebro- spinal meningitis, 298, 299 INDEX OF VOL. I. Neuralgia — in gout, 519 diagnosis of pleurisy from, 575 diagnosia of, from hysteria, 643 relation of, to alcoholism, 674, 1043 Neuralgic iritis, 1038 treatment of, 1045 Neuralgic pains in inHuenza, 42 in locomotor ataxy, 954 Neuritis, acute, 1020 chronic, 1021 Neuroma, Idiopathic, 1023 traumatic, 1035 a cause of epilepsy, 1024 Neuromata, syphilitic, 435 Nitric acid, in hooping-cough, 56 in rickets, 495 as a caustic in bites of rabid animals, 200 [Nitrite of amyl in epilepsy, 782] Nitro-hydrochloric acid in rickets, 495 Nodes, syphilitic, on bones, 488 of cellular tissue, 433 in the muscles, 433 periosteal, in congenital syphilis, 429, 440 treatment of, 487 periosteal swellings, in scurvy, mistaken for, 452 Nomenclature of diseass, 17 Nose, discharge from, lu glan- ders, 189, 190 in congenital syphilis, 429, 430 sunken bridge of, a sign of inherited syphilis, 441 Nux vomica, in glanders, 193 in hooping-cough, 56 in rheumatoid arthritis, 557 in rickets, 496 Nyctalopia in scurvy, 453 OBJECTIVE symptoms con- sidered generally, 25 Occipital nerve, the great, neu- ralgia of, 1033 Occiput, tenderness of, in rickets, 477 Occupation, a predisposing cause of alcoholism, 673 of insanity, 588 of meningitis, 814 of wasting palsy, 786 influence of, on liability to cholera, 390 want of, a cause of hypo- chondriasis, 626, 629 of hysteria, 632 value of, in treatment of epi- lepsy, 783 of insanity, 619 of hysteria, 644 of hypochondriasis, 629 Ochlesis, a predisposing cause of typhus fever, 253 Odor, the peculiar, of the breath in alcoholism, 677 CEdema, rare in diphtheria, 67 in dengue, 100 in erysipelas, 333 in purpura, 463 in rickets, 483, 483 CEdema — iu scarlet fever, 93 in smallpox, 139 a sequel of typhoid fever, 209 ' of joints in gout, 513, 514, 536 over rheumatic joints, a rare occurrence, 501 of lung in influenza, 42 of lung in scurvy, 453, 456 CEdema glottidis, in erysipelas, 827 In scarlet fever, 86, 93 in typhoid fever, 225 after typhus, 263 CEsophagus, affection of, in gout, 619 exudation on, in diphtheria, 75, 76 inflammation of, in hydro- phobia, 199 muscular rheumatism in, 574 spasm of, 1058 ulceration of, in tertiary syphilis, 433 ulceration of, in typhoid fever, 210 Oinomania, description of, 681 prognosis, 083 Olecranon, abscess of the bursa over the, in gout, 517 enlargement of, in rickets, 488 Olivary bodies, functions of the, 943 Operations, surgical, a cause of pyaemia, 888 Ophthalmia, complicating den- gue, 103 in gout, 520 in relapsing fever, 279 treatment of, 2S0 in smallpox, 1 34 treatment of, 144 gonorrhoeal, complicating gonorrhoeal rheumatism, 576, 577 [Ophthalmia, a sequela of measles, 113] Ophthalmoscopic appearances in locomotor ataxy, 985 in meningitis, 834 in tumor of the brain, 884 Opisthotonos in cerebro-spinal meningitis, 297, 300 in meningitis, 833 in tetanus, 971 Opium, in cerebro-spinal men- ingitis, 313 ' in cholera, 415, 416, 418 in choleraic diarrhoea, 430 in dengue, 104 in diphtheria, 78, 81 in dysentery, 380 in erysipelas, 328 in hooping-cough, 55 in influenza, 46 in intermittent fever, 360 in measles, 115 in pyaamia, 351 in acute rheumatism, 568 in rheumatic pericarditis, 571 in gonorrhoeal rheumatism, 579 in rickets, 495 in scurvy, 458 in smallpox, 143 in typhoid fever, 247 1091 Opium — iu typhus, 268 enemata, in chronic dysen- tery, 383 in typhoid fever, 248 for diarrhoea in diphtheria, 82 external application of, in gout, 540 in muscular rheumatism, 575 Opium, value of, in treatment of chorea, 715 of infantile convulsions, 751 of delirium tremens, 686, 088 of mania, 621 of spinal meningitis, 956 of neuralgia, 1044 of tetanus, 979 Opium-eating, a cause of in- sanity, 5S9 Opium-poisoning, diagnosis of, from cerebral hemorrhage, 939 rapid death from, 930 Optic neuritis, relation of, to cerebral hemorrhage, 023 a symptom of meningitis, 824 of cerebral tumor, 846 Optic thalamus, the, arterial circulation through, 909 a frequent seat of cerebral hemorrhage, 903 of cerebral softening, 873 symptoms of hemorrhage into, 913 Orchitis, in mumps, 119 syphilitic, 434 Organic cerebral disease, diag- nosis of, from epilepsy, 77'J Os calcis, nodes on, in tertiary syphilis, 433 Osseous tumors in the brain, 893 Ossification, abnormalities of, in rickets, 488 Osteo-malaliia, diagnosis of, from rickets, 485 Otitis, in influenza, 43 in smallpox, 133 Otorrhosa, in cerebro-spinal meningitis, 300 in measles, 113 after scarlet fever, 90 treatment of, 97 Otorrhoea, or otitis, chronic, a cause of abscess in the brain, 935, 937 of convulsions, 746 of facial palsy, 1051 of meningitis, 813, 831 Over-crowding, a cause of heat apoplexy, 662, 663 Over-eating, a cause of cerebral hemorrhage, 934 of somnambulism, 659 see also Food, excess of. Over-exertion, a cause of con- gestion of the brain, 848 of neuralgia, 1027 of paralysis agitans, 725 of wasting palsy, 787, 790 of writer's cramp, 734 Over-work, a cause of convul- sions, 757 of epilepsy, 765 of hysteria, 633, 641 of hypochondriasis, 627 of sunstroke, 663, 004 1092 INDEX OF VOL. I. Over-work, a cause — of vertigo, 69i Oxalates, in urine of diphthe- ria, 68 of rickets, 484 Oxalic acid, in the blood in gout, 531 free, in the blood, a supposed cause of rickets, 487 In urine of gouty subjects, 530 Oxygen, inhalation of, in cho- lera, 431 Ozone, deficiency of, in cho- lera epidemics, 387 its influence in exciting in- fluenza, 37 influence of, on occurrence of typhoid, 338 PACKING, Tvet, in acute mania, 630 Pain in the head, se« Headache. Pain, articular and muscular, in glanders, 189, 190 character of, in cerebro- spinal meningitis, 397 in dengue, 100 in erysipelas, 333 in gout, 513, 514, 536 in influenza, 41 in parotitis, 119 in acute rheumatism, 561 In muscular rheumatism, 574 in back, in epidemic cerebro- spinal meningitis, 397, 299 in intermittent fever, 355, 356 In relapsing fever, 377 in smallpox, 133, 135 in yellow fever, 284 in limbs, in erysipelas, 323 in relapsing fever, 377 in typhoid fever, 303, 304 its effect. on appetite and di- gestion, 121 Pains, in the back, from spinal congestion, 967 from spinal meningitis, 953 character of the, in hypo- chondriasis, 625 in hysteria, 635 in spinal irritation, 993 the sudden, paroxysmal, of neuroma, 1023, 1033 of locomotor ataxy, 984 of spinal hemorrhage, 1007, 1016 neuralgic, relation of, to in- flammation, 947 Palate, ulceration of, in ter- tiary syphilis, 433 bones of, frequently affected in tertiary syphilis, 433 Palate, soft, condition of, in diphtheria, 65, 75 redness of, in influenza, 41 state of, in measles, 110 state of, in scarlet fever, 86 unilateral paralysis of, in facial palsy, 1053 Pali plague, 316 history and symptoms of, 318 Palpitation of the heart in re- trocedent gout, 519 in spinal irritation, 994 Palsv, facial, 1050 metallic, 801 Palsy- shaking, 718 Pancreas, injection of, a post- mortem appearance in ty- phus, 365 morbid anatomy of, in cho- lera, 411 in typhoid fever, 317 in yellow fever, 293 Papillae of skin in rash of measles, 108 Papules in smallpox, 139, 203 in typhoid, 303, 304, 317 in vaccinia, 159 in varicella, 136 Paralysis, i.bsence of, in some eases of apoplexy, 927 in locomotor ataxy, 984 in spinal irritation, 996 in sunstroke, 667 in spinal meningitis, 953 Paralysis, in cerebro-spinal meningitis, 298, 300 in gout, 519 in pytemia, 346 facial, a sequel of scarlet fever, 90 diphtheritic, 68, 74 affecting the bladder, 70 heart, 09 muscles of abdomen, 70 of deglutition, 69 of limbs, 69 of respiration, 69 of tongue, 69 nerves of special sense, 69 pathology of, 73 treatment of, 83 local, in relapsing fever, 378 of lower jaw, in hydrophobia, 199 of special nerves from syphi- litic nodes, 433, 435, 440 Paralysis agltans, article on, 718 definition, 718 history, 719 varieties and description, 730 causes, 735 diagnosis, 736 complications, 737 pathology and morbid ana- 737 prognosis, 739 treatment, 729 references, 730 Paralysis, a complication of sciatica, 1036 following infantile convul- sions, 744 [following scarlet fever, 93] partial, in chorea, 698 Paralysis, general, of the in- sane, 605, 999 due to chronic menineltis, 817 or to cerehritis, 856 Paralysis, general spinal, 999 essential, of children, 1004 histrionic, 1050 hysterical, 638, 1000 from cerebral softening-, 863, 865 ^' ' see also Hemiplegia and Para- plegia. Paralysis, local, from nerve disease, article on, 1048 facial palsy, 1050 of the third cranial nerve, 1054 Paralysis, facial — of the Uith, sixth, &c., 10.55 [Paralysis, spastic spinal, 1009] Paraplegia, diagnosis of, from muscular anaesthesia, 330 from locomotor ataxy, 963, 989 due to hysteria, 640, 1000 to myelitis, 958 to reflex causes, 1001 incomplete, from spinal con- gestion, 966 Paroxysm, the epileptic, 770 hysterical, 639 tetanic, 971 Partial mania, 599 Par vagum, paralysis of, in diphtheria, 69 Parotid glands, inflammation of, in cerebro-spinal men- ingitis, 303 in cholera, 404 In dengue, 103 in influenza, 43 in parotitis, 119 in relapsing fever, 378 Inflammation of, in typhus, 361 treatment of, 268 a sequel of typhus, 363 morbid anatomy of, in ty- phus, 305 suppuration of, in cholera, 404 after scarlet fever, 90 Parotitis, article on, 118 definition, 118 diagnosis, 120 pathology, 119 symptoms, 118 synonyms, 118 treatment, 130 Patella, nodes of, in tertiary syphilis, 433 Pathological anatomy con- sidered generally, 28 Patholog}', considered gener- ally, 37 in relation to diagnosis, 27 Pelvis, deformity of, in rickets, 480, 536 Pemphigus, complicating pur- pura, 460 Penis, gangrene of, an occa- sional sequel of cholera, 404 in erysipelas, 336 Popsine, in yellow fever, 294 Perforation of the bowel In typhoid fever, 175, 303, 308 Pericarditis, in cerebro-spinal meningitis, 303 in cholera, 413 in influenza, 43 in pyaemia, 333, 346 in acute rheumatism, 560, .563 treatment of, .570 as a sequela of scarlet fever, 93 absence of tendency to, in acute rheumatoid arthritis, 5.53 supposed occurrence of, after injection of lactic acid into the peritoneum, 566 Pericardium, effusion into, in acute rheumatism, 560 in scarlatinal dropsy, 93 INDEX OP VOL. I. Pericardium, effusion into— m scurvj', 4or in yellow fever, 201 extravasation of blood into in purpura, 40o ' morbid anatomy of, in p-se mia, S:io white patches on, in rickets. Periodicity, in mania, 597 in epilepsy, 775 in neuralgia, 1029 in somnambulism, 059 of gout, cause of, 535 "seof, in diagnosis of gout. impress of, on various dis- eases, by malaria, 354 Periosteum, inflammation of in secondary syphilis, 425 ' in tertiary syphilis, 432 effusion under, in scurvy 452 gouty deposits under, 516, 525 nodes of, in tertiary syphilis 420, 432 thickening of, over heads of bones in rickets, 490 Peripneumonia notha, see Influ- enza. Peritoneum, congestion of, in cholera, 411 effusion into, in the plague, 316 morbid anatomy of, in cho- lera, 413 morbid anatomy of, in DV£e- mia, 334 Peritonitis, in cholera, 412 in pyaemia, 334 in acute rheumatism, 560 as a sequel of scarlet fever, 93 ' in smallpox, 133 in typhoid fever, from per- foration of intestines, 203, 208 from suppuration of mesen- teric glands, 215 in typhus, 258 tubercular, diagnosis of, from typhoid fever, 245 Perivascular canals in the brain, 850, 909 dilatation of, from chronic congestion, 852 state of, in tubercular men- ingitis, 834 [Pernicious fever, 359] Perspiration, see Sweat and Sweating. Petechise, in cerebro-spinal meningitis, 299, 302 in diphtheria, 91 in glanders, on serous sur- faces, in horses, 184 in malignant measles, 108 in the plague, 314 In pyaimia, 331, 333, 334, 335 in purpura, 460, 463 in relapsing fever, 278 in remittent fever, 368 in scarlet fever, 86 in scurvy, 451 in smallpox, 130, 133 in semi-confluent smallpox, 130 in typhus, 357 in yellow fever, 293 Petit Mai, le, symptoms of, 768 i-eyer s patches, enlargement of, in cholera, 411 in scarlet fever, 94 in typhus, 264 fragments of, in stools of tv- phoid, 244 inflammation of, in pneumo- nia, 221 iu scarlatina, 323 inflammatory products iu, in typhoid fever, microscopi- cal appearances of, 212 morbid anatomy of, in diph- theria, 70 in typhoid fever, 209 in yellow fever, 393 tubercular disease of, in pul- monary phthisis, 226, 245 ulceration of, in severe forms of intermittent fever, 239 in pulmonary phthisis, 221 in scurvy, 331 iu typhoid fever due to he- patic congestion, 219 Phantom tumor, in hypochon- driasis, 627 in hysteria, 643 Pharynx, affection of, in gout, 519 ' 6 I occasionally affected in paro- titis, 119 condition of, in diphtheria, 65 in hydrophobia, 199 iu measles, 69, 110 in scarlet fever, 86, 88 in syphilis, 424 in typhus, 257 exudation from, in diphthe- ria, 65, 67, 75 muscular rheumatism in, 574 paralysis of, in diphtheria, 09 smallpox eruption in, 131 spasm of, 1058 spasm of, in hydrophobia, 198 ulceration of, in glanders, 190 iu tertiary syphilis, 433 in typhoid fever, 316 Phlebitis, a cause of pyajmia, 338 a sequel of typhus, 263 Phlegmasia dolens after abor- tion, in typhoid fever, 206 Phlegmon, diagnosis of, from erysipelas, 325 Phlegmonous inflammation in smallpox, 133 Phosphates, deposit of, from the urine, in chorea, 700 excess of, in the urine of acute mania, 597 in urine, in rickets, 477, 484 in scarlet fever, 87, 88 in typhus, 260 Phosphates of iron, quinine, and strychnine, formula for, 364, foot-note Phosphoretted hydrogen in the air of marshes, 353 Phosphoric acid, in roseola, 106 free in the blood, a supposed cause of rickets, 487 Phosphorus, value of, in treat- ment of chronic alcohol- ism, 686 of chorea, 717 1093 Phosphorus, value of, in treat- ment of locomotor ataxy 990 ^ ' of myelitis, 964 of spinal irritation, 998 Phrenic nerve, supposed seat of hooping-cough, 52 Phthisical insanity, 590 Phthisis, connection of, with alcoholism, 683 tendency to, in the insane, 590 a sequel of chronic mercurial poisoning, 804 in measles, 112 relation of gouty diathesis to, 530 tubercular disease of intes- tines in, 221, 236, 245 ulceration of intestines in, resembling typhoid fever. Physical sign, meaning of the term, 24 Pigeon-breast, in rickets, 470 Pigment, deposits of, in the brain, after chronic conges- tion, 853 Pigment iu urine, in intermit- tent fever, 358 in remittent fever, 367 iu scarlet fever, 87 Pigmentation of viscera iu in- termittent fever, 359 Piles in gout, 519 as a sequel of dengue, 103 Pins and needles, causes of in- fantile convulsions, 750 Pitting after smallpox, preven- tion of, 144 after syphilitic eruptions, 432, 439, 441 after varicella, 126, [136] Pituitary and pineal bodies, tumors of the, 803 Plague, the, article on, 314 causes of, 317 deflnition, 314 diagnosis, 315 morbid anatomy, 316 natural history, 317 prophylaxis, 317 symptoms, 314 synonyms, 314 treatment, 317 [Plague, since 1873, 320] Plaques jaunes, of Cruveilhier, in the brain, 878 Plethora, supposed relation of, to gout, 531 Pleura, effusion into. In the plague, 316 in pyfemia, 332 in rickets, 483 in scarlatinal dropsy, 93, 95 in typhoid fever, 331 effusion of bloody fluid into, in scurvy, 453, 456 morbid anatomy of, in pya3- mia, 333 Pleurisy, diagnosis of pleuro- dynia from, 575 Pleurisy, in cerebro-spinal men- ingitis, 519 in cholera, 303 in gout, 404 in influenza, 43 in pyaemia, 332 in relapsing fever, 278 1094 INDEX OF VOL. I. Pleurisy — in ricliets, 482 in acute rheumatism, 560 treatment of, 573 a sequela of scarlet fever, 93 In smallpox, 133, 146 treatment of, 143 in hereditary syphilis, 430 in typhoid fever, 332 Pleurodynia, 574 Pneumogastric nerve, paralysis of, in diphtheria, 69 supposed paralysis of, in in- fluenza, 43 supposed seat of hooping- cough, 53 Pneumogastricnerves, affection of, in diphtheria, 09 Pneumonia, complicating deli- rium tremens, 683 influence of, on prognosis, 083 treatment of, 689 gouty, 518 in cerebro-spinal meningitis, 303 in cholera, 404 in diphtheria, 76 in chronic glanders, 190 In influenza, 43 a sequel of measles, 113 treatment of, 116 in relapsing fever, 378 in scarlet fever, 90, 93 in smallpox, 133 treatment of, 143 in typhoid fever, 331 in typhus, 358, 365 treatment of, 268 idiopathic, diagnosis of, from typhus, 363 diagnosis of pyaemia from, 348 lobular, concealing the com- mencement of rickets, 476 lobular, in pyaemia, oo'3 Podophylline, in gout, 540 in intermittent fever, 363 [Polio-myelitis, 1004] Pons Varolii, symptoms of hemorrhage into, 914 Portal venous system, conges- tion of, in cholera, 410 Portio dura, paralysis of the, 1050 Port^wine, influence of, in pro- duction of gout, 538 Posterior columns of the spinal cord, functions of the, 943 degeneration of, in locomotor ataxy, 983 [Posterior spinal sclerosis in locomotor ataxy, 983] Potash in gout, acute, 539 chronic, 543 want of, in food, a supposed cause of scurvy, 455 Potash, acetate of, in intermit- tent fever, 363 In measles, 115 Potash, arsenite of, in rheuma- toid arthritis, 557 Potash, bicarbonate of, in in- termittent fever, 360, 363 in acute rheumatism, 569, 573 in muscular rheumatism, 575 in rickets, 495 topical use of, in rheumatism, 573 Potash, chlorate of, in diphthe- ria, 80, 83 in acute rheumatism, 569 in yellow fever, 394 for suppression of urine in influenza, 47 Potash, citrate of, in intermit- tent fever, 363 in acute rheumatism, 569, 573 in rickets, 497 in smallpox, 141 Potash, nitrate of, in dengue, 104 in influenza, 46 in acute rheumatism, 569 in scurvy, 456 in yellow fever, 394 as an external application in rheumatism, 573 Potash, permanganate of, in diphtheria, 80 Potash, tartrate of, in acute rheumatism, 573 Potassa fusa, as a caustic in bites of rabid animals, 200 Potassse, liquor, in lickets, 495 Potassium, bromide of, in cere- bro-spinal meningitis, 313 in rheumatoid arthritis, 557 see, also. Bromide. Potassium, iodide of, in cere- bro-spinal meningitis, 313 in chronic gout, 543 causing purpura, 463 in rheumatism, 570 in gonorrhoeal rheumatism, 579 in muscular rheumatism, 575 in rheumatoid arthritis, 557 in rickets, 496 in scurvy, 458 in syphilis, 437, 438 see, also. Iodide. Potato, failure of crop followed by scurvy, 446 Poverty, relation of, to alco- holism, 678 Predisposing causes of disease, meaning of the term, 31 Pregnancy, danger of, in small- pox, 1.37 exemption from scarlet fever, caused by, 94 influence of, in dengue, 103 in relapsing fever, 379 in typhoid fever, 308 in typhus, 361 Pregnancy, insanity of, .593 Pregnancy predisposes to cho- rea, 710 to torticollis, 1061 Pressure, on nerve trunks, a cause of local paralysis, 1049, 1050 Priapism, in myelitis, 961 in spinal meningitis, 054 Primary fever, stage of, in smallpox, 139, 133 Prognosis, generally con- sidered, 39 Progressive locomotor ataxy, 980 Progressive muscular atrophy, 786 Prophylaxis, of cerebro-spinal meningitis, 313 of cholera, 431 of intermittent fever, 361 Prophylaxis — of pyaemia, 348 of relapsing fever, 380 in scurvy, 448, 459 of typhoid fever, 350 of typhus, 369 [of yellow fever, 384] Prostate, abscess of, in pyfe- mia, 334 Protective influence of vaccina- tion, 154, 155, 166 Prurigo in gouty diathesis, 520 Prussic acid, see Hydrocyanic. [Pseudo-hypertrophic muscu- lar paralysis, 799] " Psorenterie," 311 Psoriasis in gouty subjects, .530 Psoriasis palmaris in constitu- tional syphilis, 431 Ptosis, diagnostic value of, 1054 a complication of facial neu- ralgia, 1038 of locomotor ataxy, 985 Ptyalism, in dengue, 103 in smallpox, 139 Puberty as a cause of renewed susceptibility to smallpox after vaccination, 174 Pubes, deformity of, in rickets, 480 [Puerperal convulsions, 761] Puerperal convulsions, relation of, to epilepsy, 766 Puerperal fever, relation of, to pyEemia, 830 Puerperal mania, 590, 598 prognosis of, 617 Puerperal state, a predisposing cause of scarlet fever, 94 Pulmonary apoplexy, compli- cating cerebral hemorrhage, 904 Pulmonary apoplexy, in diph- theria, 76 In purpura, 463 in pyjemia, 333 Pulmonary arteries, engorge- ment of, in cholera, 410 theory of contraction of, in cholera, 412 Pulse, in cerebro-spinal men- ingitis, 398, 303 in cholera, 399, 400 in uraemia in cholera, 403 in delirium tremens, 679 in dengue, 99 in diphtheria, 65, 67, 69, 77 in dysentery, acute, 876 malignant, 377 scorbutic, 377 in epilepsy, 771 in erysipelas, 333, 334, 336 in glanders, 189 in acute gout, 513 in hooping-cough, 50 in hydrophobia, 198 in influenza, 43 in intermittent fever, 357 in mania, 597 in measles, 107 in melancholia, .594 in acute meningitis, 809, 810 in tubercular meningitis, 831 In mercurial poisoning, 803 In myelitis, 961 in malarious neuralgia, 1039 in parotitis, 118, 119 in the plague, 315 INDEX OF VOL. I. Pulse- in purpura, 462 in pyaemia, 344, 345 In relapsing fever, 377 in remittent fever, 306 in acute rheumatism, 559, 562 in muscular rheumatism, 574 iu acute rheumatoid arth- ritis, 553 in rickets, 476, 483 in roseola, 105 in scarlet fever, 85, 87, 88, 89 in scurvy, 452 in smallpojr, 133 in sunstroke, 667 in tetanus, 973 in typhoid fever, 203 iu typhus fever, 256, 201, 363 value of, iu prognosis iu ty- phus, 366 in varicella, 126 iu yellow fever, 284, 285, 288, 393 ' ' . , Pulse, value of the, in diagno- sis of cerebral hemorrhage, 933, 930 occasional Irregularity of, iu children, 830 Pupils, condition of the, in catalepsy, 653 in cerebro-spinal meninsritis, 300 in infantile convulsions, 755 in delirium tremens, 079 in epilepsy, 768, 771 in facial neuralgia, 1037 in general paralysis, 605, 606 after cerebral hemorrhaare, 921 ^ ' in hydrophobia, 196 in locomotor ataxy, 986 in acute meningitis, 809, 810 in tubercular meningitis, 833 in opium-poisoning, 929 in scurvy, 458 in softening of the brain, 860 in sunstroke, 667 in tetanus, 975 in typhoid, 246 in typhus, 246, 359 in yellow fever, 293 Purgatives, in cerebro-spinal meningitis, 312 in cholera, 418 iu cholera fever, 407 danger of, during cholera epidemics, 389, 422 in delirium tremens, 687 in dengue, 103, 104 in diphtheria, danger of, 81 in erysipelatous meningitis, 339 In gout, acute, 539 chronic, 545 in hooping-cough, 54 in intermittent fever, 360 in acute mania, 631 in measles, 115 ready action of, iu measles, 111 in simple meningitis, 815 in tubercular meningitis, 835 in parotitis, 120 in the plague, 317 in purpura, 467 in pyaemia, 350 in remittent fever, 369 in acutei rheumatism, 570 Purgatives— in gouorrhoeal rheumatism, 579 ' in rickets, 495 iu scarlet fever, 95 in scarlatinal dropsy, 97 in smallpox, 141 in typhoid, danger of vege- table, 247 ^ in typhus, 268 iu yellow fever, 293 Purging in cholera, 399, 403 occasional absence of, in cholera, 406 a means of elimination of cholera-poison, theory of, 413 Purpura, article on, 460 causes, 463 definition, 460 diagnosis, 466 nature of, 460 pathological anatomy of, 463 prognosis, 466 symptoms of, 460 treatment of, 467 varieties of, 461 Purpura, diagnosis of, from scurvy, 454 Purpura hsemorrhagiea, 461 papulosa of Hebra, 463 rheumatica, 461 senilis, 461 causes of, 466 simplex, 461 urticans, 463 Purpura, in cerebro-spinal meningitis, 298, 299, 302, 303 iu cholera, 415 in diphtheria, 67, 76 in smallpox, 131, 137 Pus in blood, a supposed cause of pyaemia, 339 in joints in rheumatism, 664 in urine in pya?mia, 346 in veins in pyjemia, 335, 339 in vessels in erysipelas, 326 theory of its presence in blood of pj'semia, 336 Pustular eruption about mouth in influenza, 42 Pustules, in congenital syphilis, 441 in glanders, 189 on skin iu pyaemia, 335, 344, 345 • in smallpox, 129, 130, 146 corymbose, arrangement of, 131 doubtful occurrence of, iu alimentary canal, 146 on eye, 134 morbid appearance of, 146 relation to secondary lever, 133 in benign smallpox, 132 Putrid remittent lever, 367 Pyaemia, article on, 331) commencement of, 347 definition, 330 diagnosis, 347 duration, 347 etymology, 330 general pathology, 338 morbid anatomy, 331 mortality, 347 prognosis, 347 symptoms collectively, 344 1095 Pyaemia — symptoms in relation to va- rious organs, 345 treatment, 348 Pyaemia, a cause of abscess of the brain, 936, 937 Pyaemia, diagnosis of gout from, 536 of rheumatism from, 567 in chronic farcy, 191 after rcvaceination, 161 in smallpox, 133 a sequel of typhus, 262 relation of, to erysipelas, 330 to puerperal fever, 317 Pyrraont waters, in rheumatoid arthritis, 557 Pyrosis in gout, 518 QUARTAN fever, 355 Quieksilver workers, sani- tary condition of, 804 Quinine, in chronic alcoholism, 685 In cerebro-spinal meningitis, 311, 313 after cholera, 419 after dengue, 104 in diphtheria, 78, 81 in malarious dysentery, 383, 384 in erysipelas, 328 in chronic gout, 542 influence of, on excretion of uric acid, 543 in influenza, 46 iu intermittent fever, 361 after measles, 116 in neuralgia, 1043 iu pyemia, 350 in purpura following rheu-' matism, 468 in relapsing fever, 380 in remittent fever, 370 in acute rheumatism, 569 in rheumatoid arthritis, 557 in rickets, 496 in scarlet fever, 96 in smallpox, 142, 143 in typhoid fever, 247 after varicella, 127 in yellow fever, 293 [Quinine in influenza, 46 in typhoid fever, 250 substitutes for, 303] Quino-alkaline treatment of acute rheumatism, 573 Quotidian fever, 355 RABIES canina, see Hydro- phobia. Race, as a predisposing cause of typhus fever, 353, 2(i6 influence of, on susceptibility to smallpox, 138 Rachalgia, see Pain in the back. Rachitis, see Rickets. Radius, deformity of, in rick- ets, 479 [Rage, in the dog, endangers hydrophobia, 197] Rain, influence of, on cholera, 387 influence of, on occurrence of typhoid fever, 235, 242 Raptus melancholicus, 594 1096 INDEX OF VOL. I. Rash, in cerebro-spinal menin- gitis, 2'J8 in dengue, 101 its relation to tlie course of the disease, 101 occasional in diphtheria, 68, 71 in influenza, 42 in measles, 107, 108 in measles, diagnosis of, 113 in measles, recession of, 109 in malignant measles, 107 in purpura, 460 in relapsing fever, absence of, 377 in roseola, lOS In scarlet fever, 85, 89 in smallpox, 133 in corymbose smallpox, 181 in malignant smallpox, 133 on mucous membrane in smallpox, 131, 137 value of, in prognosis, 136 occasional absence of, in smallpox, 139 in constitutional syphilis, 424 duration of, 424 treatment of, 436, 437 in inherited syphilis, 441 in interval between secondary and tertiary stages of syphi- lis, 425, 426 treatment of, 437 in typhoid fever, 203, 204, 217 in typhoid fever, absence of, occasionally, 317 in typhus fever, 256 value of, in prognosis, 266 in varicella, 125 Raving madness, 596 Raw meat for diarrhoea, after measles, 117 Reaction, stage of, in cholera, 401 complications of, 401 imperfect, 403 in cholera, physiology of, 414 Reactionary fever in cholera, 402 Receptaculum chyli, emptiness of, in typhoid fever, 315 Recession of ribs in inspiration in rickets, 479 Rectum, affection of, in gout, 519 stricture of, from syphilitic ulceration, 433 ulceration of, in tertiary syphilis, 433 'Recurrence, of cholera, in the same individual, 393 of diphtheria, 64 of gout, 513, 536, 638 of parotitis, 120 of relapsing fever, 275 of rheumatism, 561 of muscular rheumatism, 574 of gonorrhoea! rheumatism, 576, 577 of roseola, 106 in scarlet fever, 84 of smallpox, 139 of syphilis, 436, 437 of typhus fever, 426 of varicella, unknown, 125 of yellow fever, 386 Recurrent mania, 598 Red eofteuing of the brain, 874 Reflex action, diminished Jn diphtheria, 70 Reflex nervous irritability, in- crease of, from injury of the spinal cord, 945 in hysteria, 638 in tetanus, 9T2 absence of, in myelitis, 960 no excess of, in spinal con- gestion , 967 in spinal meningitis, 954 Reflex nervous irritation, a cause of chorea, 710 of insanity, 613 of paralysis agitans, 734 of paraplegia, lOUl Regimen, see Diet. Regiments, marching, liability of, to cholera, 389 Relapses, in cerebro-spinal meningitis, 304 in cholera, 403 in dengue, 101, 103 in diphtheria, 64 in erysipelas, 334 in measles, 106 in relapsing fever, 377 in scarlet fever, 84 in tertiary syphilis, 431 in typhoid fever, 303 rare in typhus, 261 Relapsing fever, article on, 369 bibliography of, 369 definition, 369 etiology, 374 geographical distribution, 273 history, 269 nomenclature, 369 symptoms, 377 synonyms, 373 therapeutics, 380 Relapsing fever, non-identity of, with typhus, 376 occurring in epidemics, with typhus, 376 [Relapsing fever in Philadel- phia, 374, 375, 377, 379] Remissions, in cerebro-spinal meningitis, 311 in erysipelas, 335 in simple meningitis, 813 in tubercular meningitis, 835 in remittent fever, 365, 366 in pyrexia of typhoid, 338 of pyrexia in typhus fever, 2.55 in yellow fever, 285 Remittent fever, article on, 365 causes, 366 definition, 365 diagnosis, 368 history, 365 modes of commencement, 365 pathology, 368 prognosis, 369 symptoms, 366 synonyms, 365 treatment, 369 Remittent fever, diagnosis of dengue from, 103 diagnosis of, from yellow fever, 286 relation of, to typhoid fever, 228 Remittent fever, infantile, com- plicating hooping-cough, 51 Remittent fever, infantile — treatment of, 57 rickets mistaken for, 475 Renal calculi, diagnosis of pain from, from lumbago, 575 Residence, change of, a predis- posing cause of typhoid fever, 238 Respiration, character of the, in catalepsy, 653 after cerebral hemorrhage, 933 in cerebro-spinal meningitis, 398, -Ml in cholera, 400 in diphtheria, 65, 67 in diphtheritic paralysis, 69 in hooping-cough, 50 in intermittent fever, 357 in measles, 107 in tubercular meningitis, 821 in parotitis, 118 in pyaemia, 344, 345 in scarlet fever, 87 in scurvy, 453 in sunstroke, 666 in typhoid fever, 303 in typhus, 358 Respiration, difficulty of, see Dyspnoea. Rest, importance of, in treat- ment of chorea, 716 of hysteria, 644 of spinal meningitis, 956 of writer's cramp, 735, 737 Restraint, in treatment of de- lirium tremens, 689 of acute mania, 619 Retarded cow-pox, 160 Rete mucosum, changes of, in smallpox, 147 Retention of urine, in dysen- tery, 376 in meningitis, 833 in myelitis, 960 a rare symptom in smallpox, 141 in typhoid fever, 304, 308 in typhus, 361 Retina, congestion of the, in meningitis, 824 degeneration of, in Bright's disease, 923 Retinitis, in congenital syphi- lis, 441 in secondary stage of syphi- lis, 425 treatment of, 436 infiuence of mercury on, 437 Retraction of the abdominal walls in meningitis, 810, 820 Retrocedent gout, 518 Revaccination, 155 indications for, 174 necessity for, 173 phenomena of, 161 protective power of, 175 time for, 174 Rheumatic gout, see Rheuma- toid arthritis. Rheumatic iritis, 1038 treatment of, 1045 Rheumatic meningitis, 811 neuralgia, 1044 Rheumatism, article on, 558 articular rheumatism, causes of, 564 definition, 559 description of acute, 559 INDEX OF VOL. I. 1097 Eheumatism — subacute, 500 diagnosis of, 566 history, 559 morbid anatomy, 563 pathology, 5(15 prognosis, 567 symptoms, considered spe- cially, 561 synonyms, 559 treatment, 5lJ7 muscularrheumatism, causes of, 5To definition, 573 description, 573 diagnosis, 575 history, 573 pathology, 57-1 prognosis, 575 synonyms, 573 treatment, 575 Rheumatism, a cause of embo- lism of the brain, S59 of Insanity, 59t of local paralysis, 1049, 1051 of sciatica, 1037 of spinal meningitis, 955 connection of, with chorea, 699, 710 predisposes to neuritis, 1021 Rheumatism, acute, an excite ing cause of rheumatoid arthritis, 554 complicating scarlet fever, 91,93 treatment of, 97 diagnosis of, from pysemia, 348 diagnosis of, from rheuma- toid arthritis, 555 purpura during convales- cence from, 461 Rheumatism, chronic, diagno- sis of, from rheumatoid arthritis, 555 diagnosis of, from gonor- rhoea! rheumatism, 577 resemblance of pains in early stage of scurvy to, 451, 454 Rheumatism, gonorrhceal, diag- nosis of, from rheumatoid arthritis, 556 Rheumatism, muscular, a dis- tinct disease from articular, 574 Rheumatismus metallicus, 801 Rheumatoid arthritis, article on, 550 causes, 554 definition, 550 description of acute, 553 of chronic, 551 diagnosis, 555 diet and regimen, 858 history, 550 morbid anatomy, 553 pathology, 554 prognosis, 556 synonyms, 550 treatment, 556 Rheumatoid arthritis, con- founded with chronic rheu- matism, 561 diagnosis of rheumatism from, 566 Rhonchi, character of, in broncho - pneumonia of measles, 112 in influenza, 43 Rhonchi, character of— in measles, 107 in typhus, 2")8 in lung affection of scurvy, 453 Rhythmical movements, use of, in treatment of chorea, &c., 649 Ribs, deformity of, in rickets, 479, 481 Rice-water stools in cholera, chemical and microscopical characters of, 404 Riclcets, article on, 473 causes, 473 definition, 473 diagnosis, 473 morbid anatomy, 487 prognosis, 494 symptoms, 475 synonyms, 473 therapeutics, 495 Rickets, a cause of convulsions in children, 747 of hypertrophy of the brain, 899 of laryngismus stridulus, 743 < connection of, with chronic hydrocephalus, 839 [Rickets, infrequency of, in the United States, 474] Rigidity, muscular, distinction between the "early" and "late" varieties of Todd, 960 occurs in cerebral softening, 937, 939 in myelitis, 960 in spinal meningitis, 953 in tetanus, 971 in tubercular meningitis, 830, 833 Rigor mortis in scurvy, 456 Rigor mortis, rapid occurrence of, after tetanus, 970, 976 Rigors, in cerebro-spinal men- ingitis, 397, 398 in dengue, 99 in diphtheria, 65 in dysentery, acute, 376 in erysipelas, 333 in chronic farcy, 190 in glanders, 189 in acute gout, 513 in influenza, 41 in intermittent fever, 357 in measles, 106 in parotitis, 118 in the plague, 314 in pyaemia, 344, 345 a characteristic symptom of pyaemia, 348 in relapsing fever, 277 in remittent fever, 306 in acute rheumatism , 559 in scarlet fever, absent, 85 in scurvy, 453 in smallpox, 133 in typhoid fever, 204 in typhus fever, 254, 258 in yellow fever, 284 Risus sardonicuB vel caninus, 1059 In tetanus, 971 Roseola, article on, 104 cause, 105 course, 105 definition, 104 diagnosis, 108 Roseola — prognosis, 106 treatment, 106 diagnosis of, from flea bites, 106 from measles, 106 from scarlet fever, 04, 106 Roseola, in eerebro-spinal men- ingitis, 298, 303 in smallpox, 132 after vaccination, 159 Roseola, syphilitic, diagnosis of, from measles, 113 resemblance to rash of mea- sles, 113 Rossalia, an old name for scar- let fever, 83 [Eotheln, article on, 117 diagnosis of, 117 symptoms, 117 treatment, 117] Rubeola, see Measles. Rupia syphilitica, 435, foot- note Russian epidemic, identity of, with relapsing fever, 273 mortality of, 380 SACKXJil, deformity of, in rickets, 480 displacement of, in rickets, 493 St. Guy, the dance of, 696 St. John, the dance of, 047,701 St. Vitus, the dance of, 696 origin of, 647 relation of, to paralysis agi- tans, 719 [Salicylic acid in rheumatism, 570 in typhoid fever, 350] Salines in chronic gout, 543 Saline, injections into veins in cholera, 431 treatment of acute rheuma- tism, 569 treatment of cholera, 431 Saliva, diminished flow of, oc- sionally in parotitis, 119 Salivary glands, enlargement of, in hydrophobia, 199 treatment of, 368 inflammation of, a sequel of typhus, 263, 365 swelling of, in dengue, 103 unaffected in plague buboes, 317 Salivation, in dengue, 103 occasionally in parotitis, 119 in smallpox, 139 in scurvy, 4.53 Salt meat, a cause of purpura, 463 influence of, in the produc- tion of scurvy, 448, 449 Salts, injection of, into veins in cholera, 421 Salts of blood, transudation of, in cholera, 414 Sarcocele, syphilitic, 434 Sarsaparilla in syphilis, 437 [Scab, for vaccination, 103] Scabies often coincident with syphilitic eruptions, 439 Scalp, suppuration under, in smallpox, 142 Scammony, in dengue, 104 in remittent fever, 369 1098 INDEX OF VOL. I. Scapulae, deformity of, in rick- ets, 480 Seapulodynia, 574 [Scarlatina, popular error con- cerning, 89] see Scarlet fever. Scarlatinal dropsy, treatment of, 97 Scarlet fever, article on, 83 causes, 84 definition, S3 diagnosis, 93 history, 83 morbid anatomy, 94 prognosis, 94 prophylaxis, 95 Bcquelfe, 89 6ymptoms of latent, 89 symptoms of malignant, 88 symptoms of ordinary, 84 treatment, 05 Scarlet fever, hemorrhagic, 93 surgical, 94 Sydenham's, 89 Scarlet fever, occasional asso- ciation of, with diphtheria, 71 a cause of purpura, 463 confounded with diphtheria, 86 complicated with rheuma- tism, 565 complicating vaccination, 160 diagnosis of dengue from, 103 diagnosis of, from diphthe- ria, 70 diagnosis of, from measles, 113 diagnosis of roseola from, 106 diagnosis of, from roseola In smallpox, 1:;:3 mistaken for rheumatic fever, 94 rash mistaken for typhus, 94 relation of, to diphtheria, 58, 61, 64, 70 relation of, to typhoid fever, 233 Schwalbach waters in rheuma- toid arthritis, 557 Sciatica, 1035 Sciatica in gout, 519 Sciatica neuritis, 1021 [Sclerosis, lateral, 1009 multiple, 1011 posterior, 983 recent study of, 1009 treatment of, 1014] Sclerosis of the brain, in idiocy, 603 in insanity, 615 of the spinal cord, 1008 in locomotor ataxy, 982 see also Induration. Sclerotic coat of eye, deposits of urate of soda in, 517, 520 Sclerotitis in gout, 520 in rheumatoid arthritis, 552 Scorbutus, or scurvy, article on, 445 definition, 445 diagnosis, 454 etiology, 445 morbid anatomy, 456 pathology, 453 prognosis, 4.57 symptoms, 451 Scorbutus, or scurvy — synonyms, 445 therapeutics, 458 Scorbutus, as a cause of cho- lera, 390 complicating dysentery, 372, 373, 377 complicating remittent fever, 367 diagnosis of, from purpura, 467 outbreak of, among the troops in the Crimea, 447 relation of, to typhoid fever, 231 Scrivener's palsy, 732 [Scrofula, article on, 497 anatomy, 503 causation, 507 history, 497 pathology, 503 symptomatology, 498 treatment, 509] Scrofula, a cause of caries of the vertebrae, 1017 communicated by vaccina- tion, 177 eflFect of, on course of syphi- lis, 426 Scrofulosis, diagnosis of, from rickets, 485 supposed relation to rickets, 484, 485 Scrotum, gangrene of, a sequel of cholera, 404 after smallpox, 134 [Scurvy, best preventives of, 459] see Scorbutus. Season, influence of, on cere- bral-spinal meningitis, 308 on cholera, 386 on diphtheria, 62 on gout, 530 on hooping-cough, 48 on influenza, 36 on pulmonary complications in measles. 111 on parotitis, 120 on the plague, 319 on pyaemia, 344 on relapsing fever, 274 on rheumatism, 565 on scarlet fever, 84 on epidemics of smallpox, 156 on typhoid fever, 235 on typhus fever, 253 on vaccination, 160 Secondary fever in smallpox,129 Secondary syphilis, see Syphilis. Secretion suppressed in cho- lera, 400 Secunderabad barracks, dysen- tery at, 374 Sedatives, in treatment of epi- lepsy, 780 see also Opium. Sedentary occupations, a cause of sciatica, 1035, 1036 Semiconfluent smallpox, 128, 130 Semilunar ganglia, supposed inflammation of, in yellow fever, 391 Senega, in diphtheria, 82 in influenza, 46 in long complications of ty- phus, 268 Senile vertigo, 693 treatment of, 695 Sensation, condition of, in chronic alcoholism, 078 in chorea, 698 in congestion of the brain, 845 in epileptics, 774 in general paralysis, 606 in hysteria, 635 in infantile paralysis, 1004 in locomotor ataxy, 984 melancholia attonita, 594 in meningitis, 823 in cerebral softening, 839 in tumors of the brain, 884 in spinal congestion, 906 in spinal meningitis, 954 in wasting palsy, 789 Sensation, loss of, see Anses- thesia. Senses, special, paralysis of, in diphtheria, 69 state of, in congestion of the brain, 845, 846 in idiocy, 604 in locomotor ataxy, 983 in cerebral softening, 859 in vertigo, 690 Sensibility, loss of, in diphthe- ria, 69 Septicaemia, relation of, to py- aemia, 330 Septum narium, perforation of, in chronic glanders, 190 Sequelae, of convulsions, 744 of epilepsy, 772 of sunstroke, 669 Serous apoplexy, 930 Serpentaria in influenza, 46 Serum of blood, changes of, in gout, 521 changes of, in acute rheuma- tism, 562 character of, in yellow fever, 288 effusion of, in rickets, 482 Sewage in drinking water as a cause of cholera, 389 Sewage gases, as a cause of cholera, 388 a cause of typhoid fever, 241 [Sewer gas promotive of ty- phoid fever, 341, 2.51] Sex, considered generally as o. cause of disease, 22 influence of, on mortality in diphtheria, 61 Inflaence of, on the move- ments of respiration, 946 influence of, on occurrence of cerebro spinal meningitis, 308 of cholera, 390 of chicken-pox, 125 of erysipelas, 322 of gout, 527, 536 of hooping-cough, 49 of influenza, 40 of parotitis, 120 of pyasmia, 344 of rabies in dogs, 196 of relapsing fever, 274 of rheumatism, 564 of gonorrhoeal rheumatism, 577 of chronic rheumatoid arth- ritis, 5.51, 5.54, 555 of rickets, 475 INDEX OF VOL. I. Sex, influence of, on occurrence of scarlet fever, 84, !)5 of cellular nodes in tertiary eyphilis, 433 of typhus fever, 353 influence of, on prognosis of chronic alcoholism, e83 of epilepsy, 774, 779 of Insanity, 618 Sex, as a predisposing cause of congestion of the brain, 848 of chorea, 697 of epilepsy, 764 of general paralysis, 605 of hypochondriasis, 626 of hysteria, 631 of insanity, 587 of^ laryngismus stridulus, of locomotor ataxy, 988 of simple meningitis, 814 of tubercular meningitis, 818 of paralysis agitans, 735 of wasting palsy, 786 of writer's cramp, 734 Sexual development, arrest of, in hereditary syphilis, 436 Sexual diseases, a cause of al- coholism, 674 Sexual disorders, of women, a cause of epilepsy, 767 of hysteria, 633, 039 of insanity, 590 Sexual excess, a cause of de- mentia, 600 of epilepsy, 766 of hysteria, 633 of insanity, 589, 603 of locomotor ataxy, 989 of myelitis, 963 of paralysis agitans, 725 of sciatica, 1036 of spinal irritation, 997 of wasting palsy, 788 Sexual organs of women, in- volution of the, a cause of insanity, 587 of neuralgia, 1031 Sexual power, loss of, in idiocy, 604 In general paralysis, 606 state of, in locomotor ataxy, 986 Shaking palsy, 718 Sheep-pox, 138 inoculation of man from, re- sults of, 128 Sherry, influence of, in produc- tion of gout, 538 Shock, a predisposing cause of pysemia, 843 Shock, nervous, a factor in the apoplectic condition, 931 a cause of insanity, S89 of neuralgia, 1038 see also Fright and Emotion. Sick-headache, description of, 1031 Sight affected in diphtheria, 69, 74 in typhus, 259 Sight, defects of, premonitory of cerebral hemorrhage, 933 from cerebritis, 855 In chronic alcoholism, 676 in meningitis, 810 ft-om neuralgia, 1037 Sight- less of, in locomotor ataxy, 9S5 ^' after infantile convulsions, 744 in chronic hydrocephalus. Signs of disease considered generally, 33 Silver, nitrate of, in typhoid fevw, 248 topical use of, in bites of rabid animals, 300 in diphthei-ia, 78 in erysipelas, 329 in hooping-cough, 55 in scarlet feyer, 96 in smallpox, to prevent pit- ting, 144 in scurvy, to gums, 458 in variolous ophthalmia, 144 Singultus, 1058 Sinus of the brain, thrombosis of, 870 Skin, condition of the, in mania, 597 in mercurial poisoning, 803 in sunstroke, 666 Skin, diseases of the, due to chronic alcoholism, 677 Skin, hemorrhage into, in pur- pura, 464 question of elimination of uric acid by, in gout, 523 state of, in cerebro-spinal meningitis, 298, 303 in dengue, 99 in diphtheria, exudation on, 68 in dysentery, acute, 376 malignant, 377 mild, 375 in erysipelas, 333, 334, 326 in farcy, 190 in gout, 514, 530 in hooping-cough, 50 in hydrophobia, 198 in influenza, 43 in Intermittent fever, 356, 358 in measles, 107 in the plague, 314 in purpura, 460 in pyoemia, 344 in acute rheumatism, 559 in gonorrhceal rheumatism, 576 in muscular rheumatism, 574 in rickets, 476 in relapsing fever, 377, 278 in remittent fever, 366 in scarlet feyer, 85, 87, 89 in scurvy, 451 in smallpox, 146 in secondary syphilis, 434 in tertiary syphilis, 431 in typhoid fever, 303, 317 in typhus fever, 256 in yellow feyer, 285 yellow tint of, in yellow fever, 285, 386, 390, 393 Skull, bones of, thickening of, in syphilis, 440 Skull, deformities of the, in idiocy, 603 in chronic hydrocephalus, 837, 838 1099 Skull, fracture of the, a cause of abscess of the brain, 934 diagnosis of, from apoplexy, 939 i- F J, [Skunk, subject to rabies, 197] Sleep, efl'ect of, on prognosis of delirium tremens, 683 value of, in acute mania, 631 Sleeplessness, see Insomnia. Sleep-walking, 658 Sloughing in erysipelas, 324 Smallpox, article on, 127 after vaccination, 149 anatomical characters of a variolous pock, 146 definition, 127 description, 124 diagnosis, 135 epidemic diffusion of, 156 history of, 127 infectious nature of, 138 inoculation for, 156 morbid appearances of, 146 mortality, 145 prognosis, 136 susceptibility to, 137 symptoms, 132 synonyms, 127 treatment of, 140 varieties of, 129 Smallpox, a cause of purpura, 403 complicating scarlet feyer, 93 diagnosis of, from continued feyer, 136 diagnosis of, from febrile lichen, 15 diagnosis of, from measles, 135 diagnosis of, from scarlatina , 132 diagnosis of, from varicella, 136 non-identity of, with chicken- pox, 124 theory of hereditary immu- nity from, 437, 428 Smell, sense of, affected rarely in cerebro-spinal meningitis, 301 Snutfles in hereditary syphilis, 439, 441 Soda in gout, acute, 539 chronic, 543, 557 Soda, arseniate of, in rheuma- toid arthritis, 557 Soda, bicarbonate of, in reac- tionary stage of cholera, 418 Soda, phosphate of, in gout, 544 Soda, sulphate of, in purpiu'a, 407 Soda, tartrate of, in smallpox, 141 Softening, of bones, in rickets, 478, 487 of brain substance in pyse- mia, 334 an occasional sequel of ty- phus, 259 Softening of the brain, acute, 8.57 chronic, 874 post-mortem, 879 red, 804 white, 873 yellow, 875 predisposes to cerebral hem- orrhage, 907 1100 INDEX OF VOL. I. Softenine; of the brain — secondary to abscess, P:"!9 Softening of tlie spinal cord, 1008 Soil, nature of, influence of, on occurrence of cereljro- spinal meningitis, 309 of cholera, 388 of influenza, 36 of the plague, 818 Solitary glands, enlargement of, in cholera, 411 enlargement of, in dysentery, 378 ulceration of, in dysentery, 379 inflammation of, in pneu- monia, 231 inflammation of, in scarlet fever, 223 morbid anatomy of, in ty- phoid fever, 209, 211 in typhus, 205 Bwelllng of, lu scarlet fever, 94 tubercular disease of, in pul- monary phthisis, 221 ulceration of, in severe forms of intermittent fever, 228, 229 ulceration of, in scurvy, 231, 457 Somnambulism, article on, 658 varieties and symptoms, 659 treatment, 660 Sordes on lips, distinction of, from diphtheritic exuda- tion, 72 on teeth and gums in diph- theria, 66, 72 in erysipelas, 324 in measles, 107, 108 in malignant measles, 108 in pysemia, 344 in relapsing fever, 278 in remittent fever, 368 in typhoid fever, 203 in typhus fever, 255, 257 in yellow fever, 287 Sore throat, in dengue, 103 in diphtheria, 65 herpetic, diagnosis of, from diphtheria, 107 in erysipelas, 823 in chronic glanders , 190 in measles, 107 in scarlet fever, 85, 86, 89, 90 treatment of, 96 as a sequel of scarlet fever, 90 treatment of, 96 in smallpox, 131 treatment of, 141 in secondary syphilis, 424 in tertiary syphilis, 430 in typhoid, 203, 223 Spa "waters in rheumatoid arth- ritis, 557 Spasm, definition of, 1055 relation of, to spinal conges- tion, 950 Spasm, of dorsal muscles, in cerebro-spinal meningitis, 297, 299 Spasm, muscular, complicating epilepsy, 774 facia] neuralgia, 1038 paralysis agitans, 721 sciatica, 1037 Spasm — in cerebral softening, 865 in spinal irritation, 995 in tetanus, 971 Spasmodic asthma, causes of, 1056 Spasmodic cholera, 407 Spasms, local, article on, 1055 asthma or bronchial spasm, 1056 cardiac spasm, 1057 hiccup, 1058 muscular cramp, 1059 et seq. treatment, 1060 [Spastic spinal paralysis, 1009] Specific gravity of the brain, in insanity, 615 Speech affected in parotitis, 119 changes in, from abscess of the brain, 938 from cerebral congestion, 845 from general paralysis, 605 from mercurial poisoning, 803 from softening of the brain, 858, 860 in wasting palsy, 789 defective, in epilepsy, 753 a premonitory sign of cere- bral hemorrhage, 924 Speech, loss of, see Aphasia. Spermatorrhoea, treatment of, 660 Sphincter ani, paralysis of, in chronic dysentery, 376 Sphincters, paralysis of the, in myelitis, 960 in spinal meningitis, 954 partial, in locomotor ataxy, 985 absence of, in spinal conges- tion, 966 in spinal irritation, 996 Sphygmograph, use of the, in alcoholism, 672, 079 an aid in prognosis, 683 in epilepsy, 773 Spina bifida, 1018 Spinal congestion, article on, 965 symptoms, 965 post-mortem appearances, 968 diagnosis, 968 prognosis, 968 treatment, 968 Spinal congestion, diagnosis of, from refiex paraplegia, 1003 i- i- S , relation of, to infantile para- lysis, 1004 Spinal cord, affection of, in gout, 519 atrophy of, 1015 concussion of, 1016 congestion of, 905 congestion of, in yellow fever, 291 hemorrhage into, 1007 hypertrophy of, 1015 Induration of, 1008 irritation of, 991 local softening of, in cerebro- spinal meningitis, 305 oedema of, in cerebro-spinal meningitis, 305 physiology of, 944 Spinal cord — softening of, 1008 tumors, 1016 Spinal induration, 1008 a result of myelitis, 963 Spinal irritation, article on, 991 symptoms, 991 post-mortem appearances, 997 causes, 997 diagnosis, 997 prognosis and treatment, 998 Spinal nerves, physiology of the, 943 Spinal paralysis, general, symp- toms of, 999 treatment, 1000 Spinal tenderness, localized, a symptom of hysteria, 635 of spinal irritation, 993, 994 absence of, in myelitis, 960 in spinal congestion, 967 in spinal meningitis, 954 Spine, deformity of, in rickets, 477, 478, 491 Spirits, distilled, a very slight cause of gout, 527, 528 Spleen, albuminoid degenera- tion of, in rickets, 483 disease of the, 623 enlargement of, in intermit- tent fever, 358 treatment of, 364 in remittent fever, 368 in typhoid fever, 204 morbid anatomy of, in cho- lera, 411 in diphtheria, 72, 76 in erysipelas, 326 in infiuenza, 43 in intermittent fever, 359 in relapsing fever, 279 in the plague, 316 in purpura, 463 lu pyiemia, 333 in rickets, 493 in scarlet fever, 94 in scurvy, 457 in typhoid fever, 215 in typhus, 265 in yellow fever, S93 tenderness of, in relapsing fever, 277 in typhoid fever, 204 Splenization of the lung in ty- phoid fever, 221 Splints in gonorrhoeal rheuma- tism, 579 Sponging, cold, in parotitis, 131 tepid, in measles, 114 for malaria, 124 in parotitis, 131 in remittent fever, 369 in typhus, 269 Spurious cow-pox, 161 Sputa, in hooping-cough, 50 in infiuenza, 43 in measles, 111 in pysemia, 345 in scurvy, 453 in typhoid fever, 203 in typhus, 258 Squills, in infiuenza, 46 in yellow fever, 294 Stammering in mercurial poi- soning, 801, 803 relation of, to chorea, 704 INDEX OF VOL. I. Stajihyloma, a rare sequel of chulcra, iU4 Starvation, see Food, deficiency of. Status epilepticuB, 754 Steam, use of, in diplitlieria, 83 in influenza, 4.5 " in scarlet fever, 96 Steel wine in ricliets, 496 Stenosis, see Stricture. Sterno-mastoid a frequent seat of muscular nodes in syphi- lis, 433 Stertorous breathing, in sun- stroke, 667 value of, in prognosis of cere- bral hemorrhage, 922 Stiffness of joints, after den- gue, 103 In gout, 516, .525 in scurvy, 452 in rheumatoid arthritis, 551 Stiffness, muscular, see Rigid- ity. Stigmata in purpura, 4C0 Stimulants, abuse of, in hys- teria, 639, 674 in neuralgia, 674, 1046 excess of, a cause of CGuges- tion of the brain, 848 predispose to sunstroke, 663 value of, in treatment of cho- rea, 715 of delirium tremens, 687 of infantile convulsions, 751 see also Alcohol. Stomach, affection of, by gouty metastasis, 519 disorders of the, causing ver- tigo, 691 treatment of, 695 disturbance of, by malaria, 354 hemorrhage from, see Hsema- temesis. irritability of, in intermittent fever, 355 in remittent fever, 365 morbid anatomy of, in cho- lera, 411 in diphtheria, 76 in hydrophobia, 199 in intermittent fever, 358 in the plague, 316 in scurvy, 457 in typhoid fever, 216 in yellow fever, 291 muscular rheumatism in, 574 pain at the pit of, in tetanus, 977 Stomatitis, in hereditary syphi- lis, 429 gangrenous, after measles, 113 treatment of, 115 Stone-pock, 133 Stools, in dengue, 100 In cholera, 399, 400, 401 chemical examination of, 404 microscopical examination of, 404 in cholera as the medium of contagion, 395 in cholera, removal of, 423 in cholera, retention of, 413 in diarrhoea, choleraic, 407 in dysentery, acute, 375, 376 chronic, 376 malarious, 377 Stools, in dysentery — malignant, 377 mild, 375 scorbutic, 377 in glanders, 189 in gout, ,515 under influence of eolchicum, 539 in measles. Ill in the plague, 315 in pyaemia, 344, 346 in remittent fever, 307 in rickets, 476, 482, 484 in scurvy, 453 in typhoid fever, 203, 204, 207 microscopical examination of, in typhoid, 244 as a means of communicat- ing typhoid fever, 243 in typhus, 2.58, 263 in yellow fever, 285, 293 rice-water, 399 Strabismus, causes of, 1059 in cerebro-spinal meningitis, 300 in diphtheria, 69 in chronic hydrocephalus, 837 in locomotor ataxy, 987 in meningitis, 810, 822 occurs after fits in children, 744 in softening of the brain, 860 Strain of muscles, a cause of muscular rheumatism, 574 Structural disease as contrasted with functional, 19 Strumous disease of the verte- bras, diagnosis of, from spi- nal irritation, 997 Strychnia, after cholera, 419 [in diphtheritic paralysis, 83] in glanders In the horse, 192 in hooping-cough, 56 after intermittent fever, 364 in rheumatoid arthritis, 557 poisoning by, diagnosis of, from tetanus, 978 value of, in treatment of al- coholism, 686 of chorea, 713 of myelitis, 964 Subjective symptoms con- sidered generally, 24 Sublingual gland, inflamma- tion of, after typhus, 263 Submaxillary gland, suppura- tion after typhus, 363 swelling of, in parotitis, 119 Submaxillary lymphaticglands, enlargement of, in diphthe- ria, 66 Subsultus tendinum, in typhus, 259 treatment of, 268 Suckling, prolonged, a cause of rickets, 474 a predisposing cause of rheu- matism, 565 want of, a cause of rickets, 474 Sudamina and miliaria, artic] ■ on, 133 Sudamina, causes of, 133 general pathology of, 123 in influenza, 43 in pysemia, 335, 344, 345 in relapsing fever, 278 1101 Sudamina — in typhoid fever, 303, 218 Sugar, to be avoided in neural- gia, 1046 Sugar in the urine in typhus, 260 increased production of, in the liver of drunkards, 684 Suicide, tendency to, in abscess of the brain, 938 in chronic alcoholism, 678 in melancholia, 592, 594 in tertiary syphilis, 433 Sulphates in urine In acute rheumatism, 563 in typhus, 260 Sulphites, use of, in influenza,47 in pyaemia, 351 Sulphur, in muscular rheuma- tism, 575 Sulphur baths, in treatment of ■ mercurial tremor, 806 of lead-poisoning, 807 Sulphuretted hydrogen in the air of marshes, 353 Sulphuric acid, in choleraic diarrhcea, 420 in hooping-cough, 56 in typhoid fever, 248 Sulphurous acid, in diphtheria, 80, 82 suggested use of, in influenza, 47 supposed efficacy of, in pyse- mia, 351 [Sunshine, curative of neural- gia, 1048] Sunstroke, article on, 661 defluition, 661 synonyms and history, 661 etiology, 6(>4 [frequency of, in cities, 664 promoted by intemperance, 665] symptoms, 666 diagnosis, 667 patiiology, 667 morbid anatomy, 668 mortality, 668 prognosis and prophylaxis, 668 treatment, 669 [by hypodermic injection of morphia, 670] of sequelte, 670 Suppression of urine, in influ- enza, 43 in malignant dysentery, 377 in smallpox, 141 in yellow fever, 290, 293 Suppuration, from chalk-stones in gout, 517 in erysipelas, 333, 336 in pysemia, 331 of bones and joints in pyse- mia, 334 of lymphatic glands in ter- tiary syphilis, 433 of parotid gland in parotitis, 119 of parotid glands after ty- phus, 362 of periosteal nodes in ter- , tiary syphilis, 433 I see, also, Abscess, jupra-renal capsules, conges- tion of, in diphtheria, 77 I Surgical operations a cause of I pyajmia, 330, 343 1102 INDEX OF VOL. I. Surgical scarlet fever, 94 Sutures, deepening of, in rick- ety skull, 491 Sweat, characters of, in acute rheumatism, 563 nature of, in rheumatoid arthritis, 553 Sweating, in cholera, 400, 406, 415 in intermittent fever, 357 in pyaemia, 344, 345 in relapsing fever, 277 in remittent fever, 366 in acute rheumatism, 559 absence of, in acute rheuma- toid arthritis, 552 at night, in chronic dysen- tery, 377 critical, in yellow fever, 285 excessive, of no use in gout, 523 of head, in rickets, 476, 483 relation of, to sudamiua, 123 Symmetry, in symptoms of acute rheumatism, 561 of congenital syphilis, 430 of secondary syphilis, 424, 435 of tertiary congenital syphi- lis, 440 ' Sympathetic epilepsy, 1034 Sympathetic nervous system, influence of, on occurrence of purpura, 465, 466 supposed affection of, in ty- phoid fever, 320 Symptoms of disease considered generally, 33 general and local, 24 objective and subjective, 24 Syncope, a cause of death in diphtheria, 66, 69 in gouty affection of the heart, 519 in the plague, 315 in purpura, 461 in relapsing fever, 379 in scurvy, 453, 455 Syncope, diagnosis of, from epilepsy, 778 from congestive apoplexy, 849 in hysteria, 635 Synovial fluid, eifusion of, in gout, 535 in acute rheumatism, 561, 563 in rheumatoid arthritis, 553 Synovial membrane, inflamma- tion of, in gout, 514 in acute rheumatism, 561, 563 in rheumatoid arthritis, 553 Syphilis, article on, 423 diagnosis of, 438 diagnosis of inherited syphi- lis, 440 stages of, 424 modes of communication, 439 tertiary symptoms, or se- queiae, 431 treatment, 435 Syphilis, a cause of abscess of the brain, 936 of infantile convulsions, 746 of insanity, 590 of local paralysis, 1050 of spinal meningitis, 955 Syphilis, a cause — of neuralgia, 1043 of paralysis agitans, 725 of purpura, 463 of sciatica, 1037 of wasting palsy, 788 Syphilis, a specific fever, 423 communicated by vaccina- tion, 178 communication of, by foetus to mother, 429 diagnosis of pains in, from muscular rheumatism, 575 In parents, a supposed cause of rickets, 473 nature of the poison of, 423 tabular view of stages of, 436 tabular statement contrast- ing acquired and inherited, 443 theory of imperfect conta- gion in, 428 transmission of, from parent to offspring, 420, 430 to the third generation, 431 value of treatment in, 413 Syphilis, hereditary, diagnosis of, 440 diagnosis of, from rickets, 485 a protection against acquired syphilis, 427 symptoms of, 439 Syplillis, secondary, diagnosis of, 439 symptoms of, 425, 426 question of prevention of, by treatment, 428 symmetry of symptoms of, 425, 431 treatment of, by mercury, 435 Syphilitic disease of the brain, diagnosis of, 756 a cause of convulsions, 760 Syphilitic mania, pathology of, 614 Syphilitic meningitis, 812 tumors in the brain, 890 TABES DORSALIS, 981, 989 Tache ceribrale, of Trous- seau, 821 Talipes following infantile pa- ralysis, 1006 Tannic acid in cholera, 416 in choleraic diarrhoea, in hooping-cough, 56 in yellow fever, 294 local use of, in hemorrhage in purpura, 468 Tapping the head In chronic hydrocephalus, 839 Tarantism , history of, 701 Taraxacum, in dyspepsia of chronic gout, 545 In intermittent fever, 363 Tarsus, deposits in joints of, in gout, 535 Tartar emetic in treatment of chorea, 714 Tartaric acid, uselessness of, in scurvy, 456 Tartarized antimony, see Anti- mony. Taste, loss of, in diphtheria, 69 Tea, in scarlet fever, 96 Teeth, early decay of, in rick- ets, 480 grinding of, a fata] sign iu smallpox In children, 137 incisors, deformity of, from hereditary syphilis, 441 late appearance of, in rick- ets, 480 loss of, in scurvy, 451 Teeth, extraction of, causing abscess of the brain, 936 Teething, a cause of roseola, 105 irritation of rickets mistaken for, 475 see, also. Dentition. Temper, irritability of the, in congestion of the brain, 847 in gout, 515 in hysteria, 635 in chronic meningitis, 816 in rickets, 476 from softening of the brain, 857 from tumor of the brain, 884 Temperament, influence of, on gout, 527 Temperament, the insane, 588 the nervous, 633, 996 Temperature of body, in cere- bro-spinal meningitis, 398, 303 variations of the, after cere- bral hemorrhage, 923 In cholera, 399, 410 occasional rise of, after death, in cholera, 410 in dementia, 601 in dengue, not recorded, 101, 103 in diphtheria, 65, 66, 77 in diphtheria, a sudden rise of, an unfavorable sign, 77 in erysipelas, 334 in general paralysis, 607 in acute gout, 511 in influenza, 41 in intermittent fever, 357, 358 in mania, 597 influence of, on prognosis of mania, 617 in measles, 109 in parotitis, 118 in the plague, 314 in pyaemia, 345 iu relapsing fever, 377 in remittent fever, 366 in acute rheumatism, 561 in rheumatoid arthritis, chronic, 551 acute, 553 in scarlet fever, 85, 89 local diminution of, afteri section of nerve, 1035 increase of, after injury to tlie spinal cord, 945 in sunstroke, 666 in tetanus, 973 in tubercular meningitis, 823 after death from tetanus, y, 149 Mead, on smallpox before birth, 132 Montague, Lady Mary Wortley, on inocula- tion for smallpox, 156 Moore, Dr., on the history of smallpox, IZb Petzholt, Dr., on smallpox pustules in the intestine, 146 Prooopius, the earliest account of smallpox by, 128 Rhazes, description of smallpox by, in 910, 128 Simon, Dr. Gustav, on the anatomical charac- ters of a variolous pock, 148 Simon, .John, on the prevention of smallpox by vaccination, 156 Sydenham, on the treatment of smallpox, 141 ; on variola sine eruptione, 139 Thompson, Dr. John, on varioloid, 150 Van Swieten, on variola verrucosa or cornea, 132 Velpeau, M., on the prevention of pitting in smallpox, 144 Watson, Sir Thomas, on smallpox pustules in the intestine, 146; on the anatomy of smallpox pustules, 147 Wedl, Carl, M.D., on the anatomy of small- pox pustules, 149 Wilson, Erasmus, on the anatomical charac- ters of the variolous pock, 147 SOFTENING OF THE BRAIN, Article on, by J. E«««^J^^ I^^g™«^°^' M.D., F.R.S., and H. Charlton Bastian, M.D., i.H.b., p. boo AUTHORS EBFEEEED TO. Abercrombie, on Diseases of the Brain and Spinal Cord, 866 Andral, Clinique Medicale, 866 Bennett, Hughes. CI nical Lee ures 868 871 Bouillard, Traite de I'Encephahte 8bl, 866 Broca, sur le Si«ge de la Faculty f" Langage articuie (Bullet, de la Soc. Anat. 1861), 861 Cruveilhier, Anat. Pathologique, 866 Durand-Fardel, Maladies desV.eiUards, 866 Gluge, Comptes Rendus, 1837, &c., 867 Hughlings Jackson, on Loss of Speech (Lon- don Hospital Reports), 861, 867 , Kirkes, on Cerebral Embolism in Med.-Chir. Transactions, vol. xxxv., 866, 8b.) Laborde, RamoUissement et Congestion du Cerveau, 867, 872 „ , rpr, Lallemand, Recherches anat.-path. sur 1 En- Jnt^'/ae'laVomb. etdel-Emb. Cerfib., 866, 869 1124 LIST OF CHIEF AUTHORS Prevost and Cotard, Recherolies sur le Ramol- lissement CeriSbrale (Gaz. MM. de Paris, 1866), 867, 868 Rokitansky, Pathol. Anat. (Syd. Society), 867 Rostan, RamoUissement du Cerveau, 867 Todd, Clinical Lectures on Paralysis, 860, 871 Trousseau, on Aphasia (Gaz. des Hopitaux, 1864), 861 For numerous additional references, to Cohn, Proust, Virchow, Van der Kolk, and other well-known authors, see foot-notes at 866, 871, &o. SOMNAMBULISM AND ITS ALLIED STATES, Articles on, by Thomas King Chambers, M.D., F.R.C.P., &c., p. 658. AUTHORS KEFEEKBD TO. Abercrombie, Dr., on the Intellectual Powers, 660 Trousseau, Clinique Medicare, 660 Transactions of the Royal Society of Edin- burgh, vol. ix. &o. DISEASES OF THE SPINAL COED, Articles on, bt C. B. Eadcliffe, M.D., F.R.C.P., &c., p. 942. AUTHORS REFERRED TO. Adams, W., on Infantile Paralysis, 1004, 1005 Barthez and Rilliet, on Infantile Paralysis, 1005 Bell, Sir Charles, on the Nervous System, 942 Briquet, on liysterical paraplegia, &c. (Traite Clinique, &c. de I' Hysteric), 994, 1000 Brodie, Sir Benjamin, on injuries of the spinal cord (Med.-Chir. Trans. 1837), 945 Brovvn-Sequard, on Phys. and Path, of the Nervous System, 943, 959 Curling, on Tetanus, 971, 975 Duchenne, on Locomotor Ataxy, &c., 981, 999 Griffin, W. and D., on Functional Affections of the Spinal Cord, 991 Lockhart Clarke, on the pathology of locomotor ataxy (Med.-Chir. Trans. 1865), 942, 977 Marshall Hall, Diseases of the Nervous Sys- tem, 943, 961 Ollivier, on Diseases of the Spinal Cord, 953, 959 Romberg, Manual of Nervous Diseases (Tabes Dorsalis), 980 Teale, on Neuralgic Diseases dependent on Irritation of the Spinal Marrow, 991, 995 Todd, on Nervous Diseases, 961, 980 Trousseau, Clinique M^ilicale, 984, 985 Watson, Sir Thomas, Practice of Physic, 976, 979 SUDAMINA AND MILIARIA, Article on, bt Sydney Ringer, M.D., p. 122. SUNSTROKE, Article on, by W. C. Maclean, M.D., &c., p. 661. AUTHORS REFERRED TO. Barclay, Dr., Natural History of Insolation, 663 Bassier, M., Dissertation sur la Calenture, 664 Boudin, M., Statistiques Medicales, 663, 664. Ludwig, on the effect of elevation of tempera- ture on the body (Handbuoli der Pliysio- logie), 665 Martin, Sir Ranald, on the Influence of Tropi- cal Climate, &c., 662 Morehead, Dr., Clinical Researches on Dis- eases in India, 666 Obernier, Dr., experiments on the effects of high temperatures on tlie body, 665 Parkes, Dr., on Practical Hygiene, 663 Papers in Indian Annals of Medicine, &o. SYPHILIS, Article on, by Jonathan Hutchinson, F.R.C.S., p. 423. authors referred to. Carmichael, on the nature of syphilitic poi- son, 423 Curling, on syphilitic orchitis, 434 Diday, M., on recurrence of syphilis, 427 Lee, Mr., on hereditary immunity from syphi- lis, 428 ; on calomel vapor baths in syphi- lis, 438 Paget, Mr. James, on syphilitic ulceration of the rectum, 430 Parker, Mr. Langstone, on calomel vapor batlis in syphilis, 438 Wilks, Dr. Samuel, on syphilitic disease of the liver, 434 KEFEERED TO IN EACH ARTICLE. 1125 TORTICOLLIS, Article on by J. Eussell Reynolds, M.D., F.R.S., &c., p. 1060. ' AUTHORS REFEEKED TO. AUTHORS REFERRED TO. Allbutt, Dr. C, paper on the diagnostic value ot the ophthalmoscope {Lancet, 1868), and on Optic Neuritis {Med. Times and Gazette, lobS), 824, 825 Bastian, Dr. C, on perivascular sheaths in the brain, 834 ^*io?* o-?*^ Barthez, on Diseases of Children, o^l, 825 Trousseau, Clinique Medicale, 821, 822 Virchow's Jahresbericht (1869), o'u tubercle in the choroid, 824 Whytt, Dr. R., on Hydrocephalus Interuus (1768), 820 TYPHOID OR ENTERIC FEVER, Article on, by John Harley, MD Lond., p. 201. AUTHORS REFERRED TO. Boudin, M., on the relation of malaria to specific fevers, 231 Bretonneau, on contagion in typhoid fever, 238 Buchanan, Dr. G., on impure water as a cause of typhoid fever, 242 Budd, Dr. William, on contagion in typhoid fever, 238 ; on impure water as a cause of typhoid fever, 242 Chomel, on the diagnosis of typhoid fever, 233 Davis, Mr., on the Walcheren fever, 228, 229 ■ De Claubry, on the distribution of typhoid fever, 234 ; on the spontaneous origin of typhoid fever, 240 Ebel, Dr., on an outbreak of typhoid fever at Stangerod, 242 Forget, M., on the blood in typhoid fever, 218 Gairdner, Dr. W. T., on the post-mortem ap- pearances in cholera, 231 Galtier, C. P., on poisoning by poisonous mushrooms, 243 Grossheim, Dr., on the cause of typhoid fever, 238 Guy, Dr., on the health of night-men, 241 Jenner, Sir Willian, on the distinction be- tween typhus' and typhoid fevers, 245 ; on pleurisy in typhoid fever, 222 ; on the state of the liver in typhoid fever, 216 Keruer, Dr., on poisoning by putrid food, 243 Latham, P. M., M.D., on the outbreals of scurvy at Milbank Penitentiary, 231 Louis, on the causes of typhoid fever, 238 ; cases of typhoid fever reported by, 226 ; on the state of the liver in typhoid fever, 216 ; on the state of the lungs in typhoid fever,' 221 ; on pleurisy in typhoid fever, 222 Mayo, Mr. C, on the camp fever in the army of the Potomac, 228 Moffat, Dr., on the effect of absence of ozone from the air, 238 Murchison, Dr., on perforation in typhoid, 208 ; on sewer emanations as a cause of ty- phoid, 241 ; on the state of the liver in typhoid, 216 ; on pleurisy in typhoid fever, 222 Parkes, Dr. E. A., on the stools in typhoid fever, 207 Piedvache, M., on the spontaneous origin of typhoid, 240 Pirogoff, on the post-mortem appearances of the intestines in cholera, 231 Schumann, Dr., on poisoning by putrid food, 243 Simon, J., on water as a cause of typhoid fever, 242 Stewart, Dr. A. P., on the distinctions be- tween typhus and typhoid, 24.o Trousseau, M., on nitrate of silver in typhoid fever, 248 ; on the blood in typhoid fever, 218 Tweedie, Dr., on nitrate of silver in typnoid fever, 248 Whitley, on the relation of malaria to ty- phoid fever, 228 Zenker, on the degeneration of muscular tis- sue in typhoid fever, 217 1126 LIST OP CHIEF AUTHORS TYPHUS FEVER, Article on, by George Buchanan, M.D., p. 251. AUTHORS KEFEEEED TO. Murchison, Dr., on the spontaneous origin of I Parkes, Dr., on the urine In typhus, 260 typhus, 254 I VACCINATION, Article on, by Edward Cator Seaton, M.D., p. 158. AUTHORS REFERRED TO. Balfour, Dr., on the amount of smallpox in the army, 167 Ceely, Mr., on inoculation of cows with hu- man smallpox, 177 ; on vaccination with lymph direct from the cow, 160 Cross, Mr., on the protective power of vacci- nation, 167 CuUerier, M., on the effects of using lymph from a syphilitic child, 179 Heim, ProtVssor, on the influence of time on the protective power of vaccination, 174 ; on revaccination, 175 Jenner, Edward, introduction of vaccination by, 158 ; on the degeneration of vaccine lymph, 172 Jenner, Sir W., on the communication of other diseases by vaccination, 178 Kinnis, J., M.D., on the effects of vaccination on smallpox, 169 Marshall, Mr., on the protective power of vaccination, 167 Marston, Mr., on failures in vaccination, 165 ; on revaccination, 175 Pachiotti, on the outbreak of syphilis at Ri- valta, 181 Paget, Mr., on the production of cutaneous eruptions by vaccination, 178 ; on the com- munication of syphilis by vaccination, 178 Sperino, on the outbreak of syphilis at Ri- valta, 181 Taupin, M., on experiments with lymph from a syphilitic child, 179 West, Dr. C, on the communication of syphi- lis by vaccination, 178 VARICELLA, Article on, by Samuel Jones Gee, M.D., p. 124. AUTHORS REFERRED TO. Abercrombie, on the relation of varicella to cow-pox, 125 Bryce, on the eruption in varicella, 126 Cross, on the diagnosis of varicella, 126 Fuller, on the non-identity of varicella and variola, 124 Gregory, on the symptoms of varicella, 126 Heberden, on the non-identity of varicella and variola, 124 Trousseau, on inoculation of varicella, 124, 125 VERTIGO, Article on, by J. Spence Ramskill, M.D., &c., p. 690. AUTHORS REFERRED TO. Brown-Sfequard, Dr., Physiology of the Ner- vous System, 694 Meniere, Dr., on Vertigo from Diseases of the Ear, in Bulletin de TAcadSmie de Medecine, vol. xxvi., 694 Trousseau, Clinique Mgdicale, 694 WASTING PALSY, Article on, by William Roberts, M.D., F.R.C.P., p. 786. AUTHORS REFERRED TO. Aran, descripton of Wasting Palsy, 793 Bergmann, papers in St. Petershurger Medicin- ische Zeitschrift, 1864, 787, 791 Cruveilhier, on Progressive Muscular Atro- phy, in Archives GSngrales, 1853, 791 Duchenne, Dr., de 1' Electrisation Localisee, &c., 786, 798 Gull, Sir W., on the pathology of wasting palsy (Guy's Hospital Reports, series iii.), 792 Lockhart Clarke, on microscopic appi a-ances of the spinal cord in wasting palsy (Beale's Archives, 1861), 787, 792 REFERRED TO IN BACH ARTICLE. 1127 WRITER'S CRAMP, Article on, by J. Russell Reynolds, M D F.R.S., &c., p. 732. AUTHORS REFERRED TO. Brown-Sgquard, Physiology and Pathology of the Central Nervous System, 735 Lockhart Clarke, on Locomotor Ataxy, 737 Solly, on Scrivener's Palsy (Lancet, January 1865), 734 ■' YELLOW FEVER, Article on, by J. Denis Macdonald, M.D., F.R.S., p. 281. AUTHORS REFERRED TO. Aitken, Dr. W., on the treatment of yellow fever, 294 Blair, Dr., on the blood in yellow fever, 288; on black vomit, 290 Blane, Sir Gr., on the yellow tint of skin in yellow fever, 287 Brvson, Dr., on infection in yellow fever, 288 Buchanan, Dr. G-., on the yellow fever at Swansea, 295 Cartwright, Dr., on the state of the semilu- nar ganglia in yellow fever, 291 Chassanoil, on urea in the blood in yellow fever, 289 Davy, Dr., on the blood in yellow fever, 288 Frost, Professor, on chlorate of potash in yel- low fever, 294 Humboldt, on the effect of elevation on yel- low fever, 284 Jackson, Dr., on the prognosis of yellow fever, 292 La Roche, Dr., on the symptoms of yellow fever, 285 ; on the varieties of yellow fever, 295 ; on the urine in yellow fever, 290 Maclean, Dr., on the diagnosis of yellow fever, 286 Mason, Dr. R. D., on contagion in yellow fever, 296 Peiinel, Dr., on the morbid anatomy of yel- low fever, 291, 292 Rogers, Professor, on the excess of salts in the blood in yellow fever, 288 ; on the com- position of the black vomit, 289 Warren, on the cause of the yellow tint of the skin ia yellow fever, 287 END OF VOLUME L